• CARDIAC PROCEDURES AND THERAPY

Congenital cardiac defects continue to be a major cause of death and suffering in the low/middle-income countries.1 This stems from the larger burden of congenital heart defects in these countries,2 coupled with the paucity of specialised centres and the reported worse outcome of operations in the existing centres. These facts have stimulated concerted efforts to establish new sustainable centres3 and, importantly, developing strategies to improve outcome in the existing centres.

The Heart paper by Khan and colleagues4 is a welcome addition to the literature as it highlights the advantages, as well as limitations, of applying some of the recommendations of a collaborative programme developed by workers at Boston Children Hospital, and currently being applied completely, or in part, by 28 centres in low/middle-income countries.5 The authors report the effect of applying some of these recommendations, including enhancing hospital infection control and nurse empowerment to lead multidisciplinary teams on short-term outcome. The end points evaluated included wound site infection, Intensive Care Unit (ICU) stay, length of ventilation and 30-day mortality. There was a dramatic effect on surgical site infection and minor, or no effect, on the others. 

The authors are to be congratulated on both the initiative and the excellent quality of the methods of evaluation. The main limitations of this study are the small number of patients particularly those below the age of 1 year, and the short period of the follow-up. To deliver the desired overall objectives, the strategies should be, a) comprehensive, to include all or most components of the service, and b) deal with the large number of neonates and infants who need operations during the first year of life6 (figure 1), as well as neglected patients who present later with secondary functional or structural changes in the heart or other organs. As pointed out by the authors, the preoperative condition of the child, both in terms of nutrition and pre-existing pulmonary, cardiovascular or systemic infection, can be one of the important predictors of outcome. This can be improved by strategies targeting the socioeconomic status of the population, early referral and intensive preoperative corrective therapy.

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Figure 1

(A) The number of operations performed for transposition of great arteries (TGA), per year, at the Aswan Heart Centre and the annual mortality rate (%). (B) Number of operations for TGA according to age at operation. 

Other strategies include involving trainees,7 the use of check lists,8 minimising human error and regular audit that involves outcome analysis, outcome prediction and performance monitoring through a statistical approach, and more importantly, finding explanation for that outcome through a forensic approach.9

In conclusion, improving results of congenital heart surgery in low/middle-income countries, by climbing mount Excellence, is achievable, in the foreseeable future, but requires a collaborative organised effort and a strong will by all concerned.