Reproductive health among women of child-bearing age after surgery for Rheumatic Heart Disease in Rwanda.

OBJECTIVE: To determine maternal and fetal outcomes in postoperative women with RHD who become pregnant after valve surgery and evaluate current anticoagulation management during pregnancy. METHODS: Data from the Rwandan RHD cardiac surgical registry identified all female patients who underwent valve surgery before or during childbearing age since 2006. 136 participants completed a mixed-methods questionnaire detailing each pregnancy after surgery, including anticoagulation regimen and outcomes. RESULTS: 38.2% (n=136) of patients reported at least one pregnancy after surgery, of which more than half were unintentional (53.9%, n=52). Among those with mechanical valves, most remained on warfarin alone during pregnancy (58.5%, n=53) while one third were switched to low molecular weight heparin during the first, second, or third trimesters (5 vs. 4 vs. 7, n=18). Women with bioprosthetic valve replacement or valve repair were more likely to experience live term births (84.6% vs 45.3%, p<0.01) and less likely to report spontaneous abortion (3.9% vs 30.2%, p<0.01) compared to women with mechanical valve replacement. Excessive bleeding was the most common complication during pregnancy (9.1%, n=79), and two infants were diagnosed with congenital defects associated with warfarin embryopathy (4.8%, n=42). CONCLUSIONS: Despite preoperative counseling discouraging conception, many women with prosthetic valves still become pregnant after surgery. The results of this study will inform evidence-based and context-specific practices for anticoagulation during pregnancy in Rwanda and the region.

A Global Systematic Review of Open Heart Valvular Surgery in Resource-Limited Settings.

BACKGROUND: Many obstacles challenge the establishment and expansion of cardiac surgery in low- and middle-income countries, despite the unmet cardiac surgical needs. One challenge has been providing adequate follow-up care to monitor anticoagulation, manage morbidity, and prevent mortality. This systematic review describes outcomes after valvular cardiac surgery and focuses on strategies for prolonged follow-up care in resource-constrained settings. METHODS: Studies published between 2012 and 2022 were collected from Embase and the Cochrane Library. Article inclusion criteria were adolescent and adult patients, open heart valvular surgery, and analysis of at least 1 postoperative outcome at least 30 days postoperatively. Studies that focused on pediatric patients, pregnant patients, transcatheter procedures, in-hospital outcomes, and nonvalvular surgical procedures were excluded. Descriptive statistics were assessed, and articles were summarized after abstract screening, full-text review, and data extraction. RESULTS: Sixty-seven relevant publications were identified after screening. The most commonly studied regions were Asia (46%), Africa (36%), and Latin America (9%). Rheumatic heart disease was the most commonly studied valvular disease (70%). Reported outcomes included mortality, surgical reintervention, and thrombotic events. Follow-up duration ranged from 30 days to 144 months; 11 studies reported a follow-up length of 12 months. CONCLUSIONS: Addressing the unmet cardiac care needs requires a multifaceted approach that leverages telemedicine technology, enhances medical infrastructure, and aligns advocacy efforts. Learning from the cost-effective establishment of cardiac surgery in low- and middle-income countries, we can apply past innovations to foster sustainable cardiac surgical capacity.

Community-Based Participatory Research to Improve Cardiovascular Health Among US Racial and Ethnic Minority Groups.

Purpose of Review: This review aims to assess the contemporary community-based participatory research (CBPR) literature seeking to improve the cardiovascular health of racial and ethnic minority groups in the USA with a higher burden of cardiovascular risk factors and social determinants of health. It summarizes recent CBPR studies based on the American Heart Association Life's Simple 7 (LS7) framework, delineating seven modifiable health behaviors and clinical factors to promote cardiovascular health. Recent Findings: Although limited in quantity, studies demonstrated preliminary effectiveness in improving individual and a composite of LS7 indicators by employing strategies centered around fortifying social networks, integrating group activities, leveraging technology, incorporating faith-based and spiritual practices, and implementing changes to the built environment. Summary: Future directions for investigators engaged in CBPR include building on the existing body of evidence through more comprehensive studies, scaling effective interventions, and translating CBPR findings to influence health policy to better address health disparities.

"Can you see my screen?" Addressing Racial and Ethnic Disparities in Telehealth.

PURPOSE OF REVIEW: Telehealth is an innovative approach with great potential to bridge the healthcare delivery gap, especially for underserved communities. While minority populations represent a target audience that could benefit significantly from this modern solution, little of the existing literature speaks to its acceptability, accessibility, and overall effectiveness in underserved populations. Here, we review the various challenges and achievements of contemporary telehealth and explore its impact on care delivery as an alternative or adjunct to traditional healthcare delivery systems. RECENT FINDINGS: Given the COVID-19 pandemic, there has been a rapid acceleration in telemedicine adoption. Recent studies of telemedicine utilization during the pandemic reveal stark disparities in telemedicine modality use based on race, socioeconomic status, geography, and age. SUMMARY: While telehealth has great potential to overcome healthcare obstacles, the digital divide stands as a challenge to equitable telehealth and telemedicine adoption. Achieving health equity in telehealth will require the mobilization of resources, financial incentives, and political will among hospital systems, insurance companies, and government officials.

Implementation of a virtual international cardiology curriculum to address the deficit of cardiovascular education in Haiti: a pilot study.

BACKGROUND: Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide, conferring a disparate burden on low-income and middle-income countries (LMICs). Haiti represents a resource-constrained setting, limited by a paucity of resources and trained cardiovascular professionals equipped to address the increasing burden of CVD. OBJECTIVE: Here, we describe the creation of a comprehensive cardiology curriculum delivered through a virtual classroom. The curriculum was created to augment cardiovascular education in LMICs such as Haiti. METHODS: Over one academic year (May 2019-2020), International Cardiology Curriculum Accessible by Remote Distance Learning-Haiti consisted of biweekly, live-streamed, synchronous didactic lectures, seminars and case presentations broadcasted to 16 internal medicine (IM) residents at Hôpital Universitaire de Mirebalais, one of only four IM training programmes in Haiti. The virtual classroom was created using commercially available videoconferencing and data-sharing platforms. Prelecture and postlecture surveys and an end of the year survey were administered to assess the impact of the curriculum. RESULTS: Participant performance analysis revealed that 80% of the curriculum demonstrated a positive trend in knowledge acquisition postintervention. Based on the end of the year evaluation, 94% of participants reported that the curriculum was educational and relevant to medical practice in Haiti and 100% reported that the curriculum was good to excellent. Additionally, the curriculum was cited as an effective means of maintaining trainee education during the COVID-19 pandemic. CONCLUSION: This international medical education pilot study demonstrates the feasibility of augmenting cardiology education in LMICs by creating a virtual curriculum made possible by local partnerships, internet access and technology.

Cardiac Surgery in Low- and Middle-Income Countries: A State-of-the-Art Review.

BACKGROUND: Six billion people in low- and middle-income countries (LMICs) lack timely or ready access to safe and affordable cardiac surgical care when needed, which remains a low priority on the global public health and global surgery agenda. Here, we report the results of a state-of-the-art review of cardiac surgical care in LMICs to highlight the important milestones and current progress as well as the challenges associated with the expansion of sustainable global cardiac surgery for those in need. METHODS: A literature review was performed searching the PubMed/MEDLINE and Google Scholar databases using a combination of cardiac surgery, global health, and LMIC keywords. The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of disease related to cardiovascular surgical diseases. RESULTS: High-income countries are estimated to have more than 100 times as many cardiac surgeons per million population compared with low-income countries. There are more than 4000 cardiac centers worldwide, but less than 1 center per 10 million population in LMICs. Approximately 1.5 million cardiac operations are performed globally, of which a disproportionally low number are in LMICs. Despite the high costs associated with cardiac operations, recent data suggest the favorable cost-effectiveness thereof in LMICs. Opportunities arise to sustainably integrate cardiac surgery in holistic health systems strengthening interventions. CONCLUSIONS: Skepticism underlying the need, feasibility, and cost-effectiveness of cardiac surgery in LMICs prevails, but recent advances, successful case studies, and existing data illustrate the potential of expanding cardiac care globally.

Postoperative Rheumatic Heart Disease Follow-Up: Creating a National Registry and First Results from Rwanda.

Background: In many developing countries, rheumatic heart disease (RHD) is diagnosed at an advanced stage and requires surgery for patient survival. However, access to cardiac surgery in this context is limited and often provided through partnerships, requiring centralized patient data systems for monitoring and follow-up. Objectives: This study used data from a national postoperative RHD registry to analyze clinical outcomes of Rwandan patients who received surgery between 2006 and 2017. Methods: The RHD registry was created in 2017 using data compiled from Rwanda Ministry of Health and RHD surgery partners. We extracted pre- and post-operative data on patients who were alive and in care. We excluded patients who died or were lost to follow-up, as their data was not collected in the registry. We evaluated the association between demographic, surgical, and follow-up characteristics and most recent patient symptoms, categorized by New York Heart Association (NYHA) class. Findings: Among the 191 patients eligible for inclusion in this study, 107(56.0%) were female, 110(57.6%) were adults at the time of surgery (>15 years), and 128(67.4%) had surgery in Rwanda. Most patients (n = 166, 86.9%) were on penicillin prophylaxis. Of the patients with mechanical valves, 47(29.9%) had therapeutic International Normalized Ratio values. 90% of patients were asymptomatic (NYHA I) at the time of most recent visit. NYHA class was not significantly associated with any of the considered variables. The median length of follow-up for patients was four years (IQR: 2, 5 years). Conclusion: This study shows both the feasibility and challenges of creating a RHD registry 11 years after the national initiation of RHD surgeries. Most patients captured in the registry are asymptomatic; however, collecting details on patients who had died or were lost to follow-up has proven difficult. Implementing strategies to maintain a complete and up-to-date registry will facilitate follow-up for pre- and postoperative patients.

Cardiac Surgery: Increasing Access in Low- and Middle-Income Countries.

PURPOSE OF THE REVIEW: Low- and middle-income countries (LMICs) have long-battled communicable diseases, and now, a rise in non-communicable diseases (NCD) is conferring tremendous burden in these areas. Cardiovascular disease (CVD) remains the number one cause of death among NCDs across the globe. The current review provides insight regarding this disease burden and highlights challenges as well as strategies for establishing functional cardiac surgery centers and sustainable access to comprehensive cardiovascular care within LMICs. RECENT FINDINGS: Without effective prevention and treatment strategies, estimates suggest that deaths from CVDs will reach 24 million by the year 2030. Surgery exists as a limited option for selected patients with advanced cardiac disease in LMICs in comparison with its availability in developed countries. Multi-lateral or public-private initiatives, government investment, philanthropic efforts, innovative financing systems to strengthen Universal Health Coverage, and expansion of training options through centers of excellence appear to be the way forward to broadening the availability of cardiovascular services, inclusive of surgery, to LMICs.

Global cardiovascular care: an overview of high-level political commitment.

BACKGROUND: Six billion people worldwide lack access to safe, timely, and affordable cardiac surgical and interventional care when needed. Cardiovascular diseases are the leading cause of mortality and morbidity around the world, and include a significant surgical backlog of rheumatic and congenital heart diseases. Here, we review the political commitment by the WHO, the UN, and the World Bank to build and strengthen healthcare services for cardiovascular diseases, with a particular focus on cardiac surgical and interventional cardiology services around the world. METHODS: A literature search was performed in the WHO, UN, and World Bank Governing Body databases to identify policy documents mentioning curative cardiovascular disease care. The Governing Body documentation, the Institutional Repository for Information Sharing database of the WHO, and the Official Document System of the UN were used. Documents only discussing prevention of cardiovascular diseases were excluded. RESULTS: Fifty-nine unique documents were identified, including 56 from the WHO, 3 from the World Bank, and none from the UN; 12 (20.4%) documents mentioned cardiac surgery, and 6 (10.2%) contained some actionable language to incorporate cardiac surgical services, but none was explicitly dedicated to cardiac surgical services. CONCLUSION: Although growing, high-level political commitment for curative cardiovascular health services remains minimal. Increased awareness is needed to develop comprehensive cardiovascular care that is necessary to mitigate the increasing burden of premature morbidity and mortality from cardiac disease, and to work towards the Sustainable Development Goals and Universal Health Coverage.

Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: Building a platform for ultimate sustainability in a resource-limited setting.

OBJECTIVE: Despite its near complete eradication in resource-rich countries, rheumatic heart disease remains the most common acquired cardiovascular disease in sub-Saharan Africa. With a ratio of physicians/population of 1 per 10,500, including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource-limited setting lacking the local capacity to detect and treat early cases of strep throat and perform lifesaving operations for advanced rheumatic heart disease. Humanitarian surgical outreach in this region can improve the delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer, and ultimately the creation of a cardiac center. METHODS: We describe the experience of consecutive annual visits to Rwanda since 2008 and report the outcomes of a collaborative approach to enable sustainable cardiac surgery in the region. The Ferrans and Powers Quality of Life Index tool's Cardiac Version (http://www.uic.edu/orgs/qli/) was administered to assess the postoperative quality of life. RESULTS: Ten visits have been completed, performing 149 open procedures, including 200 valve implantations, New York Heart Association class III or IV, with 4.7% 30-day mortality. All procedures were performed with the participation of local Rwandan personnel, expatriate physicians, nurses, residents, and support staff. Early complications included cerebrovascular accident (n = 4), hemorrhage requiring reoperation (n = 6), and death (n = 7). Quality of life was assessed to further understand challenges encountered after cardiac surgery in this resource-limited setting. Four major domains were considered: health and functioning, social and economic, psychologic/spiritual, and family. The mean total quality of life index was 20.79 ± 4.07 on a scale from 0 to 30, for which higher scores indicated higher quality of life. Women had significantly lower "social and economic" subscores (16.81 ± 4.17) than men (18.64 ± 4.10) (P < .05). Patients who reported receiving their follow-up care in rural health centers also had significantly lower "social and economic" subscores (15.67 ± 3.81) when compared with those receiving follow-up care in urban health facilities (18.28 ± 4.16) (P < .005). Value afforded to family and psychologic factors remained high among all groups. Major postsurgical challenges faced included barriers to follow-up and systemic anticoagulation. CONCLUSIONS: This report represents the first account of a long-term humanitarian effort to develop sustainability in cardiac surgery in a resource-limited setting, Rwanda. With the use of volunteer teams to deliver care, transfer knowledge, and mentor local personnel, the results demonstrate superior outcomes and favorable indices of quality of life. The credibility gained over a decade of effort has created the opportunity for a partnership with Rwanda to establish a dedicated center of cardiac care to assist in mitigating the burden of cardiovascular disease throughout sub-Saharan Africa.