Audit of Paediatric Cardiac Services in South Africa

objective: to evaluate paediatric cardiac services in south Africa with respect to referral base; services provided and human resources. study design: A descriptive study design was used. An audit of the referral base; personnel and activity of paediatric cardiac units throughout south Africa was conducted by means of a questionnaire. A specialist from each centre was asked to provide the relevant data. Where accurate data was not available; estimates were provided by practitioners within each centre. results: All identified units participated in the audit. three were private sector units while the other five were primarily public sector units. twenty four paediatric cardiologists; equally distributed between public and private sector units; were practicing in the country as at end 2008; with a further eight paediatricians undergoing training in paediatric cardiology. this is significantly less than the 88 paediatric cardiologists required for the population of south Africa. Eight paediatric cardiac surgeons were operating predominantly on children in public hospitals and five in private institutions. An estimated 1370 operations for congenital heart disease were performed over a one year period; with 800 of these in the public sector. Extrapolating from accepted estimates of congenital heart disease incidence; this represents conservatively; less that 40of operations required for the population. Additionally; only 26of the estimated 114 simple transposition of great arteries born annually were operated on; indicating serious deficiencies in the ability to adequately detect and intervene in serious congenital heart disease presenting in the neonatal period. conclusion: the infrastructure and resources to detect and manage heart disease in children in south Africa; particularly within the public sector; are grossly inadequate

Optimal Paediatric Cardiac Services in South Africa - What do we Need? Statement of the Paediatric Cardiac Society of South Africa

Most children with congenital heart disease have a good outcome if treated appropriately; however the majority of children with heart disease in south Africa do not receive appropriate care. this is related to serious deficiencies in as a major shortage of skilled personnel to care for these children at all levels .Most public sector hospitals are unable to cope with the number of patients requiring surgery; mainly due to inadequate theatre time allocation and intensive care facilities. Key interventions to address these deficiencies include: 1. strategies to improve both the training and the retention of all professionals involved in the care of congenital heart disease. 2. Programmes to increase awareness of both congenital and acquired heart disease in children among health care personnel. 3. Ensuring appropriate infrastructure and equipment designed for children with congenital heart disease are available. 4. Development of congenital heart surgery as an independent subspecialty with dedicated resources and personnel. 5. Dedicated intensive care facilities for paediatric heart surgery. In addition; development of appropriate patterns of referral; timulation of research and positive private-public partnerships are all necessary to ensure that appropriate care is delivered

The switch to balloon atrial septostomy with echocardiographic guidance--a severe complication.

To warn about a severe complication of balloon atrial septostomy (BAS) guided by echocardiography, a retrospective review was undertaken of all BASs performed at Red Cross War Memorial Children's Hospital in Cape Town from 1984 to the end of 1992. BAS with fluoroscopy was carried out in 41 infants (group I). Since April 1991, 17 infants had BAS with two-dimensional echocardiography guidance in the intensive care unit (group II). The majority of patients (72%) had simple transposition of the great arteries. Only 3 patients in group I were catheterised via the umbilical vein (the remaining 38 via the femoral vein). In group II, 12 patients (71%) were catheterised via the umbilicus. The only fatality as a result of the procedure occurred in group II. This was the result of rupture of the splenic vein. The patient was catheterised via the umbilical vein, and echocardiography was not adequately used to guide the catheter below the diaphragm. There were no other severe complications in either group. Although echocardiographically guided BAS is easier, quicker, potentially safer and keeps the baby in a better homeostatic environment, we describe a severe complication of this procedure in the learning phase that has not been noted previously.

Tuberculous pericarditis in children: a review of 44 cases.

This retrospective study reports experience in 44 children with pericardial tuberculosis seen during a 6-year period, 1986 to 1991. Thirty-seven children presented with pericardial effusion (PE), 4 with constrictive pericarditis and 3 with effusive constrictive disease. Features of cardiac tamponade were present in 90%, and in 91% radiologic cardiomegaly was found. A two-dimensional echocardiogram is diagnostic for PE. Culture and biopsy yields for Mycobacterium tuberculosis were low (18%). The Mantoux test was positive (> 10 mm) in 75%. In 14 patients doubt about etiology necessitated treatment for possible pyogenic infection with anterior pericardiotomy as opposed to diagnostic pericardiocentesis with catheter drainage. Twelve cases with PE were treated with steroids and the other 25 received only anti-tuberculous medication. Five cases of PE developed constrictive pericarditis during treatment of whom none received steroids. No statistically significant differences were demonstrated between the two groups. Only 5 of the 12 cases with constrictive pericarditis required pericardiectomy. There were no deaths and recovery has been complete in 43 cases. This study shows that tuberculous pericardial disease is common in areas with a high prevalence of tuberculosis. Prognosis is excellent for a condition in which morbidity and mortality have previously been high.

Paediatric heart transplants--should we do them?

Heart transplantation continues to evoke considerable controversy. While they are performed in adults, in South Africa children are at present denied this therapeutic option despite a very encouraging global/average 5-year survival rate of 62%. Objections to transplantation are usually based on moral and economic imperatives. These arguments will be analysed and we will present the case for the introduction of a transplant programme designed to benefit children with incurable heart disease.

Infective endocarditis in South African children.

The clinical and laboratory findings in 29 children with infective endocarditis over the past 10 years are reviewed retrospectively. Twenty children (70 per cent) had congenital heart disease, five (16 per cent) had rheumatic heart disease, and four (14 per cent) had no underlying cardiac abnormality prior to presentation. Twelve (41 per cent) patients had undergone cardiac surgery prior to developing endocarditis. The most common causative organisms were Staphylococcus aureus, Staphylococcus epidermidis, and viridans streptococci none of which was associated with a significantly greater mortality. There was a high case fatality rate of 35 per cent of children below the age of 6 months and children without an underlying cardiac abnormality were particularly at risk. There is a need for standardization of diagnostic criteria for infective endocarditis to facilitate accurate collaborative epidemiological investigation.

Nutrition status of pre-school children in a Cape Town township.

An anthropometric study evaluated the nutritional state of pre-school children in the Site C squatter area of Khayelitsha township in Cape Town. A cluster sampling method was used and the weight for age, height for age, weight for height and mid-upper arm circumference of 872 children between the ages of 1 and 5 years were recorded. The National Centers for Health Statistics percentile charts were used as a reference standard. There was a low level of acute malnutrition with 13.7% of children below the 3rd percentile for weight for age. Acute severe malnutrition was not a problem with only 1.0% below the 3rd percentile weight for height. The figure of 47.2% below the 3rd percentile for height for age indicates high levels of chronic malnutrition. Only 42.2% of children had a 'Road to Health' card. The need for further research, nutritional surveillance and health care intervention is highlighted.