August 08, 2018
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Experts: Expanded cardiac surgery access required to address rheumatic heart disease

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To better treat rheumatic heart disease, access to cardiac surgery must be expanded in low- and middle-income countries, according to the signatories of the Cape Town Declaration.

The declaration was signed by representatives of numerous cardiothoracic societies, humanitarian and government organizations, industry and health-economy entities, and journals and publications. It calls for the forming of a coalition “to evaluate and endorse the development of cardiac care in low- to middle-income countries” and for more training of cardiac surgeons at key centers in low- and middle-income countries.

Rheumatic heart disease is caused by strep throat,” R. Morton Bolman III, MD, professor of surgery at the University of Vermont Medical Center, who signed the declaration on behalf of the American Association for Thoracic Surgery (AATS), told Cardiology Today. “If untreated, in affected patients, it sets off an immune reaction that ultimately attacks one or more of the valves of the heart. The end result is end-stage heart failure, often at a very young age. The exact mechanism of how one gets from acute strep throat to rheumatic heart disease with destruction of heart valves months to years later is not well understood, despite decades of research.”

A disease of poverty

Although rheumatic heart disease has essentially been eliminated in the developed world, “in the low- to middle-income countries of the developing world, it remains a scourge, particularly among the poor. It is disease of poverty,” Bolman said. “Particular concentration of [rheumatic heart disease] exists in sub-Saharan Africa. It is estimated that in sub-Saharan Africa, exclusive of South Africa, it would require 200 cardiac surgery programs each performing 1,000 operations per year to meet the demand.”

The coalition called for by the declaration would consist of two representatives from each of the AATS, the Society of Thoracic Surgeons, the European Association for Cardio-Thoracic Surgery and the Asian Society for Cardiovascular and Thoracic Surgery, one representative from industry and one representative from the World Heart Federation or a similar organization.

“The responsibilities of the coalition will include establishing criteria for centers for clinical care and training as well as selecting and endorsing the centers,” the authors wrote. “The coalition will derive metrics of quality and performance for the endorsed centers of training and clinical care and will encourage standardization of care to the extent possible.”

The coalition would identify and endorse centers in low- and middle-income countries to increase training of cardiac surgeons and related personnel.

“It is preferred that centers endorsed by this coalition be based on an alliance of four stakeholders: a program initiator (eg, a government, a university, or a nongovernment organization), an audited training center in a low- to middle-income country, a committed partner institution in a high-income country, and a consortium of industry that would sign on as benefactors to the specific program,” the authors wrote. “Because regional centers in low- to middle-income countries typically operate within a resource-scarce environment, resulting in lower case numbers than needed for the training of outside residents, a facilitated capacity increase to help achieve higher case numbers would benefit all participants.”

Dedicated effort

“It is only by actually training in these settings that trainees will be in exposed to the surgical diseases and the austere conditions that will exist where they will practice,” Bolman said in an interview. “This is the first initiative of this kind that has the backing of the entire cardiac surgery and cardiology community as well as significant support from medical industry as well as governmental entities. If there is ever a real improvement to happen in access to cardiac surgery in the vast underserved regions of the globe, it must originate from a combined and dedicated effort such as represented in the Cape Town Declaration.” – by Erik Swain

For more information:

R. Morton Bolman III, MD, can be reached at cbolman46@gmail.com.

Disclosure: Bolman reports no relevant financial disclosures.