A glimpse of hope: cardiac surgery in low- and middle-income countries (LMICs)

Abstract

Currently, more than five times more people live in low- and middle-income countries (LMICs) than in high-income countries (HICs). As such, the downward trend in cardiac surgical needs in HICs reflects only the situation of one sixth of the world population while the vast majority living in LMICs has still no or limited access to life saving heart operations. In these countries, rheumatic heart disease (RHD) still accounts for a significant proportion of cardiac surgical needs. In low- and lower-middle income countries it remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery outweighing other indications such as congenital cardiac defects almost 4-fold. Compared to HICs with their predominance of calcific aortic stenosis in the elderly mitral valve surgery is required in >90% of the largely young patients with RHD in low-income countries (LICs) and still in 70% of the often middle aged patients in middle-income countries (MICs). Although recent government initiatives in LICs led to the establishment of local, independent cardiac surgical services gradually replacing fly-in missions, these centers still only cover less than 2% of the needs of their populations. In MICs, cardiac surgical needs continually grow with the emergence of degenerative diseases. As such, in spite of the concomitant growth of cardiac surgical capacity, significantly less than half the estimated patients in need have access. Capacities in LICs range from 0.5 to 7 cardiac operations/million population; 100-481/million in MICs and >1,200/million in HICs such as the USA and Germany. While a new level of awareness of the scope and magnitude of the problem has begun to emerge in LICs and the establishment of local cardiac surgical capacity has given rise to a glimpse of hope, the challenges of expanding these fledgling services to a significant proportion of the population still seem insurmountable. Challenges in MICs are on the other hand the widening gap between private cardiac medicine for the affluent few and overwhelmed public services for the many and the rural urban divide with the underappreciation of the ongoing dominance of RHD in the rural and indigent population on the other. Overshadowing all LMICs is the low level of valve-repair skills associated with insufficient cardiac surgical capacity and the unavailability of suitable replacement valves which address the young age of the patients and the difficulties of anticoagulation in a socioeconomic environment distinctly different from the elderly patients of HICs.

Keywords: Cardiac surgical needs; low- and middle-income countries (LMICs); operative capacity.

Figure 1

Gap between de-facto performed cardiac operations per million population (black lined white circles) and estimated patients in need of cardiac surgery (4-colour graph). The colours differentiate between operations needed for degenerative and life-style diseases (DEGEN) (e.g., coronary bypass operations; aortic valve replacement for calcific aortic stenosis); rheumatic heart disease (RHD); congenital heart defects (CHD) and other diseases affecting the heart and the aorta (OTHERS). From left to right reflects the changing needs as countries gradually transition from developing low-income countries (LICs) to industrialised high-income countries (HICs). While the incidence of CHD remains relatively unaffected by this transition, that of RHD declines as that of degenerative diseases increases. The 4-fold overall increase of non-congenital cardiac surgical needs during the transition from LIC to HIC is the result of a non-linear increase in degenerative diseases. Estimates of the respective positions of typical representatives of LICs, MICs and HICs on this graph were based on key indicators such as proportion of coronary artery bypass procedures and urbanization (2). Total numbers reflect the status-quo of 2017 (2). The congruence of needs and operations performed in the USA and Germany highlights the fact that affluence can eventually close a gap that does not only prevail in LICs but also MICs. [amended from (2) with permission].

Figure 2

Percentage of patients undergoing heart valve surgery who need mitral/aortic valve interventions in LMICs versus HICs. The largely rheumatic pathology in LICs would require mitral valve interventions in almost all patients presenting for surgery below the age of 30 (9,59) and in three quarters of urban middle-aged patients in MICs (60). Although aortic valve surgery is still required in half of all patients with RHD, 9 out of 10 of these also need mitral valve replacement/repair (59,60). In contrast, in the mostly elderly patients of HICs with their typically degenerative diseases, the aortic valve is the primarily affected heart valve—in a majority without co-affecting the mitral valve (56-58). LMICs, low- and middle-income countries; HICs, high-income countries; LICs, low-income countries; RHD, rheumatic heart disease; AV, aortic valve; MV, mitral valve.

Figure 3

Poor suitability for LMICs of heart valve prostheses that were developed for the epidemiologic and socioeconomic circumstances of patients from HICs. (A) Typical emergency operation for a clotted mechanical valve prosthesis inserted in a young rheumatic patients from a poor socioeconomic background (reproduced from Eur Heart J with permission) (71); (B) degenerated bioprosthetic heart valve after four and a half years of implantation in a 28-year-old woman with rheumatic heart disease whose anticipated ability to comply with anticoagulation was low. Leaflet immobilisation through calcification was additionally aggravated by pannus overgrowth. LMICs, low- and middle-income countries; HICs, high-income countries.

Figure 4

Cardiac surgical operations per million population assessing 16 LMICs comprising 3.6 billion inhabitants. Numbers were derived from a global study determining needs in 2017 (2). LMICs, low- and middle-income countries.

Figure 5

Level of actually performed cardiac surgery related to the individual needs of a country. The percentages depicted represent mean values thereby masking country-specific social, geographic or political diversities. In countries with a high Gini index like South Africa, for instance, the overall 32% of the population with access to heart operations comprise the 83% who depend on public services and have a low access level of 20% and the 17% on private medical aid with practically 100% access to cardiac surgery. It equally does not take geographic differences into account. In Russia, for instance, all cardiac surgery is offered in public hospitals. Yet, the 44% represent a mean value between diverse regions such as the North-West and the Caucasus. In spite of this underlying heterogenicity of the national situations the mean values of the included countries correlate with their developmental status.

Figure 6

North-South gradient of the role public services play in offering cardiac surgery. In Russia, all heart operations are provided in public hospitals. In China, private cardiac centres are negligible although all of the almost 4,000 cardiovascular surgeons are allowed to work at multiple places (e.g., public and private). The government’s medical insurance largely covers 50% of the medical cost during any admission even in private hospitals and patient contribution is significant also in the public sector. In Brazil, the law provides every citizen with free health-care but the system is strained. As all cardiac centres, public and private, provide surgery to public patients, the state insurance system (Unified Health System) covers open-heart surgery for 83% of the population in 100% of hospitals even if a significant proportion of heart centres is private. In India, even in government hospitals, patients still need to contribute 1,000 to 2,000 USD to a cardiac operation as opposed to 3,000 to 5,000 USD in a private facility. Of all cardiac hospitals, <10% are public. Government or state employees get part of their expenditure reimbursed if they get operated on in a government-endorsed private hospital. In South Africa, 87% of the population receive 29% of all cardiac operations in public hospitals while the remaining 71% of heart operations are performed on the 17% private patients in private hospitals (2).