Cardiovascular Journal of Africa: Vol 30 No 2 (March/April 2019)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 2, March/April 2019

AFRICA

30. Yan J, Zhao W, Thomson JK, Gao X, DeMarco DM, Carrillo E,

et al

Stress signaling JNK2 crosstalk with CaMKII underlies enhanced atrial

arrhythmogenesis.

Circ Res

2018; 16

;

122

(6): 821

–

835.

31. Davis RJ. Signal transduction by the JNK group of map kinases.

Cell

2000;

103

: 239

–

252

32. Yan J, Thomson JK, Zhao W, Wu X, Gao X, DeMarco D,

et al

. The

stress kinase JNK regulates gap junction Cx43 gene expression and

promotes atrial fibrillation in the aged heart.

J Mol Cell Cardiol

2017;

4: 105

–

115.

33. Yan J, Thomson JK, Zhao W, Gao X, Huang F, Chen B,

et al

. Role of

stress kinase JNK in binge alcohol-evoked atrial arrhythmia.

J Am Coll

Cardiol

2018;

(13): 1459

–

1470.

speaking with one voice, will eventually benefit the many.

As laudable as it is to have the highest standards of modern

valve repair in mind when bringing help to low-income countries,

it will continue to exclude the many from life-saving operations.

Local capacity building on the basis of simple, life-saving

replacement-valve surgery has worked before and went hand

in hand with the transition of a country from low to middle

income. Once this feasibility is established, as the examples of

Alain Carpentier’s centre in Saigon and Magdi Yacoub’s in

Aswan, Egypt, have demonstrated, advanced valve repair and

paediatric cardiac surgery can eventually blossom.

Cape Town plays more than a symbolic role in this initiative.

It is the home not solely of the only dedicated public paediatric

cardiac centre on the African continent that exclusively caters for

indigent patients, but also to an international nucleus for rheumatic

heart disease research, previously under the leadership of Bongani

Mayosi. Together with the World Heart Federation in Geneva, one

of CSIA’s founding members, this scientific embedding guides the

intersociety initiative on the basis of factual insight.

In this regard, the REMEDY study under the co-ordination

of Zühlke and the late Mayosi highlighted the frightening

percentage of rheumatic patients in need of double-valve

surgery.

Are Kinsley

et al

. proposing to send super-specialised

teams performing a combination of Ozaki or Ross procedures

with a complex mitral repair, as spearheaded by Taweesak

Chotivatanapong, in 56 to 58% of patients between 21 and 40

years of age who would need surgery for both the aortic and

mitral valve? Or are they proposing to establish ‘regional cardiac

hubs’ with this level of skills from the beginning? If not, it is

difficult to see where they take issue with the CSIA.

Kinsley

et al

. seem to be of the opinion that valve-replacement

surgery is catastrophic and therefore patients not lucky enough

to reach a ‘private–public’ partnership regional centre with its

world-class experts should rather be left to die. Based on our own

research, we concur with the authors that the implantation of

mechanical valves is far from an ideal solution.

Nonetheless, in

the neglected regions of the world, where any cardiac operation

is vanishingly rare and re-operations totally unavailable, these

operations have proven life-saving and life-extending to many

patients in very austere conditions.

Those of us working in tertiary institutions, which primarily treat

indigent patients with rheumatic heart disease, have long pushed

the boundaries towards suitable replacement valves, irrespective of

the undisputed benefit of repairs over replacements.

7,8

Connecting

all these dots as they appear on the radar screens of all, and striving

to identify and promote best practices and uniform standards of

care are among the goals of CSIA.

The CSIA is an umbrella organisation that, together with the

World Heart Federation, strives to bring structured, transparent

support and oversight to local capacity building in cardiac

surgery in low-income countries. It will be a long and challenging

journey, but the global community of professional bodies

representing both the pioneer spirit and the idealistic side of our

discipline believes that such an approach will eventually help

more indigent patients to receive life-saving heart surgery and

acknowledge the dignity of emerging modern societies in the

underprivileged regions of the world in lieu of perpetuating a

paternalistic model that helps only a few.

Although Kinsley

et al

. seem to be critical of the goals of the

CSIA, they actually confirm most of its goals.

University of Cape Town, South Africa

Peter Zilla, MD, PhD

University of Colorado, USA

R Morton Bolman III, MD

References

Sliwa K, Zilla P. Rheumatic heart disease. The tip of the iceberg.

Circulation

2012;

125

: 3060–3062.

Zilla P, Yacoub M, Zühlke L, Beyersdorf F, Sliwa K, Khubulava G,

et al.

Global unmet needs in cardiac surgery.

Global Heart

2018;

: 293–303.

Zilla P, Bolman RM, Yacoub MH, Beyersdorf F, Sliwa K, Zühlke L,

et al

. The Cape Town Declaration on Access to Cardiac Surgery in the

Developing World.

Cardiovasc J Afr

2018;

: 256–259;

J Thorac Cardiovasc

Surg

2018;

156

: 2206–2209;

Ann Thorac Surg

2018;

106

: 930–933;

Eur J

Cardiothorac Surg

2018;

: 407–410;

SA Med J

2018;

108

: 702–704;

Heart J

2018;

: 190–194;

Asian Cardiovasc Thorac Ann

2018;

: 535–539.

Yacoub M, Elguindy A, Afifi A, Yacoub L, Wright G. Taking cardiac

surgery to the people.

J Cardiovasc Trans Res

204;

: 797–802.

Zuhlke L, Engel ME, Karthikeyan G, Rangarajan S, Mackie P, Cupido

et al.

Characteristics, complications, and gaps in evidence-based inter-

ventions in rheumatic heart disease: the Global Rheumatic Heart Disease

Registry (the REMEDY study).

Eur Heart J

2015;

: 1115–1122.

Scherman J, Manganyi R, Human P, Pennel T, Brooks A, Brink J, Zilla

Isolated mechanical aortic valve replacement in rheumatic patients in

a low- to middle-income country.

J Thorac Cardiovasc Surg

2018: 1–8.

Scherman J, Appa H, Heerden C, Ofoegbu C, Bezuidenhout D, Zilla P.

Transcatheter valve with a hollow balloon for aortic valve insufficiency.

Multimedia manual of cardiothoracic surgery: MMCTS 2018.

Bezuidenhout D, Williams DF, Zilla P. Polymeric heart valves for surgi-

cal implantation, catheter-based technologies and heart assist devices.

Biomaterials

2015;

: 6–25.

…continued from page 74