The state of cardiac surgery in EthiopiaCentral MessagePerspective

Objectives: Six billion people globally do not have access to cardiac surgical care. In this study, we aimed to describe state of cardiac surgery in Ethiopia. Methods: Data on status of local cardiac surgery collected from surgeons and cardiac centers. Medical travel agents were interviewed about number of cardiac patients who were assisted to travel abroad for surgery. Historical data and number of patients treated by non-governmental organizations were collected via interviews and by accessing existing databases. Results: Patients access cardiac care via 3 avenues: mission-based, abroad referral, and care at local centers. Traditionally, the first 2 have been the main mode of access; however, since 2017, an entirely local team has begun performing heart surgery in the country. Currently, surgical cardiac care is provided at 4 local centers: a charity organization, a tertiary public hospital, and 2 for-profit centers. Procedures at the charity center are provided for free, whereas in others, patients mostly pay out of pocket. There are only 5 cardiac surgeons for 120 million people. More than 15,000 patients are on waitlist for surgery, mainly because of lack of consumables and limited numbers of centers and workforce. Conclusions: There is a change in the trend from non-governmental mission- and referral-based care toward care in local centers in Ethiopia. The local cardiac surgery workforce is growing but still insufficient. The number of procedures is limited with long wait lists due to limited workforce, infrastructure, and resources. All stakeholders should work on training more workforce, providing consumables, and creating feasible financing schemes

Ross procedure or mechanical aortic valve, which is the best lifetime option for an 18-year-old? A decision analysisCentral MessagePerspective

Objective(s): Identifying the optimal solution for young adults requiring aortic valve replacement (AVR) is challenging, given the variety of options and their lifetime complication risks, impacts on quality of life, and costs. Decision analytic techniques make comparisons incorporating these measures. We evaluated lifetime valve-related outcomes of mechanical aortic valve replacement (mAVR) versus the Ross procedure (Ross) using decision tree microsimulations modeling. Methods: Transition probabilities, utilities, and costs derived from published reports were entered into a Markov model decision tree to explore progression between health states for hypothetical 18-year-old patients. In total, 20,000 Monte Carlo microsimulations were performed to model mortality, quality-adjusted-life-years (QALYs), and health care costs. The incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analyses was performed to identify transition probabilities at which the preferred strategy switched from baseline. Results: From modeling, average 20-year mortality was 16.3% and 23.2% for Ross and mAVR, respectively. Average 20-year freedom from stroke and major bleeding was 98.6% and 94.6% for Ross, and 90.0% and 82.2% for mAVR, respectively. Average individual lifetime (60 postoperative years) utility (28.3 vs 23.5 QALYs) and cost ($54,233 vs$507,240) favored Ross over mAVR. The average ICER demonstrated that each QALY would cost $95,345 more for mAVR. Sensitivity analysis revealed late annual probabilities of autograft/left ventricular outflow tract disease and homograft/right ventricular outflow tract disease after Ross, and late death after mAVR, to be important ICER determinants. Conclusions: Our modeling suggests that Ross is preferred to mAVR, with superior freedom from valve-related morbidity and mortality, and improved cost-utility for young adults requiring aortic valve surgery

Global Access to Comprehensive Care for Paediatric and Congenital Heart Disease

Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide. Résumé: Les cardiopathies pédiatriques et congénitales (CPC) sont fréquentes, mais demeurent dans l’angle mort des politiques de santé mondiale. La cardiopathie est l’anomalie congénitale majeure la plus fréquente; elle touche environ 1 naissance vivante sur 100. Dans les pays à revenus élevés, la plupart de ces enfants atteignent désormais l’âge adulte, tandis que dans ceux à revenus faibles ou moyens, plus de 90 % des patients n’obtiennent pas les soins dont ils ont besoin. La cardiopathie rhumatismale est la maladie cardiovasculaire acquise la plus fréquente chez les enfants et les adolescents. Alors qu’elle est pratiquement éradiquée dans les pays à revenus élevés, plus de 30 à 40 millions de personnes en sont atteintes dans les pays à revenus faibles et moyens. À l’échelle mondiale, il existe de nombreux obstacles aux soins des CPC et, de plus en plus, des cardiopathies congénitales chez l’adulte (CCA). Notre article de synthèse présente un résumé de l’état actuel des soins des CPC et des CCA en abordant plusieurs aspects des systèmes de santé : ressources humaines, infrastructures, financement, services offerts, gestion des renseignements, technologies de l’information et gouvernance. Nous mettons également en lumière des lacunes dans les connaissances et des avenues d’amélioration de l’accès aux soins pour les personnes atteintes de CPC et de CCA partout dans le monde