Ten Year Clinical Experience of Humanitarian Cardiothoracic Surgery in Rwanda: Building a Platform for Ultimate Sustainability in a Resource- Limited Setting

Abstract

Objective: Despite its near complete eradication in resource-rich countries, rheumatic heart disease (RHD) remains the most common acquired cardiovascular disease in sub-Saharan Africa. With a ratio of physicians/population of 1/10,500—including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource-limited setting lacking the local capacity to detect and treat early cases of strep throat and perform life-saving operations for advanced RHD. Humanitarian surgical outreach in this region can improve delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer; and, ultimately—the creation of a cardiac center. Methods: We describe the experience of consecutive annual visits to Rwanda since 2008 and report outcomes of a collaborative approach to enable sustainable cardiac surgery. The Ferrans and Powers Quality of Life Index (QLI) tool’s Cardiac Version (http://www.uic.edu/orgs/qli/) was administered to assess postoperative quality of life. Results: Ten visits have been completed, performing 149 open procedures—including 200 valve implantations [NYHA class III or IV] with 4.7% 30-day mortality. All procedures were performed with participation of local Rwandan personnel, alongside expatriate physicians, nurses, residents and support staff. Early complications included CVA (n=4), hemorrhage requiring re-operation (n=6) and death (n=7). Quality of life (QOL) was assessed to further understand challenges encountered after cardiac surgery in this resourcelimited setting. Four major domains were considered: Health and Functioning, Social and Economic, Psychological/Spiritual, and Family. The mean total quality of life index was 20.79 ± 4.07 on a scale from 0-30, where higher scores indicated higher QOL. Women had significantly lower "Social and Economic" sub-scores (16.81 ± 4.17) than men (18.64 ± 4.10), (p < 0.05). Patients who reported receiving their follow-up care in rural health centers also had significantly lower "Social and Economic" subscores (15.67 ± 3.81) when compared to those receiving follow-up care in urban health facilities (18.28 ± 4.16), (p < 0.005). Value afforded to family as well as psychological factors remained high among all groups. Major postsurgical challenges faced included barriers to follow-up and systemic anticoagulation. Conclusions: This report represents the first account of a long-term humanitarian effort to develop sustainability in cardiac surgery in a resource-limited setting. Utilizing volunteer teams to deliver care, transfer knowledge, and mentor local personnel, the results demonstrate superior outcomes and favorable indices of quality of life. The credibility gained over a decade of effort has created the opportunity for a partnership with Rwanda to establish a dedicated center of cardiac care to assist in mitigating the burden of cardiovascular disease in Rwanda and sub-Saharan Africa.