Analysis of a five year experience of permanent pacemaker implantation at a Nigerian Teaching Hospital: Need for a national database

Introduction: Permanent pacemaker implantation is available in Nigeria. There is however no national registry or framework for pacemaker datacollection. A pacemaker database has been developed in our institution and the results are analyzed in this study. Methods: The study period was between January 2008 and December 2012. Patient data was extracted from a prospectively maintained  database which was designed to include the fields of the European pacemaker patient identification code. Results: Of the 51 pacemaker implants done, there were 29 males  (56.9%) and 22 females (43.1%). Mean age was 68.2±12.7 years. Clinical indications were syncopal attacks in 25 patients (49%), dizzy spells in 15 patients (29.4%), bradycardia with no symptoms in 10 patients (17.7%) and dyspnoea in 2 patients (3.9%). The ECG diagnosis was complete heart block in 27 patients (53%), second degree heart block in 19 patients  (37.2%) and sick sinus syndrome with bradycardia in 5 patients (9.8%). Pacemaker modes used were ventricular pacing in 29 patients (56.9%) and dual chamber pacing in 22 patients (43.1%). Files have been closed in 20 patients (39.2%) and 31 patients (60.8%) are still being followed up with median follow up of 26 months, median of 5 visits and 282 pacemaker checks done. Complications seen during follow up were 3 lead  displacements (5.9%), 3 pacemaker infections (5.9%), 2 pacemaker pocket erosions (3.9%), and 1 pacemaker related death (2%). There were 5 non-pacemaker related deaths (9.8%).Conclusion: Pacemaker data has been maintained for 5 years. We urge other implanting institutions in Nigeria to maintain similar databases and work towards establishment of a national pacemaker registry

Cardiomyopathies in Sub-Saharan Africa: Hypertensive Heart Disease (Cardiomyopathy), Peripartum Cardiomyopathy and HIV-Associated Cardiomyopathy

Cardiomyopathy is an important cause of cardiac-related morbidity and mortality in sub-Saharan Africa. Dilated cardiomyopathy is responsible for 20–30% of adult heart failure (HF) in the region. It is only second to hypertensive heart disease as etiological risk factor for HF in many parts of the continent. The aim of the chapter is to review the current epidemiology, clinical features, management, and prognosis of hypertensive heart disease, peripartum cardiomyopathy, and HIV-associated cardiomyopathy in sub-Saharan Africa

Hypertensive heart disease in Africa

Hypertension has become an important public health problem in Africa. Currently an epidemiologic transition from infectious diseases is going on in the continent and the prevalence of chronic diseases like hypertension is increasing. The response of the heart to the stress/afterload imposed on the left ventricle by the progressively increasing arterial blood pressure is described as hypertensive heart disease. Hypertensive heart disease and failure are the commonest cardiovascular diseases of Africans. Since hypertension is a treatable cardiovascular risk factor, there is need to create more awareness about the disease and educate our patients concerning drug compliance. There is also a need for longitudinal multicentre study in Africa, in order to assess the severity and burden of the disease

Preliminary experience in the management of tracheobronchial foreign bodies in Lagos, Nigeria

Aspiration of tracheobronchial foreign bodies commonly affects young children, is potentially life threatening and requires early intervention for extraction. Access to facilities and skill manpower for bronchoscopic extraction is however limited in Nigeria. The aim of this study is to describe the experience in our institution with bronchoscopic removal of tracheobronchial foreign bodies and highlight the challenges encountered. This is a retrospective study of all patients referred to the Lagos State University Teaching Hospital with a diagnosis of tracheobronchial foreign body within the period of February 2008 and February 2013. Data extracted from the medical records were age, sex, time interval between aspiration and presentation, location of tracheobronchial foreign body, bronchoscopic technique, complications and outcome. A total of 24 patients were referred and confirmed at bronchoscopy to have tracheobronchial foreign bodies. Mean age was 6.6 + 5 years. Male to female ratio was 1:1. Delayed presentation was common with 22 patients (91.7%) presenting more than 24 hours after aspiration. Aspirated material was inorganic in 17 patients (70.8%) and organic in 7 patients (29.2%). Location of tracheobronchial foreign bodies was right main bronchus in 16 patients (66.7%), left main bronchus in 6 patients (25%) and the trachea in 2 patients (8.3%). Challenges to speedy and safe removal of the foreign bodies were delayed presentation and a limited range of bronchoscopic equipment early in the series which caused prolonged procedures and increased complications. Two mortalities occurred early in the series; one from airway obstruction and the other from respiratory failure caused by tracheobronchial oedema. Extraction of tracheobronchial foreign bodies was faster, more complete and safer later in the series due to a wider range of bronchoscopy equipment which included both flexible and rigid videobronchoscopy with the use of optical forceps. This preliminary experience suggests that an adequate armamentarium of bronchoscopy equipment is required to increase the chances of complete extraction, speed up the procedure and reduce the risk of complications of Tracheobronchial Foreign Bodies in our environment. Delayed presentation increases the difficulty of the procedure so earlier referral of these patients would help reduce the risk involved in  their management.Key words: Bronchoscopy, Tracheobronchial Foreign Bodies, Lagos, Nigeri

The role of cervical mediastinoscopy in Nigerian thoracic surgical practice

Introduction: Cervical mediastinoscopy is the gold standard for obtaining histological diagnosis of mediastinal pathology. It has been used for the staging of lung cancer as well as to determine the cause of Isolated Mediastinal Lymphadenopathy. There is very limited evidence in the literature of its use in Nigeria to assess mediastinal pathology. The aim of this study was to describe our institutional experience with cervical mediastinoscopy. Methods: This study was a retrospective analysis of 40 patients that underwent cervical mediastinoscopy in our institution between March 2007 and February 2013. Results: The indication for Cervical Mediastinoscopy was Isolated Mediastinal Lymphadenopathy in 24 patients (60%) and lung cancer staging in 16 patient (40%). The mean age of the patients was 52.7 + 15.1 years. There were 21 females (52.5%) and 19 males (47.5%). The most commonly biopsied lymph nodes were level 4 in 35 patients (87.5%) and level 7 in 21 patients (52.5%). Malignant diagnosis was made in 16 (66.7%) patients with Isolated Mediastinal Lymphadenopathy and in 13 (81.3%) patients staged for lung cancer. Hospital stay was less than 24 hours in all patients and there were no complications. Conclusion: Cervical Mediastinoscopy is available in Nigeria and has been performed in our institution with high diagnostic yield and no complications. Its increased use, along with the development of other mediastinal biopsy techniques is advocated to increase tissue biopsy of mediastinal pathology, especially for lung cancer and isolated mediastinal lymphadenopathy.Pan African Medical Journal 2016; 2

The cost of open heart surgery in Nigeria

Introduction: Open Heart Surgery (OHS) is not commonly practiced in Nigeria and most patients who require OHS are referred abroad. There has recently been a resurgence of interest in establishing OHS services in Nigeria but the cost is unknown. The aim of this study was to determine the direct cost of OHS procedures in Nigeria. Methods: The study was performed prospectively from November to December 2011. Three concurrent operations were selected as being representative of the scope of surgery offered at our institution. These procedures were Atrial Septal Defect (ASD) Repair, Off Pump Coronary Artery Bypass Grafting (OPCAB) and Mitral Valve Replacement (MVR). Cost categories contributing to direct costs of OHS (Investigations, Drugs, Perfusion, Theatre, Intensive Care, Honorarium and Hospital Stay) were tracked to determine the total direct cost for the 3 selected OHS procedures. Results: ASD repair cost $6,230 (Drugs$600, Intensive Care $410, Investigations$955, Perfusion $1080, Theatre$1360, Honorarium $925, Hospital Stay$900). OPCAB cost $8,430 (Drugs$740, Intensive Care $625, Investigations$3,020, Perfusion $915, Theatre$1305, Honorarium $925, Hospital Stay$900). MVR with a bioprosthetic valve cost $11,200 (Drugs$1200, Intensive Care $500, Investigations$3040, Perfusion $1100, Theatre$3,535, Honorarium $925, Hospital Stay$900). Conclusion: The direct cost of OHS in Nigeria currently ranges between $6,230 and$11,200. These costs compare favorably with the cost of OHS abroad and can serve as a financial incentive to patients, sponsors and stakeholders to have OHS procedures done in Nigeria.Pan African Medical Journal 2013; 14:6

Economic burden of heart failure: investigating outpatient and inpatient costs in abeokuta, southwest Nigeria

Background: Heart failure (HF) is a deadly, disabling and often costly syndrome world-wide. Unfortunately, there is a paucity of data describing its economic impact in sub Saharan Africa; a region in which the number of relatively younger cases will inevitably rise. Methods: Heath economic data were extracted from a prospective HF registry in a tertiary hospital situated in Abeokuta, southwest Nigeria. Outpatient and inpatient costs were computed from a representative cohort of 239 HF cases including personnel, diagnostic and treatment resources used for their management over a 12-month period. Indirect costs were also calculated. The annual cost per person was then calculated. Results: Mean age of the cohort was 58.0±15.1 years and 53.1% were men. The total computed cost of care of HF in Abeokuta was 76, 288,845 Nigerian Naira (US$508, 595) translating to 319,200 Naira (US$2,128 US Dollars) per patient per year. The total cost of in-patient care (46% of total health care expenditure) was estimated as 34,996,477 Naira (about 301,230 US dollars). This comprised of 17,899,977 Naira- 50.9% ($US114,600) and 17,806,500 naira −49.1$US118,710) for direct and in-direct costs respectively. Out-patient cost was estimated as 41,292,368 Naira ($US 275,282). The relatively high cost of outpatient care was largely due to cost of transportation for monthly follow up visits. Payments were mostly made through out-of-pocket spending. Conclusion: The economic burden of HF in Nigeria is particularly high considering, the relatively young age of affected cases, a minimum wage of 18,000 Naira ($US120) per month and considerable component of out-of-pocket spending for those affected. Health reforms designed to mitigate the individual to societal burden imposed by the syndrome are required

Characterisation of heart failure with normal ejection fraction in a tertiary hospital in Nigeria

<p>Abstract</p> <p>Background</p> <p>The study aimed to determine the frequency and characteristics of heart failure with normal EF in a native African population with heart failure.</p> <p>Methods</p> <p>It was a hospital cohort study. Subjects were 177 consecutive individuals with heart failure and ninety apparently normal control subjects. All the subjects underwent transthoracic echocardiography. The group with heart failure was further subdivided into heart failure with normal EF (EF ≥ 50) (HFNEF) and heart failure with low EF(EF <50)(HFLEF).</p> <p>Results</p> <p>The subjects with heart failure have a mean age of 52.3 ± 16.64 years vs 52.1 ± 11.84 years in the control subjects; p = 0.914. Other baseline characteristics except blood pressure parameters and height were comparable between the group with heart failure and the control subjects. The frequency of HFNEF was 39.5%. Compared with the HFLEF group, the HFNEF group have a smaller left ventricular diameter (in diastole and systole): (5.2 ± 1.22 cm vs 6.2 ± 1.39 cm; p < 0.0001 and 3.6 ± 1.24 cm vs 5.4 ± 1.35 cm;p < 0.0001) respectively, a higher relative wall thickness and deceleration time of the early mitral inflow velocity: (0.4 ± 0.12 vs 0.3 ± 0.14 p < 0.0001 and 149.6 ± 72.35 vs 110.9 ± 63.40 p = 0.001) respectively.</p> <p>The two groups with heart failure differed significantly from the control subjects in virtually all echocardiographic measurements except aortic root diameter, LV posterior wall thickness(HFLEF), and late mitral inflow velocity(HFNEF). HFNEF accounted for 70(39.5%) of cases of heart failure in this study.</p> <p>Hypertension is the underlying cardiovascular disease in 134(75.7%) of the combined heart failure population, 58 (82.9%) of the subjects with HFNEF group and 76(71%) of the HFLEF group. Females accounted for 44 (62.9%) of the subjects with HFNEF against 42(39.3%) in the HFLEF group (p = 0.002).</p> <p>Conclusion</p> <p>The frequency of heart failure with normal EF in this native African cohort with heart failure is comparable with the frequency in other populations. These groups of patients are more likely female, hypertensive with concentric pattern of left ventricular hypertrophy.</p

Echocardiographic partition values and prevalence of left ventricular hypertrophy in hypertensive Nigerians

BACKGROUND: Left ventricular hypertrophy (LVH) is a well known independent risk factor for cardiovascular events. It has been shown that combination of left ventricular mass (LVM) and relative wall thickness (RWT) can be used to identify different forms of left ventricular (LV) geometry. Prospective studies have shown that LV geometric patterns have prognostic implications, with the worst prognosis associated with concentric hypertrophy. The methods for the normalization or indexation of LVM have also recently been shown to confer some prognostic value especially in obese population. We sought to determine the prevalence of echocardiographic lLVH using eight different and published cut-off or threshold values in hypertensive subjects seen in a developing country's tertiary centre. METHODS: Echocardiography was performed in four hundred and eighty consecutive hypertensive subjects attending the cardiology clinic of the University college Hospital Ibadan, Nigeria over a two-year period. RESULTS: Complete data was obtained in 457 (95.2%) of the 480 subjects (48.6% women). The prevalence of LVH ranged between 30.9–56.0%. The highest prevalence was when LVM was indexed to the power of 2.7 with a partition value of 49.2 g/ht(2.7 )in men and 46.7 g/ht(2.7 )in women. The lowest prevalence was observed when LVM was indexed to body surface area (BSA) and a partition value of 125 g/m(2 )was used for both sexes. Abnormal LV geometry was present in 61.1%–74.0% of our subjects and commoner in women. CONCLUSION: The prevalence of LVH hypertensive patients is strongly dependent on the cut-off value used to define it. Large-scale prospective study will be needed to determine the prognostic implications of the different LV geometry in native Africans