Valvulopathies in sub-Saharan African children: patterns, humanitarian interventions and cardiac surgical problems.

Despite the high burden of rheumatic fever in sub-Saharan African, there is currently no sustained and comprehensive strategy to control the disease. Consequently in this area the number of patients affected by rheumatic valve disease (RVD), most with a surgical indication, is 10-20 fold higher than in industrialised countries and estimates indicate that more than 50% of African RVD patients will die before age 25. In this paper, we review clinical and management issues of RVD in children in sub-Saharan Africa. Severe heart failure and undergrowth are the prevalent presentation of the illness. Severe mitral regurgitation is the commonest rheumatic valvulopathy observed in the first and second decades. Valve repair, the approach of choice, may be associated with unfavourable outcomes in patients with extreme cardiomegaly. In young people, whenever correct anticoagulation may reasonably be achieved, mechanical mitral prostheses should be preferred, even in females. The early deterioration of biologic mitral prostheses strongly suggests limiting their use to those cases in which correct anticoagulation is not feasible. In most sub-Saharan countries, socioeconomic factors strongly limit access to health services and to cardiac surgery in particular. Efforts to overcome these barriers have resulted in humanitarian projects along two patterns: creation of high tech on site health care structures or transfer of children with complex diseases to receive highly specialised cardiac surgical care abroad. We summarise the experience of our programme that followed the latter approach.

Cardiac deatH prevention by aUtomated defibrillatoRs in ChurcHes: rationale and design of the CHURCH trial.

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA). We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session. The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks. The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period. The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

[The project "Don Carlo Gnocchi Foundation--Cardio-Thoracic Department De Gasperis--Lombardy Region" for the care of children from socio-economically deprived areas affected by cardiac disease]. / II progetto "Fondazione Don Carlo Gnocchi--Dipartimento Cardiochirurgico De Gasperis--Regione Lombardia" per la cura di bambini cardiopatici provenienti da paesi esteri a basso livello assistenziale.

BACKGROUND: In 2001 the Cardiac Rehabilitation Unit IRCCS S. Maria Nascente Center and the International Area of Don Carlo Gnocchi Foundation, in collaboration with the Cardiac Surgery Department "De Gasperis" of Niguarda Ca' Granda Hospital in Milan, planned a project to treat children from impoverished countries. The "Fondo Sanitario Regionale" of the Lombard Region cosponsored the program. METHODS: From October 2001 to November 2006, 32 patients (25 from Zimbabwe and 7 from Albania) were selected and submitted to cardiac surgery: 22 patients were affected by acquired valvular heart disease in NYHA class III-IV, 10 by congenital heart disease. After surgery the patients admitted to our rehabilitation unit underwent a period of comprehensive cardiac rehabilitation. Afterwards, the patients were in the care of selected Italian families for about 3 months. In both populations the problems faced in the selection, management and surgical approach are discussed. RESULTS: At 21 months the survival of the whole study population was 93 % (2 valvular patients died during the follow-up); 2 patients who initially underwent mitral valve repair were submitted to valve replacement for late appearance of severe regurgitation. In 3 patients with mitral valve bioprosthesis a significant structural valve deterioration occurred in the follow-up and 2 of them underwent valve replacement. CONCLUSIONS: The advantage of the excellent performance in durability of mechanical prosthetic valves (with respect to the limited durability of porcine bioprostheses), the problems with long-term anticoagulation have to be taken into consideration in the management of patients coming from socio-economically deprived areas.

Work-rate affects cardiopulmonary exercise test results in heart failure.

AIMS: Cardiopulmonary exercise test (CPET) is used to evaluate patients with chronic heart failure (HF) usually by means of a personalized ramp exercise protocol. Our aim was to evaluate if exercise duration or ramp rate influences the results. METHODS AND RESULTS: Ninety HF patients were studied (peak V (O(2)): >20 ml/min/kg, n=28, 15-20 ml/min/kg, n=39 and <15 ml/min/kg, n=23). Each patient did four CPET studies. The initial study was used to separate the subjects into three groups, according to their exercise capacity. In the remaining studies, work-rate was increased at three different rates designed to have the subjects reach peak exercise in 5, 10 and 15 min from the start of the ramp increase in work-rate, respectively. The order was randomized. The work-rate applied for the total population averaged 22.7+/-8.0, 11.6+/-3.7, 7.5+/-2.9 W/min with effective loaded exercise duration of 5 min and 16 s+/-29 s, 9 min and 43 s+/-49 s and 14 min and 32 s+/-1 min and 12 s for the 5-, 10- and 15-min tests, respectively. Peak V (O(2)) averaged 16.9+/-4.3*, 18.0+/-4.4 and 18.0+/-5.4 ml/min/kg for the 5-, 10- and 15-min tests, (*=p<0.001 vs. 10 min). The shortest test had the lowest peak heart rate and ventilation and highest peak work-rate. Peak V (O(2)) and heart rate were lowest in 5-min tests regardless of HF severity. The DeltaV (O(2))/Deltawork-rate was lowest in 5-min tests and highest in 15-min tests. At all ramp rates, DeltaV (O(2))/Deltawork-rate was lower for the subjects with the lower peak V (O(2)). The V (e)/V (CO(2)) slope and V (O(2)) at anaerobic threshold were not affected by the protocol for any grade of HF. CONCLUSIONS: In chronic HF, exercise protocol has a small effect on peak V (O(2)) and DeltaV (O(2))/Deltawork but does not affect V (O(2)) at anaerobic threshold and V (e)/V (CO(2)) slope.