Initial Experience with Open Heart Surgery in Sub-Saharan Africa: Challenges in Mali with Minimum Standards for Practice

Introduction: There has been limited experience with Open Heart Surgeries (OHS) in Sub-Saharan Africa. In west Africa especially in Mali, most fled-gling centers are unable to overcome the myriad of challenges encountered in establishing OHS though there is a high prevalence of surgically correctable heart diseases. The aim of this paper is to review our initial experience of our first cases in developing OHS program and discuss the challenges and prospects that need to be overcome to further develop it. a tricuspid valvuloplasty. Three patients had mitral valve replacement with tricuspid valvuloplasty. Four patients had mitral valve replacement. Sixty-day mortality was 0%. Conclusion: Safe conduct of open heart surgery in Mali Hospital setting is feasible. Grant financial aid is required for rapid growth of Open-Heart Surgery in this part of Sub-Saharan Africa.


Introduction
Open Heart Surgery (OHS) is defined as "surgical repair of the heart during which the blood circulation is often maintained mechanically requiring Cardiopulmonary Bypass (CPB)" [1]. There has been limited experience with OHS in West Africa with only a few established cardiac centers [2] [3]. In Mali most fledgling centers are unable to overcome the myriad of challenges encountered in establishing OHS though there is a high prevalence of surgically correctable heart diseases. OHS is relatively expensive as income is low in Mali. It has been demonstrated that in sub-Saharan Africa, gross domestic product (GDP) per capita remains low comparing to OHS cost, which remains beyond the reach of our population's financial capacities [4]. Confronted with this deficit, funding from our States is insignificant or does not exist at all in some of them [5]. Cardiothoracic practice in Mali faces multiple challenges that need to be overcome to enable sustainable practice. A seed fund was provided by the Malian government which was used as the start of specialized cardiac training abroad. A small fraction of patients are sponsored or are able to fund their own surgery abroad but the goal for any country has to be to establish its own programs that can be developed and sustained. Despite some early attempts to develop OHS in Mali [6], this has not been sustained. An OHS program is in the first time being performed at the Mali University Teaching Hospital. It is encouraging to see the surge in OHS activity but we need to transit from cardiac missions. Successful OHS requires 24-hour laboratory support, an active blood bank and cardiac catheterization support. Access to these various support facilities were very limited in sub-Saharan Africa. The aim of this article is to share the result of our first cases in developing OHS program and discuss the challenges and prospects that need to be overcome to further develop and sustain it.

Patients and Methods World Journal of Cardiovascular Surgery
by the government to develop it. In spite of our challenges, our human and economic potential enable us to anticipate positive developments, including rapid growth of OHS. To overcome these challenges a "Cardiac Mission" was then organized with patients recruited and screened by the local cardiologists of our hospital. The core of the local Cardiac Team is made up of 2 cardiac surgeons, 2 cardiologists, 1 Cardiac anaesthetist, 1 intensivist, and 6 theatre nurses. This team works with the Morocco "Cardiac Mission" team which contributes a further 3 cardiac surgeons 2 theatre nurses, 4 intensive care nurses and 1 perfusionist. During the cardiac mission, OHS consumables are sourced from Morocco team and all procedures were entirely free for the selected patients. The surgery was performed by the Morocco team as an international humanitarian service for OHS which also provided all the equipment and materials required for OHS.
The first 6 OHS cases were performed in 2016 with success in Mali University Teaching Hospital. Clinical assessment and appropriate investigations are done.
Transthoracic echocardiography was performed in all cases for diagnosis. For the inclusion criteria, the euroscore is computed and if deemed acceptable the patient is offered surgery. High risk patients are discussed with Cardiac surgeons, cardiologists and anesthesists before surgery. The exclusion critera for this study was the patients who had an indication of open-heart surgery and could not be operated for technical reasons (suspicion of coronary artery disease without possibility for coronarography or coronary angiography); patients that conditions were associated with active viral hepatitis, positive for HIV, morbid obesity and global heart failure; patients selected for surgery are put on a waiting list. Mitral valve disease was of rheumatic origin in five cases (4 cases of mitral valve stenosis and 1 case of mitral regurgitation), and there was one case of congenital heart disease (atrial septal defect). The surgery is performed by the Morocco team and assisted by the local team. Cardiac surgery missions do have adult heart surgery arm and only an infrequent congenital programme. Patients are admitted 7 days before surgery and a checklist is used to assess that there are no impediments to the surgery. Following aortic and bicaval cannulation, cardiopulmonary bypass was instituted with the heart lung machine. All cases have been done with the Stockert Compact heart lung machine (Sorin, Italy). All patients underwent surgery utilizing aortic, bicaval cannulation. Myocardial protection was with blood cardioplegia in all cases with retrograde approach and moderate systemic hypothermia (30˚C -32˚C). Following surgery the patients were transferred to the Intensive Care unit and once weaned off cardiac or respiratory support, the patients were moved to a side room of cardiothoracic surgery department. The patients were usually seen 2 weeks afterwards in the cardiothoracic department, and further follow up was done with the cardiologysts of the hospital. The medical records of the patients were examined and data on age, sex, diagnosis, type of surgery, cardiopulmonary bypass details, complications and length of hospital stay were extracted. After been discharged from the hospital, patients were followed up weekly at the first and second month to seek ur- Teaching Hospital for use of the patient data from the database. The results are presented below, as well as the challenges encountered in achieving these results.
Data are expressed as absolute values, percentages, or mean ± SD where appropriate. Fisher exact test was used for statistical analysis and P < 0.05 was statistically significant.

Results
A total of 6 OHS cases were performed during 7 days in our hospital. The pa-    Table 3 Table 4.

Discusions
Since 1950s, one of the major challenges was to accomplish correction of intracardiac lesions within a bloodless heart using a heart-lung machine. Throughout   "bridged" with an oral anticoagulant, usually warfarin. The target INR is dependent on patient risk factors, thrombogenicity of the prosthesis used [17] and the position of the valve that was replaced. Mitral valve replacement poses greater risk of thrombosis. Atrial fibrillation is common after cardiac surgery, and typically occurs two to four days after the operation [18]. The incidence is around 40% after valve surgery [18]. Most patients will convert spontaneously back to sinus rhythm in 24 hours [18]. Beta blockers are used to reduce the risk of atrial fibrillation. The European Society of Cardiology (ESC) guidelines recommend ventricular rate control for patients who develop AF following surgery, or direct current cardioversion for patients with AF and haemodynamic instability [18].
Anticoagulants are started if AF persists for more than 48 hours [18]. Epicardial pacing wires placed in-situ, help to detect and treat post-operative arrhythmias.
The choice of whether to use a pacing wire depends on the surgeon and it has been used in one patient. Infection of the sternal wound occurs in up to 5% of patients [19]. It is normally detected within two weeks of surgery, although it can occur more than a month later. Treatment includes surgical debridement, sternal rewiring, intravenous antibiotics, and vacuum assisted closure (VAC) therapy which uses negative pressure to promote wound healing. One patient with superficial sternal wound was treated by intravenous antibiotics only. Fortunately, despite challenges enumerated [20] [21], and serious difficulties met, as said, a few cardiac centers in sub-Africa continue to offer OHS. However, the progress of medicine including heart surgery must have respect for the fundamental ethics for the benefit of humanity and Human Rights. The success of this mission was achieved with minors' complications and the mortality was null. We found an improvement in the functional class of NYHA after surgery (100% of our patients were in NYHA class I). This functional improvement was well correlated with the degree of recovery of left ventricular function. It has been reported that there is a close relationship between LV size preoperatively and the possibility of ventricular recovery. Thus, author reported that patients with preoperative LV DTD ≤ 55 mm were more likely to improve their left ventricular function [22].
Morris and al reported that patients who had an improvement in the postoperative ejection fraction had a better survival curve [23].

Conclusion
By encouraging international humanitarian services for OHS in developing countries without any capacity to take care of patients with acquired or congenital heart disease, OHS can be done with success in Mali. Grant financial aid to the care of the poorest patients by public, governmental or private initiatives is required for rapid growth of Open-Heart Surgery in sub-Saharan Africa.