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Archives of cardiovascular diseases
Volume 110, n° 2
pages 82-90 (février 2017)
Doi : 10.1016/j.acvd.2016.05.006
Received : 18 April 2016 ;  accepted : 23 May 2016
Cardiac surgery in low-income settings: 10 years of experience from two countries
Chirurgie cardiaque : dix ans d’expérience dans deux pays en voie de développement
 

Mariana Mirabel a, b, c, 1, , Matthias Lachaud d, e, 1, Lucile Offredo a, Cécile Lachaud d, Benjamin Zuschmidt a, Beatriz Ferreira d, Daniel Sidi b, d, f, g, Sylvain Chauvaud b, f, Phang Sok h, Alain Deloche b, f, Eloi Marijon a, b, c, Xavier Jouven a, b, c
a Inserm U970, Paris Cardiovascular Research Centre, European Georges-Pompidou Hospital, 56, rue Leblanc, 75737 Paris, France 
b Paris Descartes University, 75005 Paris, France 
c Cardiology Department, European Georges-Pompidou Hospital, 75015 Paris, France 
d Instituto do Coração (ICOR), 1100 Maputo, Mozambique 
e Institut du Thorax, 44093 Nantes cedex 1, France 
f Chaîne de l’Espoir, 75014 Paris, France 
g Paediatric Cardiology Department, Necker–Enfants-Malades Hospital, 75015 Paris, France 
h Centre de Cardiologie de Phnom Penh, Phnom Penh, Cambodia 

Corresponding author. Inserm U970, Paris Cardiovascular Research Centre, hôpital européen Georges-Pompidou, 56, rue Leblanc, 75737 Paris cedex 15, France.
Summary
Background

Access to cardiac surgery is limited in low-income settings, and data on patient outcomes are scarce.

Aims

To assess characteristics, surgical procedures and outcomes in patients undergoing open-heart surgery in low-income settings.

Methods

This was a cohort study (2001–2011) in two low-income countries, Cambodia and Mozambique, where cardiac surgery had been promoted by visiting non-governmental organizations.

Results

In Cambodia and Mozambique, respectively, 1332 and 767 consecutive patients were included; 547 (41.16%) and 385 (50.20%) were men; median age at first surgery was 11 years (interquartile range [IQR] 4–14) and 11 years (IQR 3–18); rheumatic heart disease affected 490 (36.79%) and 268 (34.94%) patients; congenital heart disease (CHD) affected 834 (62.61%) and 390 (50.85%) patients, with increasingly more CHD patients over time (P <0.001); and the number of patients lost to follow-up reached 741 (55.63%) and 112 (14.6%) at 30 days. A total of 249 (32.46%) patients were lost to follow-up in Mozambique, remoteness being the only influencing factor (P <0.001). Among patients with known vital status, the early (<30 days) postoperative mortality rate was 6.10% (n =40) in Mozambique and 3.05% (n =18) in Cambodia. Overall, 109 (8.18%) patients in Cambodia and 94 (12.26%) patients in Mozambique underwent re-do surgery. In Mozambique, a further 50/518 (9.65%) patients died at a median of 23months (IQR 7–43); in Cambodia, a further 34/591 (5.75%) patients died at a median of 11.5months (IQR 6–54.5).

Conclusions

Cardiac surgery is feasible in low-income countries with acceptable in-hospital mortality and proof of capacity building. Patient outcomes after cardiac surgery in low-income countries remain unknown, given the strikingly high numbers of lost to follow-up.

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Résumé
Contexte

L’accès à la chirurgie cardiaque est limité dans nombre de pays en voie de développement et le devenir des patients opérés a été peu décrit à ce jour.

Objectifs

Étudier les caractéristiques, les procédures entreprises et le devenir des patients ayant une chirurgie cardiaque dans des pays en voie de développement.

Méthodes

Étude de cohorte (2001–2011) dans deux centres au Cambodge et au Mozambique, où des programmes de chirurgie cardiaque ont été mis en place par des organisations non gouvernementales.

Résultats

Un total de 1332 patients ont été inclus au Cambodge, et 767 au Mozambique. Parmi les patients, 547 (41,16 %) et 385 (50,20 %) étaient de sexe masculin. L’âge médian lors de la première intervention était de 11 (IQR 4–14) et 11 (IQR 3–18) ans, respectivement au Cambodge et au Mozambique. Les étiologies comportaient : cardiopathie rhumatismale dans 490 (36,79 %) et 268 (34,94 %) cas ; cardiopathie congénitale dans 834 (62,61 %) et 390 (50,85 %) cas au Cambodge et au Mozambique, avec un nombre croissant de patients avec cardiopathie congénitale au cours de l’étude (P <0,001). Cent douze (14,6 %) et 741 (55,63 %) patients ont été perdus de vue à 30jours au Mozambique et au Cambodge. Au Mozambique, la distance du domicile au centre chirurgical était le seul facteur associé avec le statut perdu de vue (P <0,001). La mortalité postopératoire précoce (<30jours) était de 40 (6,10 %) au Mozambique, et de 18 (3,05 %) au Cambodge (en tenant compte des patients au statut vital renseigné). Le nombre de ceux nécessitant une chirurgie redux était de 109 (8,18 %) au Cambodge et de 94 (12,26 %) patients au Mozambique. Au Mozambique, 50 patients parmi 518 (9,65 %) sont décédés secondairement à une médiane de 23 mois (IQR 7–43). Au Cambodge, la mortalité tardive était de 34/591 (5,75 %) à une médiane de 11,5 mois (IQR 6–54,5).

Conclusions

Le devenir des patients opérés du cœur demeure inconnu dans certains pays en voie de développement étant donné le nombre de patients perdus de vue.

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Keywords : Cardiac surgery, Rheumatic heart disease, Acute rheumatic fever, Congenital heart disease, Developing countries, Global health

Mots clés : Échographie cardiaque, Échographie cardiaque ciblée, Éducation, Médecine d’urgence

Abbreviations : CCCPP, CHD, ICOR, IQR, NGO, RHD


Background

Access to cardiac surgery remains limited in many developing countries, especially in low-income settings [1, 2, 3]. Therefore, the natural history of severe rheumatic heart disease (RHD) and congenital heart disease (CHD) in need of cardiac interventions still remains of importance in countries with no access to cardiac surgery [4, 5]. Timely interventions are needed to improve outcomes in these young patients, and the majority of the world's population aged<15 years live in low- and middle-income countries with poor access to cardiac interventions [6, 7].

Humanitarian efforts have led non-governmental organizations (NGOs) to launch surgical programmes in low- and middle-income countries, in an attempt to fill the gap in these fragile healthcare systems [8, 9]. The methods of these NGOs vary, with some providing overseas treatment, while others carry out fly-in fly-out missions with varying levels of capacity building [1]. The data on the outcomes of these initiatives are scarce; publications focus either on the methods of the NGO missions [10] or on patient short-term outcomes from a single centre [11, 12].

We aimed to assess two cardiac surgery programmes conducted over 10 consecutive years in two low-income countries, by describing patient characteristics, surgical procedures, temporal trends and patient outcomes.

Methods
Objectives

The main objective was to describe patient characteristics, interventions and early postoperative mortality in two low-income countries; we also explored factors associated with loss to follow-up in these settings.

Settings

Cambodia and Mozambique are two low-income countries with a gross national income per capita in 2014 of 1010 USD and 630 USD, respectively. Cambodia is an East Asian country of 15.41 million inhabitants, with a life expectancy at birth of 72 years. Mozambique is a sub-Saharan African country of 26.47 million inhabitants, with a life expectancy at birth of 50 years [13].

Free-of-charge cardiac interventions are not available in the healthcare system in these two countries. Several paediatric cardiac surgery NGOs – including Chaîne de l’Espoir, France, which co-promoted this work – have built a partnership with two private hospitals: the Centre de Cardiologie de Phnom Penh (CCCPP) in Phnom Penh, Cambodia, and the Maputo Heart Institute (Instituto do Coração [ICOR]) in Maputo, Mozambique. These NGOs include senior cardiac surgeons with expertise in valve repair in RHD, who had been working in Northern and Southern countries for over 20 years before the study period [14]. These were the two only centres to provide cardiac surgery in the corresponding countries during the study period.

Inclusion criteria and data collection

All consecutive patients undergoing open-heart surgery at ICOR and CCCPP between 1 January 2001 and 31 December 2011 were included retrospectively. Patients who had been operated on overseas, those who underwent percutaneous interventions during the study period, and those with non-cardiac (i.e. thoracic) surgery were not included.

Data collected included demographic characteristics, underlying aetiology, surgical procedure, distance between the place of residence and the surgical centre, and early (i.e.<30 days) postoperative mortality. In addition, data on the use of secondary prophylaxis were collected in patients with RHD at follow-up. In Mozambique, the Aristotle basic complexity score was computed for patients with CHD [15]. We calculated expected early postoperative mortality by using the Aristotle basic complexity score with regard to the underlying CHD and the procedure performed.

In Cambodia, passive surveillance of surgical patients was part of the standard of care, with new visits recorded on the database. The definition of ‘lost to follow-up’ in Cambodia was the absence of a second visit at the institution (CCCPP).

In Mozambique, cross-sectional active follow-up was attempted in 2012, targeting all patients who had not attended the clinic for over 2 years. Patients and their parents were contacted by telephone on three occasions.

The methods comply with the STROBE statement [16]. The local ethics committees of ICOR and CCCPP approved the study and waived written consent from the patient and parent/guardian. This study complies with the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Statistical analysis

All participants’ characteristics are described as medians and interquartile ranges (IQRs) or proportions, as appropriate. Categorical variables were compared using the χ2 test or Fisher's exact test, and continuous variables were compared using Student's t test or the Wilcoxon rank sum test, as appropriate. A two-sided P value<0.05 was considered to indicate statistical significance. All data were analysed at the Paris Cardiovascular Research Centre, INSERM 970, Paris, France, with the use of Statistical Analysis System software, version 9.4 (SAS Institute, Cary, NC, USA).

Results
Patient characteristics

The study population comprised 1332 patients included in Cambodia plus 767 included in Mozambique (Figure 1). In Cambodia and Mozambique, respectively, median age at first surgery was 11 years (IQR 4–14) and 11 years (IQR 3–18), and 547 (41.16%) and 385 (50.20%) patients were male. The two main underlying aetiologies were: CHD in 834 (62.61%) and RHD in 490 (36.79%) patients in Cambodia; and CHD in 390 (50.85%) and RHD in 268 (34.94%) patients in Mozambique. Endomyocardial fibrosis was present in Mozambique only, where it affected 49 (6.39%) patients. Patient characteristics were different between the two countries, with a male predominance in Mozambique and differences in the underlying heart diseases (Table 1). There were increasingly more CHD and fewer RHD patients over the study period in both centres (P <0.001) (Figure 2). Patients with CHD were younger than those with RHD in both countries: median age 3 years (IQR 1–8) in CHD patients and 16 years (IQR 12–23) in RHD patients (P <0.001) in Mozambique; median age 6 years (IQR 3–11) in CHD patients and 14 years (IQR 12–17) in RHD patients (P <0.001) in Cambodia.



Figure 1




Figure 1. 

A. Flow chart of the Mozambican cohort. B. Flow chart of the Cambodian cohort.

Zoom



Figure 2


Figure 2. 

Temporal trends in the underlying aetiology in surgical patients in Cambodia and in Mozambique. CHD: congenital heart disease; RHD: rheumatic heart disease.

Zoom

Cardiac surgery procedures

Heart valve interventions for RHD are detailed in Table 2. Interventions varied across the two centres, with surgical mitral commissurotomy performed only in Cambodia, and more frequent mitral valve repair in Mozambique. No significant changes in the use of mitral valve repair were observed during the study (P =0.47 in Mozambique and P =0.13 in Cambodia) (Figure 3).



Figure 3


Figure 3. 

Temporal trends in the use of mitral valve repair in patients with rheumatic heart disease.

Zoom

In Mozambique, no change in the complexity of interventions for CHD was witnessed during the study, as assessed by the Aristotle basic complexity score (P =0.096) (Figure 4). The number of procedures increased throughout the study period in Mozambique (Appendix B), where the number of interventions performed by the local team with no visiting surgeon increased from 2009, reaching 30% in 2011. In Mozambique, six cardiologists, two senior anaesthetists, two cardiac surgeons, one perfusionist and the nursing team completed their training during the study period.



Figure 4


Figure 4. 

Temporal trends in the degree of complexity of patients with congenital heart disease in Mozambique, according to the Aristotle basic score [15].

Zoom

In Cambodia, the number of procedures varied from one year to another (Appendix B), with no local team performing surgery outside the fly-in fly-out humanitarian missions.

Outcomes

The number of patients lost to follow-up at 30 days was 112 (14.60%) in Mozambique and 741 (55.63%) in Cambodia. In Mozambique, where cross-sectional active follow-up was undertaken in 2012, 249 (32.46%) patients were lost to follow-up. In Cambodia, where passive surveillance was carried out, all patients lost to follow-up had no visit recorded in the outpatient clinic (total of 741 cases, 55.63%). The factor associated with loss to follow-up was the distance between the place of residence and the surgical centre in Mozambique (P <0.001). No patient lived>1000km away from the surgical centre in Cambodia (Table 3 and Table 4). There was a trend towards less loss to follow-up among CHD patients with palliative surgery (Table 3).

The early (i.e.<30 days) postoperative mortality rate was 6.10% (n =40) in Mozambique and 3.05% (n =18) in Cambodia, after exclusion of patients lost to follow-up. In patients with CHD in Mozambique, after exclusion of patients operated on for infective endocarditis (n =6) and those lost to follow-up in this group (n =71), 23/313 (7.35%) patients were dead at 30 days. The expected early mortality rate in this cohort was 5.61% according to the Aristotle score.

One hundred and nine (8.18%) patients in Cambodia and 94 (12.26%) patients in Mozambique underwent re-do surgery during the study period.

Among the subset of patients who were followed-up, a further 50/518 (9.65%) died at a median of 23months (IQR 7–43) in Mozambique, and a further 34/591 (5.75%) died at a median of 11.5months (IQR 6–54.5) in Cambodia. Overall mortality did not differ according to the underlying heart disease (CHD or RHD) in Cambodia (P =0.33) or in Mozambique (P =0.25).

Among the patients with RHD, 37/268 (13.8%) in Mozambique and 179/490 (36.5%) in Cambodia were known to be receiving secondary prophylaxis (either injectable benzathine penicillin or oral penicillin) after discharge.

Discussion

We report here, to the best of our knowledge, the largest series of open-heart surgery in two low-income countries. Two main underlying heart diseases (RHD and CHD) need cardiac surgery in the young in Cambodia and Mozambique, with increasing numbers of CHD patients over the past decade. In patients with RHD, heart valve repair is often offered to these young patients. Secondary prophylaxis is, however, underused. The number of patients lost to follow-up is unexpectedly high in deprived settings. Patients living in remote locations are more at risk of being lost to follow-up. A proactive approach using cross-sectional follow-up increases attendance at the outpatient clinic, but there is room for improvement. Long-term outcomes of cardiac surgery in low-income settings therefore remain unknown. Nevertheless, early postoperative mortality rates may be acceptable, and not far from what would be expected in high-income settings. The initiatives of NGOs are commendable, although capacity building should be part of these humanitarian efforts.

Humanitarian medicine often targets the young. The NGOs that have built a cardiac surgery programme at CCCPP and ICOR aim to provide high standards of care for disadvantaged children [8]. The population here is therefore mainly composed of children and young adults in their early twenties. The main underlying heart disease is CHD, because of the young age of our study population. As previously shown by our group, RHD remains endemic in both countries [17]; this preventable condition [5, 18] is still the second leading cause for open-heart surgery. The number of patients operated on for RHD declined over the study period. Our results suggest that there is either an epidemiological shift, with a decline in young patients with severe RHD, improved diagnostic capability for CHD or a combination of these two factors. Importantly, the majority of RHD patients do not receive secondary prophylaxis, the only treatment known to halt the progression of the disease, by preventing recurrent attacks of acute rheumatic fever [19]. Although this is difficult to estimate in patients lost to follow-up, the lack of comprehensive RHD control programmes in Cambodia and in Mozambique may explain the absence of secondary prophylaxis in these patients.

Despite some differences in the surgical techniques used across the centres, valve repair was mainly performed for RHD. This contrasts with the results of other groups, where valve replacement – often with mechanical valves – has been preferred [20]. The younger age of our study population, leading to less mitral valve damage and calcification, and the surgeons’ expertise in valve repair, may account for these differences [14, 21]. Whenever feasible, mitral valve repair seems a preferable option, to avoid the need for oral anticoagulants [22]. Indeed, smaller series of RHD patients have demonstrated high rates of mortality and morbidity, especially in women of childbearing age with mechanical heart valves [20, 23]. Authors from developing countries have advocated the use of the Ross procedure to avoid mechanical aortic valve replacement in children, as performed in some cases in this series [24, 25].

Capacity building was achieved in one of the centres, with an increasing caseload over the years. As in other settings, the Mozambican programme still relies on funding from NGOs, but has reached sufficient independence to provide cardiac surgery outside of fly-in fly-out missions [11, 26].

The rate of loss to follow-up is extremely high in our series, despite active recalls for non-attendees in one of the two centres. We identified remoteness as a factor associated with loss to follow-up, and active surveillance of non-attendees may prove useful. Our results highlight issues around patient selection in settings with limited resources. In contrast, authors from Ghana have shown surprisingly high attendance rates (>90% of patients) at medical-surgical clinics dedicated to patients with mechanical valves [27]. Questions around patient selection prior to surgery are raised by this report [28]. In Fiji, a low-income country in the South Pacific, 82% of patients undergoing valve replacement are seen in the clinics or are known to have died (with, however, a mean follow-up time of only 4.2 years [standard deviation 4.24] for a 20-year inclusion period) [20]. Our results contrast with these studies, in which methodological flaws may hamper conclusions. In patients with corrected simple CHD (e.g. atrial septal defect), regular follow-up may not be a priority. High rates of non-attendance are, in contrast, worrying in CHD patients in need of repeat procedures, and in RHD patients in need of secondary prophylaxis.

Early postoperative mortality may appear acceptable in both centres, ranging from ∼3 to 7%, provided those lost to follow-up have not died. In patients with CHD, early mortality was close to expected rates based on the Aristotle score, which combines the underlying CHD and the procedure performed, and was designed in high-volume centres in North America [15]. Larrazabal in Guatemala, where a local team has gained expertise in CHD surgery after initial collaboration with North American surgeons, has demonstrated the feasibility of CHD surgery in developing countries [11]. Our results also suggest that complete cure of CHD is a preferable option in low-income settings.[25]

Although cardiac surgery is an important player in the building of cardiovascular disease control, it may prove insufficient as a stand-alone strategy. The number of initiatives taken by NGOs has been growing over the past 20 years [1, 2, 28, 29, 30, 31, 32, 33]. Political will to improve healthcare systems globally is needed to render these programmes sustainable. Commendable humanitarian actions should not be left to surgeons alone, without a framework to continue care after surgery, such as RHD and infective endocarditis prophylaxis, and international normalized ratio clinics.

Strengths and limitations

Most publications on humanitarian cardiac surgery have described the missions, with no data on the effectiveness of these programmes [9, 10]. We present here the largest series of cardiac surgery in two low-income countries, identify common patterns and assess outcomes. We acknowledge, however, a number of limitations. Data were collected retrospectively. We could not avoid patient selection bias; patients screened, but not deemed fit enough for surgery, were not included in the study. The lack of national mortality registers in Mozambique and Cambodia precluded further information on patients lost to follow-up.

Conclusions

Cardiac surgery in the young in low-income settings is mainly aimed at CHD and RHD, and appears feasible, with relatively low postoperative mortality. The number of patients lost to follow-up is extremely high, and precludes the assessment of long-term outcomes. Remoteness may be a key factor in patient selection for cardiac surgery in resource constraint settings. Sustainability may be achieved through capacity building and local political support to improve healthcare systems more broadly.

Sources of funding

Chaîne de l’Espoir, France, and Institut de la Santé et de la Recherche Médicale co-founded this project. Mariana Mirabel has received funding from la Fédération française de cardiologie , la Fondation Lefoulon-Delalande and la Fondation pour la recherche médicale .

Disclosure of interest

The authors declare that they have no competing interest.


Appendix A. Number of procedures and underlying aetiology per year during the 10-year study period (2001–2011) in Mozambique. CHD: congenital heart disease; RHD: rheumatic heart disease


Appendix B. Number of procedures and underlying aetiology per year during the 10-year study period (2001–2011) in Cambodia. CHD: congenital heart disease; RHD: rheumatic heart disease

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1  Mariana Mirabel and Matthias Lachaud contributed equally.


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