Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA)

Abstract

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Keywords: Developing countries; Sustainable cardiac surgery.

Figure 1:

The 7 principles underlying a CSIA agreement as published in the ‘Calls for Proposals to be a Pilot-Site’ in 2019 [50]. Inserted in red are the complying criteria for the Mozambiquean site selection. CSIA: Cardiac Surgery Intersociety Alliance; CEO: chief executive officer; Gov.: government; NGO: non-governmental organization; RHD: rheumatic heart disease; TSF: Thoracic Surgery Foundation

Figure 2:

Signing of bilateral Cardiac Surgery Intersociety Alliance Mentorship Agreement between the Mozambiquean Government/Maputo Central Hospital and the University of Cape Town.

Figure 3:

Mentored cardiac surgery performed in Rwanda by Rwandan team.

Figure 4:

Mentorship visit by team of the University of Cape Town at Maputo Central Hospital, Eduardo Mondlane University, Mozambique. While scrubbed in, the University of Cape Town team strictly observed the principle of the local team performing the operation.

Figure 5:

When CSIA was established in 2018, neither Latin America nor Africa had fully fledged continent-spanning Cardiac Surgical Societies. As from 2023 CSIA lives up to a global claim by having admitted Latin American Association of Cardiac- and Endovascular Surgery and Pan African Societies for Cardiothoracic Surgery at its meeting during the annual European Association for Cardio-Thoracic Surgery congress in Vienna.

Figure 6:

The CSIA ‘Seal of Approval’ represents the underlying principle of the alliance: the adherence of a programme to the principle of local capacity-building and the commitment to focus on rheumatic heart disease in accordance with its incidence. CSIA: Cardiac Surgery Intersociety Alliance.