Impact of Treatment Timing on the Risk of Cerebral Infarction in Patients with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Cerebral infarction is a major contributor to poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Timing of treatment has been discussed as a possible contributor. We aimed to analyze the impact of treatment timing on the risk of cerebral infarction and poor outcome after aSAH. METHODS: Consecutive cases of patients with aSAH treated at our institution between January 2003 and June 2016 were included. The cohort was divided into 2 groups, depending on the treatment during (day 4-14 after ictus) or beyond the vasospasm phase. Statistical assessment included a 1:1 propensity score matching analysis and multivariable logistic regression analysis within the whole cohort. RESULTS: Of 943 patients with aSAH, 111 underwent treatment in the vasospasm phase. In the propensity score matching analysis, patients treated during the vasospasm phase were at higher risk of vasospasm requiring intra-arterial spasmolysis (P < 0.0001), cerebral infarction distal to the treated vessel (P < 0.0001), and poor outcome (modified Rankin Scale score >2) at 6 months follow-up (P = 0.025). In the multivariable analysis, aneurysm treatment in the vasospasm phase was independently associated with higher risk of cerebral vasospasm necessitating intra-arterial spasmolysis (P < 0.0001; adjusted odds ratio [aOR], 3.62), cerebral infarction distal to the treated aneurysm (P = 0.01; aOR, 2.02), and poor outcome (P = 0.03; aOR, 2.05). CONCLUSIONS: Our data confirm a considerable risk of cerebral infarction and poor outcome in cases of aneurysm treatment between day 4 and 14 after aSAH. A more intense surveillance and prophylactic treatment of cerebral vasospasm might be necessary in cases of aneurysm treatment in the vasospasm phase.

Conotruncal Heart Defect Repair in Sub-Saharan Africa: Remarkable Outcomes Despite Poor Access to Treatment.

BACKGROUND: The outcome of children born with conotruncal heart defects may serve as an indication of the status of pediatric cardiac care in sub-Saharan Africa (SSA). This study was undertaken to determine the outcome of children born with conotruncal anomalies in SSA, regarding access to treatment and outcomes of surgical intervention. METHODS: From our institution in Ghana, we retrospectively analyzed the outcomes of surgery, in the two-year period from June 2013 to May 2015. The birth prevalence of congenital heart defects (CHDs) in SSA countries was derived by extrapolation using an incidence of 8 per 1,000 live births for CHDs. RESULTS: The birth prevalence of CHDs for the 48 countries in SSA using 2013 country data was 258,875; 10% of these are presumed to be conotruncal anomalies. Six countries (Nigeria, Democratic Republic of the Congo, Ethiopia, Tanzania, Uganda, and Kenya) accounted for 53.5% of the birth prevalence. In Ghana, 20 patients (tetralogy of Fallot [TOF], 17; pulmonary atresia, 3) underwent palliation and 50 (TOF, 36; double-outlet right ventricle, 14) underwent repair. Hospital mortality was 0% for palliation and 4% for repair. Only 6 (0.5%) of the expected 1,234 cases of conotruncal defects underwent palliation or repair within two years of birth. CONCLUSION: Six countries in SSA account for more than 50% of the CHD burden. Access to treatment within two years of birth is probably <1%. The experience from Ghana demonstrates that remarkable surgical outcomes are achievable in low- to middle-income countries of SSA.

The development of cardiac surgery in West Africa--the case of Ghana.

West Africa is one of the poorest regions of the world. The sixteen nations listed by the United Nations in this sub-region have some of the lowest gross domestic products in the world. Health care infrastructure is deficient in most of these countries. Cardiac surgery, with its heavy financial outlay is unavailable in many West African countries. These facts notwithstanding, some West African countries have a proud history of open heart surgery not very well known even in African health care circles. Many African health care givers are under the erroneous impression that the cardiovascular surgical landscape of West Africa is blank. However, documented reports of open-heart surgery in Ghana dates as far back as 1964 when surface cooling was used by Ghanaian surgeons to close atrial septal defects. Ghana's National Cardiothoracic Center is still very active and is accredited by the West African College of Surgeons for the training of cardiothoracic surgeons. Reports from Nigeria indicate open-heart surgery taking place from 1974. Cote D'Ivoire had reported on its first 300 open-heart cases by 1983. Senegal reported open-heart surgery from 1995 and still runs an active center. Cameroon started out in 2009 with work done by an Italian group that ultimately aims to train indigenous surgeons to run the program. This review traces the development and current state of cardiothoracic surgery in West Africa with Ghana's National Cardiothoracic Center as the reference. It aims to dispel the notion that there are no major active cardiothoracic centers in the West African sub-region.

Experience from a single centre concerning the surgical spectrum and outcome of adolescents and adults with congenitally malformed hearts in West Africa.

BACKGROUND: This study was undertaken to review the spectrum and surgical outcome of adolescents and adults with congenitally malformed hearts from January, 1993 to December, 2008. The lack of data on this emerging problem from the West African sub-region prompted this report. PATIENTS AND METHOD: This retrospective study is based on 135 adolescents and adults with congenitally malformed hearts. A review of their case notes and operative records was carried out and results analysed. RESULTS: Selected patients made up 23% of all congenital cardiac surgeries performed at our institution in the same period. A total of 23 patients (17%) were non-Ghanaian West Africans. There was a female preponderance of 53.3%. The ages ranged from 16 to 70 years (mean 28.6 plus or minus 10.3 years). The mean follow-up was 7.5 plus or minus 4.4 years. Patients were functionally classified (New York Heart Association) as class I (23%), II (58%), and III (19%). In 14 (10.4%) patients, the defects were discovered incidentally. Ventricular septal defects, oval fossa type atrial septal defects, Fallot's tetralogy, and patent arterial duct together accounted for 77.8% of the cases. Surgical correction was undertaken in 117 (86.7%) patients; the remainder had palliative procedures. There were six (4.3%) reoperations. The functional class improved to class I or II in 95% of patients within the first postoperative year. The overall hospital mortality was 3% with two late deaths (1.5%). CONCLUSION: The study demonstrates the feasibility of surgery for adolescents and adults with congenitally malformed hearts in the sub-region with a good outcome. Majority (77.8%) of patients present with less complex lesions.

Freedom from thromboembolism despite prolonged inadequate anticoagulation.

Life-long and meticulous control of anticoagulation is mandatory following mechanical valve replacement to prevent thromboembolism. Two patients who underwent mechanical mitral valve replacement with third generation bi-leaflet valves and in whom therapeutic anticoagulation could not be achieved for many months postoperatively form the basis for this report. In the first patient, the target international normalised ratio (INR) of 2.5-3.5 could not be achieved until 53.5 months postoperatively despite good compliance with oral anticoagulation and INR monitoring. In the second patient, the target INR was achieved after 16.9 months of oral anticoagulation treatment and regular INR monitoring. No thromboembolism occurred in either patient; nor did any valve-related event occur. The two patients are in excellent physical health 8 and 5 years, respectively, after the procedure. This unusual phenomenon is reviewed in light of the few reported cases of patients with mechanical heart valves surviving for prolonged periods without anticoagulation.