Single Ventricle Palliation in a Developing Sub-Saharan African Country: What Should be Improved?

Abstract

Introduction: Single ventricle physiology management is challenging, especially in low-income countries. Objective: To report the palliation outcomes of single ventricle patients in a developing African country. Methods: We retrospectively studied 83 consecutive patients subjected to single ventricle palliation in a single center between March 2011 and December 2017. Preoperative data, surgical factors, postoperative results, and survival outcomes were analyzed. The patients were divided by palliation stage: I (pulmonary artery banding [PAB] or Blalock-Taussig shunt [BTS]), II (Glenn procedure), or III (Fontan procedure). Results: Of the 83 patients who underwent palliation (stages I-III), 38 deaths were observed (31 after stage I, six after stage II, and one after stage III) for an overall mortality of 45.7%. The main causes of operative mortality were multiple organ dysfunction due to sepsis, shunt occlusion, and cardiogenic shock. Twenty-eight survivors were lost to follow-up (22 after stage I, six after stage II). Thirteen stage II survivors are still waiting for stage III. The mean follow-up was 366 + 369 days. Five-year survival was 28.4 % for PAB and 30.1% for BTS, while that for stage II and III was 49.8% and 57.1%, respectively. Age (hazard ratio, 0.61; 95% confidence interval: 0.47-0.7; P ¼ .000) and weight at surgery (hazard ratio, 0.45; 95% confidence interval: 0.31-0.64; P ¼ .002) impacted survival. Conclusion: A high-mortality rate was observed in this initial experience, mainly in stage I patients. A large number of patients were lost to follow-up. A task force to improve outcomes is urgently required.

Prognostic value of the preoperative neutrophil‐lymphocyte ratio in patients undergoing the bidirectional Glenn procedure

“…In the present cohort, the median age at the time of surgery was older than that typically reported in developed countries. In Angola, less than 5% of CHD cases are diagnosed before 30 days of life, which is justified by such reasons as a lack of an adequately trained health system and socioeconomic constraints . In Brazil, diagnosis prenatally and before 30 days of life is higher than that in most African countries; however, the referral centers are not sufficient to promptly serve these patients; that is, the demand is higher than the supply.…”

“…Patients undergoing the Glenn procedure between January 2011 and December 2017 were enrolled retrospectively from the following institutions: Heart Institute (InCor) of Sao Paulo University (São Paulo, Brazil) and Clínica Girassol (Luanda, Angola) . The institutional review board from both participating centers approved the study (1.856.909—InCor and 287/CG/GEPP/2018—Clínica Girassol).…”

Palliation of Functionally Single Ventricle Patients in Sub-Saharan Africa—Is It Justifiable?

“…Manuel and coworkers report 2 indicates that embarking upon an FSV palliation program in sub-Saharan Africa requires more than operating room skills, state-of-the-art infrastructure, political priority, and financial support of patients. Adherence to tried-and-proven perioperative care protocols, continuity of care beyond hospital discharge with processes in place for parental education, and regular follow-up care are essential to obtain current acceptable outcomes.…”

“…In the report of Manuel and coworkers, 2 operative mortality was particularly high for stage 1 palliation: 45.2% for the modified Blalock-Taussig shunt and11.7% for pulmonary artery banding. Although smaller numbers were involved, the Glenn and Fontan procedures also had high operative mortality (16.7% and 20%, respectively).…”

“…Now, we have the opportunity to read in this issue of the journal, the results of single ventricle palliation in Angola reported by Manuel and coworkers. 2 But it is difficult to shake off the question—why would you add palliating single ventricles to this country’s problems?…”