Late primary arterial switch for transposition of the great arteries with intact ventricular septum in an african population

Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward

In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.

Extremely late presentation of children with transposition the great arteries

We present three cases of primary arterial switch operation for extremely late presenting transposition the great arteries with intact ventricular septum: a 7-year-old female, 3-year-old male, and 6-year-old female. Two patients were discharged on postoperative day 9 and 11, the other developed hemodynamic instability 12 h after surgery and died due to left ventricular failure and pulmonary hypertension. Left ventricular mass index >35 g·m^-2 and left ventricular posterior wall >4 mm are criteria for a primary arterial switch operation. Circulatory support post- or intraoperatively might provide better results. Two patients survived without extracorporeal membrane oxygenation or nitric oxide.

Transposition of the great vessels and intact ventricular septum: is there an age limit for the arterial switch? Personal experience and review of the literature

OBJECTIVE

Prognosis of the transposition of the great arteries has completely changed since the introduction of the arterial switch. Time limit to perform this intervention is still controversial. The aim of this study is to demonstrate the early and late outcome of primary arterial switch operation beyond the age of months.

METHODS

We included all patients with the diagnosis of transposition of the great arteries with intact ventricular septum beyond the age of 8 weeks who underwent primary arterial switch operation. The procedures were performed by the same surgeon, in two different institutes. Patients who had transposition of the great arteries and associated anomalies (except atrial septal defect and persistent arterial duct) were excluded. Ventricular shape, geometry, and mass were not considered during the decision on procedure type.

RESULTS

In the study, 11 patients with the diagnosis of simple d-transposition of the great arteries beyond 8 weeks were undergone primary arterial switch operation with a mean age of 90.63 days (60-137 days), and 7 patients had a Rashkind procedure. All patients had squashed left ventricle shape with preserved function. The sternum was left open in 10 patients. Extracorporeal membrane oxygenation support was necessary in 45.45% of cases. The mean mechanical ventilation time was 7.27 days (1-16 days). No mortality was recorded until now. Post-operatory left ventricular function was preserved in 90.9% of the patients. Only one patient had mild myocardial dysfunction at the time of discharge.

CONCLUSIONS

Primary arterial switch procedure can still be the best surgical option in patients with the diagnosis of transposition of the great arteries with intact ventricular septum beyond 8 weeks of age, providing that mechanical circulatory support and an expert cardiac intensive care unit service are available.

Use of Left Ventricular Assist Device After Arterial Switch Operation in Late Presenting D-Transposition of Great Arteries-A Technique for Retraining the Regressed Left Ventricle

The preferred approach for patients with D-transposition of the great arteries with an intact ventricular septum (DTGA/IVS) is the arterial switch operation (ASO). In those patients presenting late, with regressed left ventricle (LV), successful LV preparation is of paramount importance to achieve this goal. We present a toddler with DTGA/IVS who underwent ASO followed by successful left ventricular retraining with postoperative left ventricular assist device support with CentriMag centrifugal pump.

Conotruncal Heart Defect Repair in Sub-Saharan Africa: Remarkable Outcomes Despite Poor Access to Treatment

BACKGROUND

The outcome of children born with conotruncal heart defects may serve as an indication of the status of pediatric cardiac care in sub-Saharan Africa (SSA). This study was undertaken to determine the outcome of children born with conotruncal anomalies in SSA, regarding access to treatment and outcomes of surgical intervention.

METHODS

From our institution in Ghana, we retrospectively analyzed the outcomes of surgery, in the two-year period from June 2013 to May 2015. The birth prevalence of congenital heart defects (CHDs) in SSA countries was derived by extrapolation using an incidence of 8 per 1,000 live births for CHDs.

RESULTS

The birth prevalence of CHDs for the 48 countries in SSA using 2013 country data was 258,875; 10% of these are presumed to be conotruncal anomalies. Six countries (Nigeria, Democratic Republic of the Congo, Ethiopia, Tanzania, Uganda, and Kenya) accounted for 53.5% of the birth prevalence. In Ghana, 20 patients (tetralogy of Fallot [TOF], 17; pulmonary atresia, 3) underwent palliation and 50 (TOF, 36; double-outlet right ventricle, 14) underwent repair. Hospital mortality was 0% for palliation and 4% for repair. Only 6 (0.5%) of the expected 1,234 cases of conotruncal defects underwent palliation or repair within two years of birth.

CONCLUSION

Six countries in SSA account for more than 50% of the CHD burden. Access to treatment within two years of birth is probably <1%. The experience from Ghana demonstrates that remarkable surgical outcomes are achievable in low- to middle-income countries of SSA.

D-transposition of the great arteries: the current era of the arterial switch operation

This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early- and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO.

The walter sisulu paediatric cardiac centre for Africa: proceedings of the march 2011 symposium

The 2011 symposium opened with a consideration of the challenges in the management of children undergoing the Fontan operation. Management options for patients with congenitally corrected transposition were then discussed, using several illustrative case examples and a review of the results from the Texas Children's Hospital. There was a session dedicated to borderline hypoplastic left heart syndrome, concluding with a review of the results of the Single Ventricle Reconstruction (SVR) Trial in North America. Results of pediatric mechanical circulatory support were considered in the context of surgery for anomalous left coronary artery from the pulmonary artery after a more general overview of pediatric applications of extracorporeal membrane oxygenation and ventricular assist devices. Problems of monitoring in the intensive care unit, quality assurance, feeding algorithms for children, and morbidity associated with mechanical ventilation occupied most of the second day's sessions. Results of the arterial switch operation for transposition, issues related to neonatal brain protection during open cardiac procedures, and, finally, training paradigms for congenital heart surgeons concluded the symposium's talks.

The development of cardiac surgery in West Africa--the case of Ghana

West Africa is one of the poorest regions of the world. The sixteen nations listed by the United Nations in this sub-region have some of the lowest gross domestic products in the world. Health care infrastructure is deficient in most of these countries. Cardiac surgery, with its heavy financial outlay is unavailable in many West African countries. These facts notwithstanding, some West African countries have a proud history of open heart surgery not very well known even in African health care circles. Many African health care givers are under the erroneous impression that the cardiovascular surgical landscape of West Africa is blank. However, documented reports of open-heart surgery in Ghana dates as far back as 1964 when surface cooling was used by Ghanaian surgeons to close atrial septal defects. Ghana's National Cardiothoracic Center is still very active and is accredited by the West African College of Surgeons for the training of cardiothoracic surgeons. Reports from Nigeria indicate open-heart surgery taking place from 1974. Cote D'Ivoire had reported on its first 300 open-heart cases by 1983. Senegal reported open-heart surgery from 1995 and still runs an active center. Cameroon started out in 2009 with work done by an Italian group that ultimately aims to train indigenous surgeons to run the program. This review traces the development and current state of cardiothoracic surgery in West Africa with Ghana's National Cardiothoracic Center as the reference. It aims to dispel the notion that there are no major active cardiothoracic centers in the West African sub-region.