On Tuesday morning, Peter Zilla, MD, of the University of Cape Town, and R. Morton Bolman, MD, professor of surgery, division of cardiothoracic surgery, University of Vermont, will present papers abd moderate a panel “Cardiac Surgery Intersociety Alliance: Cardiac Surgery For The Forgotten Millions.”
The AATS 99th Annual Meeting showcases the myriad of advances and progress in cardiac surgery that improve and extend the lives of millions of patients. Despite the decades of impressive progress in developing treatments, techniques, and technology in cardiac surgical care, a large population of patients in need remain untreated. Access to lifesaving cardiac surgery is beyond the reach of millions in the developing world.
An international conference convened the University of Cape Town to celebrate the 50th anniversary of the first human heart transplant by Dr. Christiaan Barnard was the scene of a movement led by Dr. Zilla to address the massive disparity in access to cardiac surgery among patients in need across the world.
Dr. Zilla commented, “With much support from the major cardiac surgical societies in its preparation – particularly during the 2017 AATS meeting in Boston – a ‘South-North Dialogue’ was organized for the day prior to the transplant anniversary that was attended by a large number of internationally renowned cardiac surgeons as well as the CEOs of major corporations, editors of the top cardiothoracic journals and representatives of all leading global cardiothoracic surgical societies. The outcome of this unique gathering, condensed in the ‘Cape Town Declaration,’ was the unanimous wish to replace the hitherto dominant cardiac surgical support from philanthropic, pediatric focused ‘missions’ to a globally supervised assistance towards building up local cardiac surgical capacity.”
The result was the Cape Town Declaration on access to cardiac surgery (CTD), a statement signed by leaders from the international cardiac surgery community, major cardiac surgery societies, the World Heart Federation, major players in the medical device industry, and governments to commit to addressing the worldwide problem of untreated rheumatic heart disease.
The CTD was published in nine cardiothoracic journals in December 2018. The scope of the problem is daunting, according to CTD. “Progress in prevention of RHD has been slow during the past 15 years, and thus, surgery will likely remain an integral part of RHD treatment for several generations. Lack of access to cardiac surgery services and the cost of valve replacement render this disease fatal for millions of patients. In endemic regions of low-income countries, the need for cardiac surgery is estimated at 300 operations per 1 million population ... yet the nearly 1 billion people living in Sub-Saharan Africa between the Maghreb and South Africa have access to only 22 cardiac centers. Although there is 1 cardiac center per 120,000 people in the United States, there is only 1 center per 33 million in Africa. Furthermore, RHD is not restricted to Sub-Saharan Africa. India, Pakistan, China, and Indonesia together account for 72% of mortality of RHD cases worldwide” (J Thorac Cardiovasc Surg. 2018 Dec;156:2206-2200).
Severely limited access to cardiac surgery is a challenge Dr. Bolman has been working on addressing for years. “A team founded in 2008 and led by me, along with my wife, Ceeya Patton Bolman, RN, MSN, a cardiac nurse, has been performing humanitarian cardiac surgery in Rwanda for the past 12 years on an annual basis. Every year, in patient screening, we encounter many more patients than we can offer surgery, and many will not survive until the arrival of another expatriate team. The patients upon whom we have performed surgery have benefited greatly, returning to school, or work and taking care of their families. Nonetheless, given the immense need that exists for cardiac surgery in countries like Rwanda (population 12M; 4 cardiologists; no cath lab; no permanent cardiac surgery), the real focus needs to be on establishing sustainable cardiac care. Indeed, the ultimate establishment of sustainability has been our major goal since we began our work.”
Implementation of the CTD will be carried out by the Cardiac Surgery Intersociety Alliance (CSIA). The mission of the CSIA at this point is, first, to identify potential sites for increased cardiac surgical care delivery in the developing world, and second, to evaluate training sites for providers to ramp up capacity for treating rheumatic heart disease.
Dr. Bolman noted, “This landmark collective agreement gives the societies added influence and allows them to address the challenge of global needs for cardiac surgery with one voice. The CSIA is dedicated to improving access to cardiac surgery in the developing world through increasing clinical cardiac surgery delivery and through training of critical providers in low and middle income countries. By educating providers in such settings, they will be trained in the diseases and working conditions that prevail in the countries where they will be working.”
Surgeons who want to be involved can have role in this ambitious project, said Dr. Bolman. “One critical feature of envisioned success for the programs selected by CSIA will be mentoring of the program surgeon(s). Even with all the resources assembled, and the critical caregivers in place, in order to provide the very best chance for program success, it will be desirable to make available senior mentorship for the program surgeons. It is very likely that US surgeons will have the opportunity to serve in this capacity, namely, as hands-on mentors and teachers, assisting new and/or growing established programs in establishing and maintaining sustainable cardiac surgery.”