Making the Transition From Cardiac Missions to Autonomous Heart Surgery at a Nigerian Teaching Hospital: Challenges and Lessons Learned.

Open-Heart Surgery at the Lagos State University Teaching Hospital commenced in 2004. Early years were based on a Cardiac Mission Model, but since 2017 the focus was on the transition to a Local Team Model with autonomous Open-Heart Surgery. The aim of this study is to describe our progress in making this transition, highlight lessons learned, and detail the outstanding challenges to be overcome. This study is a retrospective analysis of prospectively maintained data from the Lagos State University Teaching Hospital cardiothoracic database and Nigeria Open-Heart Surgery Registry between November 2004 and December 2021. Data extracted included patient demographics, EuroSCORE II, operative procedure, operative category, lead surgeon, complications, and outcomes. Over the study period, 100 operations were done over 2 time periods, 51 operations between 2004 and 2011 (Cardiac Mission Period) and 49 operations between 2017 and 2021 (Transition Period). In the Cardiac Mission Period, 21.6% of the operations were done by the Local Team and in the Transition Period this increased to 85.7% of the operations completed. Overall mortality was 14%, dropping from 17.6% in the Cardiac Mission Period to 10.2% in the Transition Period. The Local Team is now gradually taking on more diverse cases while striving to maintain good outcomes. Our institution has successfully made the transition from Cardiac Missions to Autonomous Open-Heart Surgery without an increase in mortality and a gradual increase in surgical volumes. Lessons learned included a strategy to focus on adult surgery, avoidance of high-risk cases, and moving from free surgery toward an appropriate cost structure for program sustainability. Contributory factors to the successful transition include the active support of the hospital management (provision of appropriate infrastructure and equipment, investment in training of the Local Team), continued humanitarian international collaborations focused on skill transfer, and maintenance of Local Team skills by collaborations with other active cardiac centers in Nigeria. Remaining challenges include financing to bridge equipment gaps, maintenance and replacement of equipment as well as the evolution of a national health insurance schema that would ideally support Open-Heart Surgery for Nigerian patients. Until that time, patients and programs must rely on supplemental funding of surgery to increase surgical volumes.

Metal allergy to Amplatzer occluder device presented as severe bronchospasm.

Percutaneous closure of an atrial septal defect has become increasingly popular among interventional cardiologists. With this relatively new technology being more widespread, it is important to acknowledge any device-related complications. We report a case of severe bronchospasm secondary to a metal allergy after an atrial septal defect device closure requiring device removal.

Left ventricular assist device malfunction: an approach to diagnosis by echocardiography.

OBJECTIVES: A protocol using transthoracic echocardiography was designed to diagnose the common malfunctions of patients on chronic support with a left ventricular assist device (LVAD). BACKGROUND: Mechanical circulatory support, primarily with a LVAD, is increasingly used for treatment of advanced heart failure as a bridge to transplant and for long-term treatment of heart failure. The LVAD dysfunction is a recognized complication. To date, no studies have defined the role of transthoracic echocardiography in evaluating long-term mechanical complications of chronic LVAD support. METHODS: Transthoracic echocardiography was used in a protocol designed to detect the common types of mechanical malfunction. Patients were followed up with serial echocardiograms, and clinical validations were made with findings from a catheter-based protocol and inspection at the time of cardiac transplant or corrective surgery. RESULTS: Thirty-two patients with 44 LVADs were followed up during a four-year period using this protocol that correctly identified 11 patients with inflow valve regurgitation, 2 with intermittent inflow conduit obstruction, 1 with severe kinking of the outflow graft, and 9 with new insufficiency of the native aortic valve. CONCLUSIONS: As LVAD use for end-stage heart failure becomes widespread, and durations of support are extended, dysfunction will be increasingly prevalent. Transthoracic echocardiography provides a practical method to accurately identify the causes of mechanical dysfunction with patients on chronic LVAD support.

Left ventricular assist device malfunction: a systematic approach to diagnosis.

OBJECTIVES: A protocol was designed to diagnose the common malfunctions of a left ventricular assist device (LVAD). BACKGROUND: Mechanical circulatory support, primarily with an LVAD, is increasingly used for treatment of advanced heart failure (HF). Left ventricular assist device dysfunction is a recognized complication; but heretofore, a systematic method to accurately diagnose LVAD dysfunction has not been thoroughly described. METHODS: We developed a catheter-based protocol designed to characterize a normally functioning LVAD and diagnose multiple types of dysfunction. A total of 15 studies of 10 patients supported with an LVAD were reviewed. All patients had been evaluated due to concerns regarding LVAD dysfunction. RESULTS: Of 15 examinations performed, 11 documented severe LVAD inflow valve regurgitation. One of these cases proved to have coexistent severe mitral valve regurgitation. One case was diagnosed with distortion of the LVAD outflow graft. One case of suspected embolization from the pumping chamber excluded the outflow graft as the source of emboli. One study had aortic insufficiency. CONCLUSIONS: As LVAD use for treatment of end-stage HF becomes widespread and durations of support are extended, dysfunction will be increasingly prevalent. This catheter-based protocol provided a practical method to diagnose multiple causes of LVAD dysfunction.