Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 288 AFRICA Prospects for the future and remaining challenges PTMC is a procedure that should be available in any major cath lab on the continent. For the future we propose that similar workshops should be conducted to expand and consolidate PTMC skills among local cardiologists. To further enhance the experience, we propose the following recommendations: • Two categories of trainees should be identified. The first would be experienced interventional cardiologists with prior experience in PTMC but who require further training, and these could be first operators, with experienced trainers as the second operator. The other category would be interventional cardiologists with no or limited exposure to PTMC and these could assist with the procedure and acquire basic training that would allow them to obtain further training in their own institutions. • A didactic basic knowledge syllabus has been drawn up, which trainees must review before the workshop. A step-by- step visual guide has been prepared that includes criteria for patient selection, echocardiographic assessment of the mitral valve, role of transoesophageal echo, review of the equip- ment, how to perform trans-septal puncture, balloon prepara- tion, mitral valve dilatation, procedural haemodynamics and possible complications. The workshop should be followed by a mentorship period in their own institutions. We propose at least 20 cases as first operator before becoming independent. The use of telemedicine for challenging cases, either in the selection phase or during the procedure, can also be utilised. Several challenges remain in the face of advancing PTMC training and development on the continent. Financial support for trainees to cover travel and accommodation costs, as well as institutional charges is one challenge. Support of the industry for rheumatic heart disease interventions may not be as strong and forthcoming as would be expected for other cardiac procedures. Ensuring that trainees would be able to secure the required consumables and number of patients in their own institutions to maintain their skills, as well as the issue of cardiac surgery back- up during the procedure is another challenge. Although it is important to train cardiologists in Africa in the older traditional techniques, as these are the available resources, it is important to incorporate newer technology and multimodality imaging for the future, especially the use of three- dimensional (3D) and 4D echocardiography. 5 Traditionally, 2D echo has been the mainstay for the diagnosis and follow up for patients with mitral stenosis. Given the complexities of the procedure we believe 3D echo imaging will enable better imaging and assessment of the mitral valve pre-, during and post procedure. This therefore calls for more collaboration between the old and new: mitral stenosis meeting new technology in the form of 3D and 4D echo. Indeed, geometry and mitral valve volume can be assessed more accurately by 3D echocardiography, giving clinicians the extra edge required to refine patient outcomes. 6 Real-time 3D echocardiography has been shown be highly useful in atrial septal puncture, providing an accurate and safe access to the fossa ovalis floor and its immediate margin of the rim. 7 References 1. Mayosi BM, Gamra H, Dangou JM, Kasonde J; 2nd All-Africa Workshop on Rheumatic Fever and Rheumatic Heart Disease partici- pants. Rheumatic heart disease in Africa: the Mosi-o-Tunya call to action. Lancet Glob Health 2014; 2 (8): e438–439. 2. Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, et al . Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med 2007; 357 (5): 470–476. 3. Diao M, Kane A, Ndiaye MB, Mbaye A, Bodian M, Dia MM, et al . Pregnancy in women with heart disease in sub-Saharan Africa. Arch Cardiovasc Dis 2011; 104 (6–7): 370–374. 4. Rwebembera J, Jeilan M, Ajijola OA, Talle M, Sani MU, Karaye KM, et al . Cardiac pacing training in Africa: endorsed by the Africa Heart Rhythm Association (AFHRA): JACC International. J Am Coll Cardiol 2020; 76 (4): 465–472. 5. Meel R. Incorporating multimodality imaging in training in the South African context. SA Heart 2021; 17 (3). 6. Valocik G, Kamp O, Visser CA. Three-dimensional echocardiography in mitral valve disease. Eur J Echocardiogr 2005; 6 (6): 443–454. 7. Faletra FF, Nucifora G, Ho SY. Imaging the atrial septum using real- time three-dimensional transesophageal echocardiography: technical tips, normal anatomy, and its role in transseptal puncture. J Am Soc Echocardiogr 2011; 24 (6): 593–599. Dr Ngunga (left) is first operator, supervised by Dr Suliman.