Early myocardial injury in children on doxorubicin for cancer chemotherapy: a cross-sectional study in a tertiary referral centre in Kenya.

INTRODUCTION: Use of doxorubicin, an anthracycline chemotherapeutic agent has been associated with late-occurring cardiac toxicities. Detection of early-occurring cardiac effects of cancer chemotherapy is essential to prevent occurrence of adverse events including toxicity, myocardial dysfunction, and death. OBJECTIVE: To investigate the prevalence of elevated cardiac troponin T (cTnT) and associated factors of myocardial injury in children on doxorubicin cancer chemotherapy. METHODS: Design: A cross-sectional study. SETTING AND SUBJECTS: A hospital-based study conducted on children aged 1-month to 12.4-years who had a diagnosis of cancer and were admitted at Kenyatta National Hospital (KNH). INTERVENTIONS AND OUTCOMES: The patients underwent Echocardiography (ECHO) before their scheduled chemotherapy infusion. Twenty-four (24) hours after the chemotherapy infusion the patients had an evaluation of the serum cardiac troponin T (cTnT) and a repeat ECHO. Myocardial injury was defined as cTnT level > 0.014 ng/ml or a Fractional Shortening (FS) of < 29% on ECHO. RESULTS: One hundred (100) children were included in the final analysis. Thirty-two percent (32%) of the study population had an elevated cTnT. A cumulative doxorubicin dose of > 175 mg/m2 was significantly associated with and elevated cTnT (OR, 10.76; 95% CI, 1.18-97.92; p = 0.035). Diagnosis of nephroblastoma was also associated with an elevated cTnT (OR, 3.0; 95% CI, 1.23-7.26) but not statistically significant (p = 0.105). Nine percent (9%) of the participants had echocardiographic evidence of myocardial injury. CONCLUSION: When compared to echocardiography, elevated levels of cTnT showed a higher association with early-occurring chemotherapy-induced myocardial injury among children on cancer treatment at a tertiary teaching and referral hospital in Kenya.

Evaluation of a portable assembly catheter simulator using a 3D-printed heart model for percutaneous transvenous mitral commissurotomy in developing countries: Catheter simulator for PTMC.

AIMS: We developed a catheter simulator for percutaneous transvenous mitral commissurotomy (PTMC) based on the data from a patient with mitral valve stenosis. The simulator has the following characteristics: 1) the simulator is portable and easy to assemble and disassemble, 2) the cardiac portion is created using a 3D-printer, based on patient computed tomography data, 3) the simulator uses a foot-operated water pump to create pulsatile flow, and 4) the fossa ovalis in the atrial septum of the heart model is made of a thin polyurethane membrane and is interchangeable. We aimed to assess the effectiveness of this novel simulator for training in PTMC using the Inoue balloon in developing countries. METHODS AND RESULTS: We used this simulator for training in the National Institute of Cardiovascular Diseases in Bangladesh (13 physicians), and in Kenyatta National Hospital in Kenya (11 physicians). The effectiveness of training was evaluated by questionnaire and the procedure time in simulation. The questionnaire obtained from the trainees showed that the model scored 4.7±0.5 for realism, utility of pulsatile flow scored 4.7±0.5, simulator utility scored 4.9±0.3, and the effect of training on PTMC performance scored 4.9±0.5. The procedure time in simulation was shortened from 30.0±12.6 min (first time), to 23.4±11.9 min (second time) and to 20.4 ± 11.1 min (third time) (p<0.01). CONCLUSIONS: The novel portable assembly catheter simulator using a 3D-printed heart model for PTMC received positive comments and improved the skills of trainees.

Transcatheter embolization of a large aneurysm in a congenital coronary cameral fistula from the left coronary artery to the right ventricle.

A congenital coronary cameral fistula (CCCF) is characterized by left ventricular dysfunction, electrocardiographic changes due to a reduced left coronary blood flow and impaired physical activity. CCCF's with a giant aneurysm are very rarely seen. The presence of a giant aneurysm imposes even greater health risks. We report a case of a CCCF from the left coronary artery to the right ventricle with a large distal aneurysm in a 20-year-old woman that we closed percutaneously with coils for the closure of ventricular septal defects (VSD) and persistent ductus arteriosus (PDA).

Prevalence and associated factors of pulmonary hypertension in Kenyan children with adenoid or adenotonsillar hypertrophy.

OBJECTIVES: Adenotonsillar hypertrophy is a common condition in childhood, whose serious complications of pulmonary hypertension and cor pulmonale are devastating but local prevalence is unknown. This study determined the prevalence and associated factors of pulmonary hypertension in children with adenoid or adenotonsillar hypertrophy at Kenyatta National Hospital, Kenya. METHODS: This was a cross sectional hospital based survey conducted among children below 12 years of age with clinical and radiological adenoid hypertrophy attending the ear, nose and throat (ENT) outpatient clinic and general pediatric wards. Doppler echocardiography was used to determine pulmonary hypertension defined as a mean pulmonary arterial pressure (mPAP) of ≥ 25 mm Hg using the Chemla equation. Children with mPAP of ≥ 25 mm Hg were compared to those with lower pressures and clinical and radiological factors associated with pulmonary hypertension determined using multivariate logistic regression analysis. RESULTS: Of the 123 eligible children in the study, 27 had pulmonary hypertension giving a prevalence of 21.9% (95% CI 14.64%-29.27%). Independent factors associated with pulmonary hypertension included nasal obstruction (OR=3.0 [95% CI 1.08-8.44] p=0.035) and hyperactivity on history (OR=0.2 [95% CI 0.07-0.59] p=0.003) and adenoid-nasopharyngeal ratio (ANR) >0.825 on lateral neck radiography (OR=5.0 [95% CI 1.01-24.37] p=0.048). CONCLUSION: One in five children with adenoid or adenotonsillar hypertrophy had pulmonary hypertension with a 3-fold and 5-fold increased odds in those with nasal obstruction on history and ANR >0.825 on lateral neck radiography respectively and an 80% reduced odds in reportedly hyperactive children.

Cardiac surgery capacity in sub-saharan Africa: quo vadis?

BACKGROUND: Current data on cardiac surgery capacity on which to base effective concepts for developing sustainable cardiac surgical programs in Africa are lacking or of low quality. METHODS: A questionnaire concerning cardiac surgery in Africa was sent to 29 colleagues-26 cardiac surgeons and 3 cardiologists in 16 countries. Further, data on numbers of surgeons practicing in Africa were retrieved from the Cardiothoracic Surgery Network (CTSNet). RESULTS: There were 25 respondents, yielding a response rate of 86.2%. Three models emerged: the Ghanaian/German model with a senior local consultant surgeon (Model 1); surgeons visiting for a short period to perform humanitarian surgery (Model 2); and expatriate surgeons on contract to develop cardiac programs (Model 3). The 933 cardiothoracic surgeons listed by CTSNet translated into one surgeon per 1.3 million people. In North Africa, the figure was three surgeons per 1 million and in sub-Saharan Africa (SSA), one surgeon per 3.3 million people. The identified 156 cardiac surgeons represented a surgeon to population ratio of 1:5.9 million people. In SSA, the ratio was one surgeon per 14.3 million. In North Africa, it was one surgeon per 1.1 million people. Open heart operations were approximately 12 per million in Africa, 2 per million in SSA, and 92 per million people in North Africa. CONCLUSION: Cardiothoracic health care delivery would worsen in SSA without the support of humanitarian surgery. Although all three models have potential for success, the Ghanaian/German model has proved to be successful in the long term and could inspire health care policy makers and senior colleagues planning to establish cardiac programs in Africa.

African experiences of humanitarian cardiovascular medicine: a Kenyan perspective.

The burden of cardiovascular diseases (CVD) is on the rise in Kenya; this is in tandem with that of other non-communicable diseases. Most cardiovascular services are available in the main cities (Nairobi and Mombasa), but almost non-existent in rural and other urban centers. In an attempt to bridge this gap on service delivery, humanitarian activities have been developed over the years by various interested parties. Three models of humanitarian activities are described. The first model (hereby referred to as Model 1) is a school-based rheumatic fever and rheumatic heart disease (RF/RHD) prevention outreach program which offers diagnostic, preventive, educational and curative services to primary and secondary school children in various parts of the country. The second model (hereby referred to as Model 2) is a hospital-based cardiovascular outreach program located in Kericho, a highland tea growing region that has long been perceived as a "hot spot" for CVD. The third model (hereby referred to as Model 3) is a fixed clinic-based cardiovascular outreach in Kisumu, the lake shore town, about 400 kilometers west of Nairobi. THESE PROGRAMS PROVIDE: prevention services, early detection and prophylaxis, facilitation for further treatment, follow-up, early disease management, staff motivation, training in basic cardiology skills and increased local awareness of CVD to clinicians in there far-flung centers. Data from these programs is also presented, with two of the programs reporting Kericho County as a 'hot spot' in RF/RHD. Despite various challenges, the future is still bright with sustainable initiatives.