The Nation’s Heart: Vietnam

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The “The Nation’s Heart” series features a different country every week to highlight its current state of cardiac surgery, progress made, initiatives set, and prospects to come. Today, for the third blog of this series, Global Cardiac Surgery is featuring Vietnam, a lower-middle-income country in Southeast Asia with a long standing experience and leading example for cardiac surgery in the Region.

Vietnam, officially the Socialist Republic of Vietnam, is the 15th most populous country in the world with almost 95 million people living in the vibrant, yet small country in Southeast Asia. After US forces left South Vietnam in 1973 and the US embargo was lifted in 1975, the country embarked on a painful process of recovery with reunification under a socialist government. Today, Vietnam has made important progress in political and economic sectors, but is trailing behind on education and health. Healthcare expenditure remains socialised and up to 70% of spending occurs through out-of-pocket payments by patients and their families.

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In as early as 1958, the first heart surgery -a closed mitral commissurotomy on a 30-year-old man with rheumatic mitral stenosis- was performed by Professor Ton That Tung, setting the stage for many decades of cardiac surgical endeavours to come. In 1964, deep hypothermia was first used, followed by the cardiopulmonary bypass in 1965. In the years to come, most procedures, in particular surgery for congenital heart defects, were performed at US military hospitals in South Vietnam. After the US forces left the country, fewer than 10 open-heart surgeries were done each year, due to widespread lack of supplies, devices, trained personnel, and funding.

However, in 1992, the Carpentier Heart Institute (today: Vietnam Heart Institute) was founded in Ho Chi Min City (formerly Saigon) by the French cardiac surgeon Alain Carpentier. Today, the Vietnam Heart Institute is one of the biggest heart centers in Vietnam, performing over 1,000 open-heart surgeries each year and training entire cardiac teams for the country. In 2011, cardiac transplantation was initiated at the Third Military Hospital in Hanoi and in Hue, and in 2017 at Cho Ray Hospital. In addition, several centers are now performing minimally invasive aortic and mitral valve procedures with good results. Although most senior cardiac surgeons have received all or part of their formal and additional training abroad in France, Australia, or South Korea, to date, there are three approved government cardiothoracic surgery training programs in Vietnam, in Hanoi, Hue, and Ho Chi Minh City, and one private at the Vietnam Heart Institute.

Currently, over 21 cardiac centers (of which 12 public) exist in Vietnam, covering a total of 119 cardiac surgeons and over 8,500 cardiac operations each year, yet only 4 of these perform more than 1,000 cases per year. Only 7 centers are able to perform neonatal and high-risk congenital heart surgery. Despite all efforts, the estimated backload of patients requiring cardiac care is as high as 80,000 cases. Rheumatic heart disease (RHD) and congenital heart disease (CHD) make up the bulk of cardiac conditions in Vietnam, responsible for more than 80% of cases. With a birth rate of almost 17 children per 1,000 people, close to 15,000 babies are born with CHD each year in Vietnam adding to the backload. Concurrently, although the government has put tremendous efforts in controlling rheumatic fever and thus rheumatic heart disease, over 5,000 adults wait for mitral valve surgery for RHD. Through attempting high case loads, costs are brought down to as comparably low as $1,500 for CHD surgery and $2,000 for valve surgery. Although the Vietnamese governments provides financial coverage of young patients to some extent, this program is inconsistent, and out-of-pocket payments for CHD patients average up to $500, which makes most families face catastrophic expenditure.

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To bridge the unmet need for cardiac surgery and limit catastrophic expenditure, visiting international teams largely focus on treating CHD cases in Vietnam. However, increasing governmental funding for cardiac surgery programs and services, and foster support from and cooperation with private centers will prove fundamental to achieve a sustainable, efficient, and effective national model.

The Nation’s Heart: Guatemala

Afbeeldingsresultaat voor unicar guatemalaThe “The Nation’s Heart” series features a different country every week to highlight its current state of cardiac surgery, progress made, initiatives set, and prospects to come. Today, for the second blog of this series, Global Cardiac Surgery is featuring Guatemala, a lower-middle-income country in Central America serving as a hub and leading example for cardiac surgery in the Region.

Guatemala, officially the Republic of Guatemala, bordering Mexico in Central America, holds a population of 16.58 million people at US$4,146.76 gross domestic product (GDP) per capita. The country is a representative democracy, initially ground of the Maya civilisation, conquered by the Spanish conquistadores in the 16th century, and independent since 1841. After decades of dictatorship and civil wars, Guatemala remains low on the Human Development Index, only ranking 31st of the 33 Latin American and Caribbean countries, with 23% of the population living below the poverty line of US$1/day. In Latin America, Guatemala ranks low in terms of health outcomes, and holds one of the highest infant mortality rates (24.5 per 1,000 live births) and one of the lowest life expectancies at birth in the Region.

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Traditionally, patients with cardiac disease requiring surgical care had to fly to Mexico or the United States to get treatment. However, the establishment of the Unidad de Cirugía Cardiovascular de Guatemala (UNICAR), or Guatemalan Heart Institute, has brought some light amidst the darkness. In 1972, a first to-be heart team was sent from Guatemala (including the general surgeon Raul Cruz Molina) to train at the Carolinas Medical Center in Charlotte, NC in the United States, returning in 1974 to perform the first cardiac surgeries in the Roosevelt Hospital in Guatemala City, the capital of Guatemala, with support of surgeons from Carolinas.

In 1989, the Guatemalan Heart Institute was established on the campus of Roosevelt Hospital, fully functioning by all-Guatemalan teams. The Institute had quickly grown to not only treat Guatemalan patients, but also visiting patients from neighbouring countries (Honduras, Belize, Dominican Republic, El Salvador, Haiti, and Nicaragua), under the lead of surgeons Rafael Espada and Aldo Castaneda. In 2000 UNICAR obtained autonomic status and in 2005, the cardiovascular program expanded to 2 cardiac operating rooms, 1 cardiac catheterization laboratory, a 6-bed intensive care unit, a 4-bed stepdown unit, and an 18-bed general ward. The staff now includes 3 surgeons from Guatemala, trained by Aldo Castañeda, 7 pediatric cardiologists, 3 intensivists, and 2 anesthesiologists, as well as intensive care and ward nurses, respiratory therapists, echocardiography technicians, and support personnel.

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Since the establishment, over 1300 surgeries have been performed, with over 20,000 patients seen in the outpatient clinic. 95% of the operated patients have been subsidized, of which 50% were paid by the social security system and 45% by the Ministry of Health and UNICAR-related foundation (Friends of the Aldo Castañeda Foundation). Most notably, the outcomes in the UNICAR cardiac program have shown outcomes close to those seen in the United States. UNICAR has accordingly shown the feasibility of cardiac programs in developing nations, and is an example for neighbouring countries, traditionally better off per overall development, to follow.

Rheumatic Heart Disease

On May, 25th 2018 (coinciding with Global Surgery Day), the World Health Organization (WHO) and its Member States unanimously accepted the Global Resolution on Rheumatic Fever and Rheumatic Heart Disease (RHD) at the World Health Assembly in Geneva, Switzerland. After years of global campaigning by non-governmental organizations and the wider civil society, the report was supported by countries from all six world regions, acknowledging the critical importance of addressing RHD.

In Western countries, rheumatic fever, characterized by polyarthritis, carditis, subcutaneous nodules, erythema marginatum, Sydenham’s chorea, fever, and arthralgia, is rarely seen in the 21st century, due timely diagnosis and treatment with antibiotics for streptococcus throat infections. In contrast, developing nations are still faced with a high prevalence of rheumatic fever, typically starting 20 days after the occurrence of strep throat (in 3% of untreated cases), and mostly affecting children between 5 and 17 years old. In these, case-fatality rates are as high as 5%.

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Although largely preventable, 33.4 million people suffer from rheumatic heart disease (RHD), with an additional 47 million living with asymptomatic damage to their heart valves, as a result of earlier acute rheumatic fever. RHD is the most commonly acquired heart disease for people under 25 years old and over 1.2 million suffer from long-term complications including heart failure, atrial fibrillation, stroke and infective endocarditis. RHD typically affects the mitral valve through a chronic process of inflammation and fibrinous repair, induced by group A beta-haemolytic streptococci (GAS), resulting in valvular thickening, commissural fusion, and shortening and thickening of tendinous cords, resulting in overall mitral stenosis. To prevent heart failure to occur, surgical treatment (balloon valvotomy/commissurotomy, valve repair, or valve replacement) is critical.

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In developing regions, especially in sub-Saharan Africa and Southeast Asia, lack of low-dose antibiotics to timely treat acute rheumatic fever and diagnose RHD, incidence and prevalence of RHD remains high. Auscultation of RHD in these regions have detected RHD in 2.9 per 1,000 children, whereas with the availability of echocardiography, up to 12.9 per 1,000 children were diagnosed, urging for the availability of imaging modalities to adequately and timely screen for RHD. Similarly, close follow-up of patients and ensuring adequately controlled anticoagulation is vital to ensure good long-term outcomes, a feat previously unattainable. However, proper training of community health workers and decentralization of follow-up within primary health care can prove successful.

Despite the high incidence of RHD (and other heart diseases) in developing regions, access to cardiac surgery remains scarce. For example, in the United States, 1,222 cardiac surgeries are done per 1,000,000 population every year, compared to only 18 per million in sub-Saharan Africa. With a similar maldistribution of available workforce and cardiac centers between and within regions, existing global health disparities continue to sustain.

Recently, the Cape Town Declaration on Access to Cardiac Surgery in the Developing World was released as a consensus statement of experts in the care of RHD, in order to unify efforts to tackle the global burden of rheumatic heart disease. Building on this, the expert working group will regularly meet at cardiac surgical and cardiological conferences to put forward guidelines to prevent and timely treat RHD, in order to work towards complete elimination of RHD.

More information:

One Step Closer: Bhagwan Koirala

Afbeeldingsresultaat voor bhagwan koiralaThe “One Step Closer” series features high-impact non-governmental organizations and individuals, and innovative solutions bringing the world one step closer to cardiac surgery for all. Today’s post features Bhagwan Koirala, Nepalese paediatric cardiac surgeon that introduced all-Nepalese cardiac surgery in the country and free cardiac care for the young, the elderly, and the needy.

In 1997, the first open-heart surgery in Nepal by a full Nepalese team was done, led by Dr. Bhagwan Koirala. It was not much later that cardiac care in the country dramatically took off, with the establishment of the Shahid Gangalal National Heart Center (SGNHC), where Dr. Bhagwan Koirala was appointed as Chief Cardiac Surgeon and Executive Director, serving until 2009.In 2016, approximately 2,000 cardiac surgical cases were conducted in Nepal, a country of 29 million people, of which 1,400 were done in SGNHC.

Gerelateerde afbeeldingNo child of this country shall die of heart disease because of poverty
– Dr. Bhagwan Koirala

In 2003, Dr. Koirala started the “Poor Patients Relief” program in collaboration with the Nepalese government, providing free cardiac surgical care for poor children under 15, the elderly above 75, and the needy in Nepal, providing over 100 free valve replacements for poor patients every year.

…we don’t turn away any patient for [technical] reasons. Also, we don’t refuse treatment to patients just because they don’t have money. We try to find resources for them.

After his time at SGNHC, Dr. Koirala was Executive Director of the Tribhuvan University (TU) Teaching Hospital, a philanthropic institute where he initially started as a paediatric cardiac surgeon prior to moving to SGNHC. Today, Dr. Koirala remains head of the TU Manmohan Cardiothoracic Vascular and Transplant Center, famously known for providing medicines at lower prices than the suggested retail price. Dr. Koirala continues to practice and serve as professor at the Kathmandu Institute of Medicine, hoping to inspire future generations of Nepalese cardiac surgeons. In addition, Dr. Koirala currently heads the Kathmandu Insitute of Child Health (KIOCH), in an attempt to reduce the high (36 per 1,000 children) under-5 mortality present in the country, aiming for an ambitious 1 per 1,000 by 2030.


The Nation’s Heart: Ghana

Screen Shot 2018-08-14 at 21.44.59.pngThe “The Nation’s Heart” series features a different country every week to highlight its current state of cardiac surgery, progress made, initiatives set, and prospects to come. Today, for the first blog of this series, Global Cardiac Surgery is featuring Ghana, a lower-middle-income country in West Africa with a strong history in the realms of cardiothoracic surgery.

Ghana (the Republic of Ghana) is a unitary presidential constitutional democracy located along the Gulf of Guinea and Atlantic Ocean in West Africa, after declaring independence from the United Kingdom in 1957 and transitioning into a Republic in 1960. With a GDP per capita of US$1,513, Ghana falls in the lower-middle-income group (US$996-US$3,895) spanning a population of 28.21 million people, with 10.95 million children (38.8% of total) under 15 years old. It has been reported that the estimated burden of congenital heart disease (CHD) in Ghana approximates 372 per million population, a disproportionally high number due to the higher fertility rate in the country relative to other countries in the Region. Nevertheless, with less than 20% of parents of children with CHD requiring surgical care able to cover the medical costs to undergo the operation within 12 months of diagnosis, access remains scarce.

Afbeeldingsresultaat voor ghana Flag of Ghana: red represents the blood shed to fight for independence, gold represents the mineral wealth present in Ghana, green represents the nature and grasslands of Ghana, and the black star represents African emancipation.

Traditionally, West Africa has been one of the poorest regions in the world, limiting the financial scope to scale cardiac surgical care in the region. Some countries, however, including Ghana,  have built a long and proud history establishing cardiac programs in their country. Documented reports in Ghana go back to 1964 with the use of surface cooling to close atrial septal defects (ASDs) and performing a closed mitral commissurotomy at the Korle-Bu Teaching Hospital in Accra, under Charles Easmon, general surgeon and head of the Surgery Department at the hospital. In the years that followed, due to political upheavals in the country putting cardiac development on hold, few cases were done by visiting surgeons and non-cardiac surgeons. In 1989, Dr. Frimpong-Boateng, trained in Hannover, Germany, returned to Ghana to found the National Cardiothoracic Center, the only tertiary center in the country, supported by the Ghanaian and German governments. In addition, Germany supported Ghana through initial equipment and medical personnel for up to ten years, to train the local workforce. In 1992, Dr. Frimpong-Boateng introduced the use of cardiopulmonary bypass (heart lung machine) in the country, replacing a mitral valve. The introduction of the Center allowed Ghana to treat patients in-country, saving up to US$44,000 per patient compared to sending patients to the United States, as was done prior.

Today, Ghana’s National Cardiothoracic Center remains active and is accredited by the West African College of Surgeons (WACS) for the training of cardiothoracic surgeons. The Center has a 30-bed ward, 2 operating theatres, a 6-bed intensive care unit, a 6-bed high dependency unit, a laboratory, catheterization lab, radiology, echocardiography services, and a renal dialysis unit. Dr. Frimpong-Boateng trained 7 cardiothoracic surgeons to serve as the permanent cardiac team, supported by cardiac anaesthesiologists, cardiologists, perfusionists, cardiac nurses, technicians, and other staff. Accordingly, the Center has grown to become a surgical hub for the West African region, with regular referrals from Sierra Leone, the Gambia, Liberia, Nigeria, and Togo. In addition, the Center has been able to withstand the widely perceived “brain drain” in other sectors, through ensuring opportunities for surgeons to academically advance, conduct research, integrate new technology in practice, and sustain international collaborations.

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In Ghana, as in most sub-Saharan African countries, rheumatic heart disease has been the major indication for valve surgery (together, in terms of case load, with CHD), often presenting during advanced stages of pathology. This, in turn, leads to increased calcification and difficulty of operation, often requiring re-operation causing increased financial constraints for patients. To bridge this, the Center has traditionally opted to use bi-leaflet mechanical valves, committing patients to lifelong anticoagulation but better long-term outcomes, limiting reoperation and related costs. Nevertheless, this readily underlines the importance of early detection and prevention of cardiac pathology, as well as reducing the delay of seeking care, requiring efficient systems of community health workers and referral systems in place. In addition, the cost of open-heart surgery remains beyond the scope of 90% of the population, ranging from US$6,000 for ventricular septal defect (VSD) closure to US$10,000 for double valve replacement. The national health insurance does not cover cardiothoracic surgical interventions due to the high costs, limiting patients to out-of-pocket payments and philantropic support. In some cases, the Ghana Heart Foundation, supported by the government of Ghana, financially supports patients to receive the care they need. Nevertheless, care provided at the National Cardiothoracic Center has proven to approximate outcomes seen in developed countries and higher-volume hospitals, showing the feasibility of providing cardiac surgical care in developing nations.

Building on the expertise and foundation set forth by Dr. Frimpong Boateng and the National Cardiothoracic Centre at the Korle-Bu Teaching Hospital in Accra, Ghana could build upon a decades-long history to sustain its position as one of the leading countries in West Africa providing and scaling cardiac surgical care. Together with increased awareness and escalation of the pre-hospital chain and cardiac prevention and diagnosis, the increasing volume, and thus gradually reducing costs of procedures, will allow for broader coverage of its population and sustainability of the nation’s program.

Read more:
Tettey M, Tamatey M, Edwin F. Cardiothoracic surgical experience in Ghana. Cardiovasc Diagn Ther. 2016. Open Access article.