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A surgical chief resident at Maine Medical Center, in Portland, Maine, United States of America, Dr Obieze Nwanna-Nzewunwa, speaks to GODFREY GEORGE about cardiac or heart surgeries in Nigeria
What is cardiac surgery?
The heart is basically a muscular pump, which has valves that only allow blood to flow in one direction. This pump is controlled by the “electrical cables” in the heart called the conducting system and it has tubes (blood vessels) that either bring blood to the heart (veins) or take blood away (arteries) from the heart. Cardiac surgery is a branch of surgery that involves operating on the heart or the blood vessels associated with the heart.
What are some of the reasons why people need cardiac surgery?
Historically, cardiac surgery was a dreaded operation, fraught with major complications, including death. However, in the 1950s, the “Heart-Lung Machine” was invented. This machine allowed cardiac surgeons the luxury of stopping the heart, affording the surgeons time to operate on the heart, and then restarting the heart, while the heart-lung bypass machine puts oxygen into the blood and pumps it to the rest of the body in place of the patient’s heart.
Heart attacks are a common cause of death worldwide and account for 16 per cent of deaths worldwide. Heart attacks are caused by a blockage of the blood vessels that nourish the heart. To prevent or treat this, an operation (coronary artery bypass) can be performed to the blockage and provide adequate blood supply to the heart muscle. This is the commonest adult cardiac surgery. In high-income countries, other surgeries may include heart valve repair or replacement and repair of heart birth defects. In low- and middle-income countries, there is an immense unmet need for cardiac surgery. Birth defects are a common reason for surgery in developing countries like Nigeria. Rheumatic heart disease is a complication of recurrent bacterial sore throat which leads to damage and dysfunction of the heart valves. RHD affects over 33 million people worldwide but is predominantly a disease in developing countries because of poor access to antibiotic treatment for bacterial sore throats.
Sometimes, the damage to the heart is so extensive that the heart is unable to perform its function of supplying blood to the rest of the body. This is called heart failure and there are varying levels of severity of heart failure. In the early stages, the heart can work harder to adapt or compensate for its failed ability to meet the body’s needs. In advanced cases of heart failure, the heart is unable to compensate anymore and needs to be artificially supported with mechanical devices or replaced altogether with another heart i.e. a heart transplant.
Are there risk factors that may necessitate cardiac surgery?
Certain conditions put one at risk of heart disease and ultimately needing cardiac surgery. These include birth defects, rheumatic heart valve disease (a consequence of poorly treated bacterial sore throat infection), poorly controlled diabetes, poorly controlled hypertension, high blood cholesterol levels, smoking and alcohol intake.
How do they present in patients?
The symptoms of heart disease can be variable. Some non-specific symptoms include chest pain, leg swelling, difficulty breathing, or shortness of breath that is worsened by exercise or walking may be seen in heart, respiratory, or even kidney disease. Shortness of breath that is worsened by lying down flat may point towards a cardiac cause than a respiratory cause. Other symptoms include, but are not limited to, palpitations, light-headedness, especially with exercise, fainting, or loss of consciousness.
When is a heart valve repair or replacement necessary?
The heart valves open and close to allow blood to flow forward in one direction. Sometimes, a valve may be too narrow, making it difficult for blood to flow outwards through the valve. Alternatively, a valve may be lax and not close appropriately, causing blood to flow backwards in the wrong direction. If either of these situations is severe enough, surgery may be warranted to either repair or replace the defective valve.
Is this different from a maze surgery?
Maze surgery is a procedure used to treat atrial fibrillation, one of the commonest electrical abnormalities of the heart.
Is there any link between kidney problems and cardiac surgery?
Kidney disease portends a higher risk for cardiac surgery. But if the benefit of cardiac surgery outweighs the risk, then a patient may be offered. To such a patient, dialysis may be used to temporarily support a failing kidney, if needed.
What exactly does a heart transplant entail?
When a patient’s heart fails, that heart is unable to pump blood to other organs and those organs are at risk of being damaged. About 2.4 per cent of American population suffers from heart failure. In Sub-Saharan Africa, similar population-based data is scarce, but hospital-based records show that 10-40 per cent of hospital admissions may be due to heart failure. To prevent further organ failure, it is crucial to support the failing heart. The first step is to use medications that reduce the workload of the heart and optimise its function. In some patients, medications alone are insufficient due to the severity of their condition. Such patients often require more advanced heart failure treatment options like a mechanical device to support the heart, either temporarily or permanently, or the patient may require a heart transplant.
How does it work? How is the heart used ‘sourced’?
A heart transplant is a surgical procedure where a failing heart is removed and replaced with a healthier heart from a donor. Since each person has only one heart, the donor heart usually comes from a deceased donor, typically a brain-dead patient, whose heart is otherwise in good condition. There are a series of tests and procedures in place to ensure that the donor and the recipient are a “match”, before going forward with a heart transplant. The first ever heart transplant was actually performed in South Africa by Dr Christian Barnard on December 3, 1967. Dr Barnard transplanted the heart of a 25-year-old woman who was severely injured in a car crash. Although Barnard’s first transplant patient only lived for 18 days before dying of pneumonia, this was the birth of cardiac transplantation. Today, more than half of cardiac transplant patients live for more than 10 years after their transplant.
A major breakthrough in cardiac transplantation occurred this year at the University of Maryland, where for the first time, a genetically modified pig’s heart was successfully transplanted into a human by Dr Bart Griffith. On January 7, 2022, 57-year-old David Bennet became the first human to survive a heart transplant from another animal species. He lived for another two months before passing away. Like Barnard’s patient, David’s success, though short-lived, is a landmark event that will be the impetus for further xenotransplantation surgery and research.
How successful is this kind of surgery in Nigeria?
This data is unavailable, most likely because there are few institutions performing cardiac transplants and these surgeries occur sporadically. The first open heart surgery in West Africa was performed at the University of Nigeria Teaching Hospital, Enugu on February 1, 1974, by Prof Fabian Udekwu alongside Sir. Magdi Yacoub. Since then, cardiac surgery in Nigeria has slowly evolved relative to the developed world. Today, only a few hospitals in Nigeria are capable of performing cardiac surgery in Nigeria. Many Nigerian public institutions are unable to offer open heart surgery due to a lack of adequately trained personnel, equipment, infrastructure, supplies, etc. The institutions that do offer cardiac surgery are unable to perform competitive, cutting-edge and complex surgeries, particularly open-heart surgeries. These surgeries are complex, high-risk, and expensive.
How expensive are they in Nigeria?
There are reports of centres in Lagos, Port Harcourt, Ibadan, Kano, Kaduna, Benin, Abuja and Maiduguri where cardiac transplants are possible at an estimated price of about N9.5m. About 97 per cent of Nigerians do not have any form of health insurance. Consequently, about 75 per cent of health care cost comes out of the pocket of patients and their families. Considering that about 40 per cent of Nigerians live under the poverty line, cardiac surgery would be unaffordable to the average Nigerian. Hence, many poor patients who get cardiac surgery often do so during medical missions from international partners. For cardiac surgery to be accessible to the public, there must be financial protection or insurance for the poorer citizen, who are often the ones that will need cardiac surgery. A revision and expansion of the National Health Insurance Scheme coverage may lessen this burden.
Furthermore, significant investments will be required to train and retain cardiac surgeons, cardiologists and allied medical providers. There is a need for improved cardiovascular diagnostic capabilities in Nigeria. Electrocardiography (ECG), echocardiography (echo), coronary angiography, CT and MRI scans need to be readily accessible for early detection, monitoring, and treatment of cardiovascular diseases. While the government has a key role to play in achieving the above goals, the role of non-profit organisations, and international partners (e.g. foreign universities and donor agencies) should not be minimised.
Nigeria undoubtedly has the human resource capital to achieve great feats in cardiac surgery domestically and abroad. However, the current landscape stifles her ascendancy to the position of a cardiothoracic surgical powerhouse in Sub-Saharan Africa. With the right investments, Nigeria could be the model and a hub or choice destination for cardiac surgical tourism in Africa. Such a feat will require significant stakeholder engagement and buy-in, as well as the inclusion of cardiovascular diseases and their surgical treatment as a key component of the Nigerian Health Plan.
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