CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 AFRICA 227 As I did most of my cardiology training in the late 1970s prior to the evolution of and dramatic advances in interventional cardiology, I have watched the developments in the field with awe and enormous respect for the practitioners who have pioneered many of the new techniques and the scientists and materials engineers whose work has contributed to the development of the many and varied devices that have made the procedures possible. The news of the first balloon coronary angioplasty by Gruentzig in 1977 was met with disbelief in some quarters but it, or variants, are now commonplace and often performed by relatively junior staff. Other interventions for the percutaneous catheter-based treatment of many different acquired or congenital structural heart diseases have evolved at an amazing rate and are now routine. Transcatheter aortic valve implantation (TAVI) for treatment of aortic stenosis is only one such procedure but is a truly remarkable one. In this issue of the Journal, Hitzeroth and colleagues (page 267) outline the South African Society of Cardiovascular Intervention (SASCI) and the Society of Cardiothoracic Surgeons of South Africa (SCTSSA) update on the joint consensus statement and guidelines on transcatheter aortic valve implantation (TAVI) in South Africa, last reviewed in 2016. Over the last 10 years, TAVI has become an established therapy in South Africa for many patients with aortic stenosis. Based on clinical trial evidence that has become available since then, the TAVI indications have expanded and this treatment modality can now be offered to a broader patient population. In addition to this, the TAVI technology has improved and the implantation technique has been streamlined. This has resulted in excellent procedural outcomes and reduced hospital stays. Furthermore, TAVI has been shown to be cost effective and this is of relevance in the South African resource-constrained environment. The authors and societies are to be congratulated on the update, particularly for their emphasis on the implications for performance of the procedure in a resource-constrained environment. Stassen and co-authors describe how the incidence of out-ofhospital cardiac arrest (OHCA) is expected to increase in sub-Saharan Africa (page 260). The condition carries a dismal survival rate in the best of settings. They argue that interventions to improve OHCA survival might not be cost effective for many low-resource settings, and therefore need to be targeted to areas of high incidence. The aim of this study was to describe the temporal and geographic distribution of OHCA in the city of Cape Town, South Africa, and their proximity to percutaneous coronary intervention (PCI) centres. In their description of the few interventions that have been demonstrated to improve the dismal prognosis, they describe that some interventions have been found to increase survival rate in OHCA, most notably bystander cardiopulmonary resuscitation (CPR) and early defibrillation of shockable dysrhythmias. CPR training, either through mass public training events or training targeted at family and friends of patients with high risk of sudden cardiac arrest, has been shown to increase the likelihood of bystander CPR and the quality of CPR performed. Similarly, public access placement of automated external defibrillators has been shown to decrease the time delays from collapse to defibrillation in OHCA. These interventions may be cost effective when they are targeted to areas of both a high concentration of potential victims and potential resuscitators. The authors are to be congratulated on describing the temporal and geographic distribution of OHCA in the city of Cape Town from this retrospective survey. However, as they acknowledge, there are not many PCI-capable facilities available to the majority of Cape Town citizens and it is unlikely that that will improve in the foreseeable future due to resource constraints, and early PCI may not be the most effective intervention. I feel it would be helpful if they had shared information on the availability or lack thereof of the interventions that are immediately remediable such as bystander-initiated CPR or defibrillator availability to all first-responder teams. Sudden unexpected infant death (SUDI), previously known as sudden infant death syndrome (SIDS), is reported to be extraordinarily common in sub-Saharan Africa, with the incidence rate in South Africa among the highest in the world. It is common for the cause of many such infant deaths to remain unexplained, even after a full medico-legal death investigation, and then to be categorised as a sudden unexplained infant death (SUID). The interesting case report by van Deventer and colleagues provides a perspective on the topic (page 280). Reviewers of this report were not unanimous in their responses but I took an editorial decision to publish it because although all conclusions may not be correct, the content of the case report and literature review emphasises the need for more careful investigation of SUDI cases by molecular-based diagnostics in the African forensic medical setting if a better understanding of this devastating condition is to be established. It remains a privilege to receive, edit and comment on a diverse array of articles that reflect both the strengths and weaknesses of cardiac services available in Africa and other areas with similar resource constraints. I would welcome letters to the Editor an any matter of disagreement or concern. Pat Commerford Editor-in-Chief From the Editor’s Desk
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