Advances and Challenges in Global Cardiothoracic Surgery

Written by: Anna Casey

Brighton and Sussex Medical School

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Introduction

Global cardiothoracic surgery relates to the global provision of cardiothoracic surgery. Across the world, 6 billion people lack access to safe cardiac surgery, and cardiovascular disease remains a leading cause of morbidity and mortality, with Rheumatic Heart Disease (RHD) and congenital heart defects the leading pathologies requiring surgical management in Low- and Middle-Income Countries (LMICs) (1,2). Disparities in access remain a major issue (1,3–5), meaning that conditions that can be managed relatively easily in High-Income Countries (HICs) can be fatal in areas without access to these services (1). Ensuring equitable access to cardiothoracic surgery is important also because in the coming decades, an epidemiological shift in LMICs is predicted to increase the impact of cardiovascular disease (among other pathologies) relative to previous noncommunicable diseases, according to the Lancet Commission on Global Surgery. This, coupled with the existing lack of services, provides strong justification for addressing this disparity between countries.

Advances

In the previous few decades, some advances have been made in the provision of global cardiothoracic surgery. Fuelling this has been perhaps the greatest advance - that of increased understanding of needs and availability of existing services (4). However, awareness is insufficient to address inequality on its own, and must be used to make tangible progress. In this area, advances include an increasing availability of services (4), leading to decreasing gaps between HICs and LMICs (6). Agreements such as the Cape Town Declaration on Access to Cardiac Surgery in the Developing World (1) are a step in the right direction, as international collaboration is doubtless critical to ensuring this issue is addressed.

Challenges

Despite these advances, there is still need to go further in action to address inequalities across the world. Certain areas of particular need are the remaining lack of access to cardiac surgery, the importance of having qualified staff in areas of need and financial implications of increased cardiothoracic surgical provision (6). The discussion around qualified staff ‘on the ground’ leads to technical questions regarding cardiac surgery itself, as well as training needs. In LMICs, there is a lack of practical skills in valve repair among surgeons due to the lack of cardiac surgical centres (4) – but addressing this is difficult, as training surgeons in HICs leads to them being exposed to a different patient demographic (typically older adults) than in their home countries (1). Furthermore, there is difficulty in finding suitable replacement valves, as well as practical anticoagulation difficulties specifically in low-income countries (4). Middleincome countries, on the other hand, are experiencing a widening gap between private and public health provision, as well as an increasing divide between rural and urban settings (4).

Conclusion

In conclusion, global cardiothoracic surgery has undergone much change in the past decade, with important advancements making it much more accessible. However, massive global disparities persist. Efforts to address these must continue, in order to provide this essential service to everyone who needs it. The more well-understood the limitations in provision are, the more targeted solutions can be, but it is also important to not let research overshadow the importance of healthcare provision.

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References

1. Zilla P, Bolman RM, Yacoub MH, Beyersdorf F, Sliwa K, Zühlke L, et al. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World. Cardiovasc J Afr. 2018 Aug 23;29(4):256–9.

2. Zilla P, Yacoub M, Zühlke L, Beyersdorf F, Sliwa K, Khubulava G, et al. Global Unmet Needs in Cardiac Surgery. Glob Heart. 2018 Dec 1;13(4):293–303.

3. Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S, et al. Cardiac Surgery Capacity in Sub—Saharan Africa: Quo Vadis? Thorac Cardiovasc Surg. 2014 Jun 23;62(05):393–401.

4. Zilla P, Bolman RM, Boateng P, Sliwa K. A glimpse of hope: cardiac surgery in lowand middle-income countries (LMICs). Cardiovasc Diagn Ther. 2020 Apr;10(2):336–49.

5. Vervoort C. Global cardiac surgery: a wake-up call. Eur J Cardiothorac Surg. 2019 May 1;55(5):1022–3.

6. Pezzella AT. Global Cardiothoracic Surgery Advances and Challenges in Developing Countries and Emerging Economies. [cited 2021 Apr 9]; Available from: /article/global-cardiothoracic-surgery-advances-and-challenges-developingcountries-and-emerging