Surgical Treatment of Valvular Heart Disease in Nigeria: A 6-Year Experience.

Surgical treatment of valvular heart disease in Nigeria, the most populous country in sub-Saharan Africa, is adversely affected by socioeconomic factors such as poverty and ignorance. To evaluate our experience in this context, we identified all patients who underwent surgery for acquired or congenital valvular heart disease at our Nigerian center from February 2013 through January 2019. We collected data from their medical records, including patient age and sex, pathophysiologic causes and types of valvular disease, surgical treatment, and outcomes. Ninety-three patients (43 males [46.2%]; mean age, 38.9 ± 10.0 yr [range, 11-80 yr]) underwent surgical treatment of a total of 122 diseased valves, including 72 (59.0%) mitral, 26 (21.3%) aortic, 21 (17.2%) tricuspid, and 3 (2.5%) pulmonary. The most prevalent pathophysiologic cause of disease was rheumatic (87 valves [71.3%]), followed by functional (20 [16.4%]), congenital (8 [6.6%]), degenerative (5 [4.1%]), and endocarditic (2 [1.6%]). All 3 diseased pulmonary valves had annular defects associated with congenital disease. Surgical treatment included mechanical prosthetic replacement of 92 valves (75.4%), surgical repair of 29 (23.8%), and bioprosthetic replacement of 1 (0.8%). We conclude that, in Nigeria, valvular disease is mainly rheumatic, affects mostly younger to middle-aged individuals, and is usually treated with prosthetic replacement.

Post-operative fever (POF) after cardiac surgery in a low- and middle-income-country: 7-year institutional experience.

BACKGROUND: Post-operative fever (POF) after cardiac surgery in a developing country is of great concern because of the associated morbidity and mortality. In our country, we experience this complication more because of a high rate of malaria infestations, gastroenteritis, and malnutrition. We also experience a low yield of positive diagnostic tests when POF develops; this is partly due to expense and the prioritisation of other essential items in our poorly equipped cardiac ICU. AIMS/OBJECTIVE: To assess the causes of POF after cardiac surgery and determine its impact on the outcome on patients. MATERIALS AND METHODS: International Cardiac Surgery Mission teams visited our centre for 7 years (2013-2019). During this period, a significant number of cardiac surgeries were performed. A retrospective study of patients with POF was performed with data from our hospital's database, and included standard demographics; types of surgery performed, and management protocols being used in the peri-operative care. RESULTS: A total of 242 patients were treated during the study period and underwent 266 surgeries. Of these, 151 (56.8%) and 115 (43.2%) were adult and paediatric cases respectively. Ages ranged between 0 and 90 years; 34 (14.1%) had POF. When we evaluated the clinical and associated laboratory findings, pyrexia (temp >38.0 °C) and elevated white blood cell count with differential neutrophilia were present in 10 patients (29.4%). The time of onset and duration of POF were between <24 and >144 hours. In the invasive procedure related to POF, sternotomy infections were present in seven patients (18.4%). Malaria infestations and breach in sterility protocol were predominant. CONCLUSION: The management of POF in the cardiac ICU was complicated by the requirement of co-operation from a larger number of specialties than is usually required in advanced centres with special expertise in malaria confirmation. We, therefore, introduced structured clinical, laboratory, and appropriate interventions to treat POF more aggressively. We found that more careful attention to peri-operative details to ensure strict observation of sterility protocol with anti-malaria prophylaxis led to improvements in our centre's outcomes.

Establishing an indigenous cardiac anaesthesia service in Enugu: report of two cases of Atrial Septal Defect (ASD) closure

Background: Open heart surgery program require enormous resources and commitment to establish. In low and middle income countries like Nigeria it is quite a difficult task. The surgery requires highly sophisticated equipment and specially trained professional teams. The training is done abroad and requires long term planning. Case report: We report two cases of two patients, aged 20 and 30-years diagnosed with Atrial Septal Defect (ASD) scheduled for surgical closure under general anaesthesia and cardiopulmonary bypass carried out by a completely indigenous team. The anaesthetic management and the strategy necessary for developing a sustainable open heart program are discussed

Establishing a sustainable open heart surgery programme in Nigeria, a low-income country: which is the best model?

BACKGROUND: In any country, the development of open heart surgery programme parallels stable political climate, economic growth, good leadership, and prudent fiscal management. This is lacking in a country like Nigeria without a functional cardiac hospital. OBJECTIVE: To review and compare the various models being adopted towards establishing a sustainable open heart surgery programme in Nigeria. MATERIALS AND METHODS: For ethnic and cultural reasons, Nigeria is divided into six geopolitical regions. Each region has one or more Federal Teaching Hospitals including medical centres. The hospitals have trained cardiothoracic surgeons and cardiologists as well as other auxiliary staff. After attainment of democratic rule in 1999, individual hospitals have devised various models to establish sustainable open heart surgery programme. The number of hospitals in each region, the models devised, and the limitations including the outcome were studied and analysed. RESULTS: Each geopolitical zone has about three to four centres, either public or private, trying to establish the programme. There are six different models. Each centre has been trying the different models since the year 2000. The oldest of the model is cardiac mission and the newest is employment of highly skilled retired expatriate consultant cardiac surgeon to help develop the local team. Inadequate funds, lack of governmental support, and brain drain syndrome have largely affected the programme.

Surgical management of CHD in the adult population: the role of humanitarian cardiac surgery mission in Nigeria.

BACKGROUND: The clinical effects of CHD can occur during the neonatal period, childhood, adolescent, and even adulthood. Some CHD in the adult population have indications for surgical management. OBJECTIVE: The objective of this study was to review the role of humanitarian cardiac surgery missions in the surgical management of CHD in the adult population in a developing country.Materials and methodOver a 5.5-year period - June, 2003, February, 2013-October, 2017 - five different humanitarian cardiac surgery teams visited National Cardiothoracic Center of Excellence, Nigeria. During the period, they operated on adults with CHD. A retrospective study of the patients treated was performed using data obtained from our Hospital Information Technology Department. The demography of the patients, types of CHD, operative modalities, as well as the outcome was analysed using Microsoft Excel. The results were presented in arithmetic of percentages using tables. RESULTS: During the period, a total of 18 CHD patients were treated.

Utilisation of blood and blood products during open heart surgery in a low-income country: our local experience in 3 years.

BACKGROUND: In Nigeria, access to open heart surgery (OHS) is adversely affected by insufficient blood and blood products, including the challenges because of the lack of patient-focused blood management strategies owing to the absent requisite point-of-care tests in the operating theatre (OR)/ICU. In addition, the limited availability of altruistic blood donors including the detection of transfusion transmitted infections more commonly among non-altruistic blood donors is another burden affecting the management of excessive bleeding during and after open heart surgery in our country. OBJECTIVE: The objective of this study was to review our local experience in the use of blood and blood products during open heart surgery and compare the same with the literature.Materials and methodsIn a period of 3 years (March, 2013-February, 2016), we performed a retrospective review of those who had open heart surgery in our institution. The data were obtained from our hospital health information technology department. The data comprised demography, types of operative procedures and units of blood and blood products transfused per procedure, including the details regarding the usage of the cell saver, as well as those who had severe bleeding requiring excessive blood transfusion. RESULTS: During the study period, 102 patients had open heart surgery, an average of 34 cases in a year. Among them, there were 75 (73.53%) males and 37 (36.27%) females, giving a ratio of 2:1. The ages of the patients were from 0.6 (7/12) to 74 years. Mitral valve procedure was the most common (n=22, 21.6%) surgery type. Transfusion requirements averaged 1.9 units of fresh frozen plasma, 0.36 units of platelet concentrate, and 1.68 units of packed cells per procedure. The least common surgical procedure was common atrium repair (n=1, 0.01%). CONCLUSION: Open heart procedure is a very complex procedure requiring cardiopulmonary bypass with associated severe perioperative bleeding. The attendant blood loss and haemostatic challenges are combated by intricate and selective transfusions of allogeneic blood and or blood products.

Management of complex CHD at the National Cardiothoracic Center of Excellence, University of Nigeria Teaching Hospital, Enugu: the role of foreign cardiac missions in 3.5 years.

BACKGROUND: CHD is defined as structural defect(s) in the heart and proximal blood vessels present at birth. The National Cardiothoracic Center of Excellence, University of Nigeria Teaching Hospital (UNTH), Enugu, through the aid of visiting Cardiac Missions has managed a significant number of patients within the last 3.5 years. Aim/Objective The objective of this study was to review surgical options and outcome of complex CHD among patients attending UNTH, Enugu, Enugu. Materials and Method During the period of 3.5 years (March, 2013 to June, 2016), a total of 20 cases of complex CHD were managed by cardiac missions that visited UNTH, Enugu. Their case notes and operating register were retrieved, reviewed, and analysed using SPSS version 19 (Chicago). RESULTS: There were eight females and 12 males, with a ratio of 2:5. The age range was from 5 months to 34 years with a mean of 1.7. Among all, five patients died giving a mortality rate of 25%. The operative procedures ranged from palliative shunts to complete repair. The outcome was relatively good. CONCLUSION: Complex CHD are present in our environment. Their surgical management in our centre is being made possible by periodic visits of foreign cardiac missions.

Colon interposition graft for corrosive esophageal stricture: midterm functional outcome.

BACKGROUND: Corrosive esophageal stricture is a major cause of morbidity among Nigerians. In most cases, this follows accidental or parasuicidal ingestion of caustic sodium hydroxide solution (NaOH) often used in the local production of soaps. Various treatment modalities have been advocated for the treatment of esophageal stricture. In this study, we review the results of our adopted technique in the past 10 years for pedicled colonic interposition. METHODS: This is a retrospective study of 21 patients who underwent substernal isoperistaltic pedicled colonic interposition graft for management of corrosive esophageal stricture. The right colon was pulled up into the neck in all the patients without resecting the strictured esophagus. RESULTS: Long segment strictures and multiple strictures were the main indications for the procedure. The mean duration of the procedure was 339.6 ± 71.1 min. The average intraoperative blood loss was 673.1 ± 398.1 mL. There were two (9.5 %) hospital mortalities. Graft infarction (9.5 %), cervical fistulae (19.0 %), and reflux neo-esophagitis (14.3 %) were the main non-fatal complications. In the mid-term, dysphagia was completely relieved in a little over 84 % (16/19) of patients, while one patient (4.8 %) still experienced reflux neo-esophagitis requiring treatment. There was no case of gross regurgitation or nocturnal aspiration in the mid-term. CONCLUSIONS: Although the use of pedicled colonic interposition graft offers a good mid-term functional outcome with relief of dysphagia, early postoperative morbidity is high. Graft infarction is the single most important factor for poor functional outcome and every effort must be made to prevent its occurrence.