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Address for reprints: Michael T. Cain, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Denver, 12631 E. 17th Ave, C-310, Aurora, CO 80045.
Medical care in low-income countries is often limited by inadequate resources, treatment facilities, and the necessary infrastructure for healthcare delivery. We hypothesized that the development of an independently functioning, internationally supported Kenyan cardiac surgical training program could address these issues through targeted investment.
Methods
A review was conducted of the programmatic structure and clinical outcomes from January 2008 to October 2021 at Tenwek Hospital, Bomet, Kenya. Program development phases included (1) cardiovascular care provided by 1 full-time US board-certified cardiothoracic surgeon; (2) short-term volunteer surgical teams from the United States and Canada; and (3) development of a cardiothoracic residency program based on the Society of Thoracic Surgeons training curriculum. Patient demographics and outcomes were analyzed throughout each phase of program development.
Results
A total of 817 cardiac procedures were performed during the study period, including 236 congenital (28.8%) and 581 adult (71.1%) procedures. Endemic rheumatic valvular heart disease predominated (581 patients, 62.3%). Local surgical team case volume grew over the study period, overtaking visiting team volume in 2019. Perioperative mortality was 2.1% and consistent between the visiting teams and the locally trained teams. Surgical training via a 3-year cardiothoracic residency is now in its fourth year, with the 2 graduates now retained as full-time teaching staff.
Conclusions
Global health partnerships have the potential to address unmet needs in cardiac care within low- and middle-income countries. These data support the concept that acceptable clinical outcomes and consistent growth in volume can be achieved during the transition toward fully independent cardiac surgical care.
Cardiac surgical program development in low-middle income countries is facilitated by a dedicated, structured approach focusing on knowledge transfer and locally based surgeon training.
Cardiac surgical case volume has grown steadily at Tenwek Hospital, Kenya, over the past 13 years in response to a dedicated and structured approach to surgical knowledge transfer to a local surgical team. This approach has been extended to surgical trainees, allowing for exponential growth of the program from within the local team while maintaining high surgical quality.
Cardiac surgery in Kenya has its roots in the 1970s, with the first open procedure in Nairobi, Kenya, performed in 1973.
However, in the decades that followed, many of the initial cardiac programs that showed promise gradually ground to a halt. Similar challenges in sustainability have been reported by teams in Rwanda, Nigeria, Ethiopia, and Ivory Coast.
Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: building a platform for ultimate sustainability in a resource-limited setting.
Apart from financial resources, challenges have included the absence of sufficient surgeons, specialty physicians, and other professionals to support cardiac surgical programs. Maintenance of equipment and availability of important pharmaceuticals have also hampered sustainability of programs. The question remains, how do we develop sustainable cardiac surgical programs to meet the critical needs of populations in resource-limited settings?
Several approaches to solve this problem have been attempted over the past 4 decades. Visiting teams offering clinical services and “hospital safaris” became the norm, but skills transfer to local teams was limited, resulting in poor sustainability of programs. These fly-in missions acted as stopgap measures, but many question their effectiveness and whether each departure was detrimental to the morale of local hospital staff.
Despite efforts by the global community to address the disparities in cardiac surgical care, the deficiency in Africa persists. There is 1 cardiac surgery center for every 120,000 Americans, compared with 1 center for 33 million people in Africa and 0.12 to 0.08 surgeons per million population in sub-Saharan Africa.
Care disparities are compounded by the burden of cardiac disease in lower-middle income countries, particularly rheumatic heart disease (RHD). This is a unique burden in Sub-Saharan Africa as the RHD rate in children aged 5 to 14 years is 5.7 per 1000 individuals versus 0.5 per 1000 individuals in high-income countries.
In view of this, the cardiac surgical program at Tenwek Hospital in Bomet, Kenya, stands out as unique in its approach to building a cardiac surgical program in a lower-middle income country. Tenwek Hospital is a 380-bed hospital in Western Kenya located 240 km west of Nairobi. Established in 1937, it provides primary health care to 600,000 people within a 32-km radius and acts as a regional referral location for more complex surgical care. Surgical training has been central to Tenwek since the establishment of a general surgical training program in 2008. Five operating rooms provide facilities for a wide range of surgical services. Support services include a blood laboratory, diagnostic imaging, pharmacy, physical therapy, and dentistry services. The hospital is supported by a nursing school, a certified general surgery residency program, and a community health program.
We describe Tenwek Hospital's progressive transition toward independent cardiac surgical practice and development and implementation of a cardiac surgical training program, which aims to tackle the many challenges to cardiac surgical sustainability in Sub-Saharan Africa.
Program History and Development
A concerted effort toward addressing cardiac surgical needs at Tenwek Hospital began in the early 2000s with a sonographic screening study of patients presenting to Tenwek Hospital with suspected cardiac pathology. This survey mirrored the observations of others in the region
and demonstrated that approximately 65% of patients screened had identifiable cardiac lesions. In this cohort of patients, 6 demonstrated severe pure mitral stenosis. However, Tenwek Hospital was not equipped with a cardiopulmonary bypass machine at this time. As a result, the first closed mitral valvotomy was performed by Dr Russ White and Dr James Fingleton from Brown University in 2006 using a Tubb's dilator, given to Dr White as a keepsake during residency. This demonstrated a clear need for surgical cardiac care, and we therefore continued our screening program resulting in 15 additional closed mitral valvotomies. We quickly realized the limitations of this approach; therefore, Dr White, Dr Fingleton, and local Kenyan medical officers began sourcing equipment to support open procedures at Tenwek. The first series of open procedures were undertaken in 2008.
Over the next 8 years, fly-in missions were organized involving teams from Vanderbilt Children's Hospital, Nashville, Tennessee; Boston Children's Hospital, Boston, Massachusetts; Brown University, Providence, Rhode Island; and Halifax, Nova Scotia, Canada. These efforts involved intensive camps lasting 1 to 2 weeks at a time where 10 to 20 cases were performed at a time. These initial efforts included large complete visiting teams. Although these camps provided essential care, they contributed to staff burnout and placed a strain on the limited space and resources. Over time, transfer of skills became a core focus, with Kenyan staff receiving training and hands-on experience in screening patients with cardiac disease, performing integral parts of procedures and postoperative care. These influences improved not only cardiac care but also secondarily improved the trauma, medical, and pediatric intensive care unit care at Tenwek. By 2016, the local Kenyan team included dedicated nurse anesthetists, nurses, local perfusionists, and a Kenyan surgeon, and was led by Dr White. This team began performing low-risk open valve cases in 2016, subsequently progressing to more complex multiple valve and aneurysm cases, and low-risk congenital procedures.
Despite being able to perform approximately 80 to 100 operations per year and growing into a referral regional center, Tenwek's surgical waiting list persisted with an excess of 300 patients at any given time. Compounding this was an approximate 30% mortality rate observed on our waiting list. It became painfully apparent that even the establishment of a single local cardiac surgery team could not meet the need in the region. Aiming to meet this need, we shifted focus to establishing a formal cardiothoracic training program, asking a group of surgeons from Canada and the United States who had been visiting Tenwek over the years to become the first teaching faculty.
In 2018, this training program was established and since has expanded to include training for perfusionists, cardiac anesthesiologists, echocardiography technologists, and cardiac critical care nursing. This transition was stress tested with the onset of the COVID-19 pandemic in 2020, during which fly-in missions at Tenwek came to an abrupt halt. This forced the local Kenyan team (Figure 1) to meet the challenge of continued service provision without fly-in teams. To expand the infrastructure to meet current and future need, Tenwek began construction on a significant expansion in March 2021, which is scheduled to be completed in March 2024.
Figure 1Local Tenwek cardiothoracic surgical team members and international partners.
Upon committing to development of a cardiothoracic program at Tenwek Hospital, US, Canadian, and Kenyan physicians studied the idea carefully and created a structured approach through expert opinion to select sites for developing sustainable cardiac surgery programs in underserved, low- and middle-income countries. Critical to the development of such a program was a committed local stakeholder to help provide continuity and coordinate the local efforts as the program developed. At Tenwek, Dr Russ White has fulfilled this roll. Next, assurances that local infrastructure including inpatient wards, intensive care unit care, operative space, and staff to operate these spaces must be established. A timely and accurate laboratory, and a pathway for blood banking, further facilitate effective patient care. At Tenwek, component blood products are rare; however, a reliable pathway for whole blood transfusion has been generated. Next, pathways to supply the specialized equipment for this resource-intensive surgery must be established. Our facility is fortunate to have on-site access to a 128-slice computed tomography (CT) scanner with 24-hour technician availability, greatly adding to patient care. Off-site radiologists provide CT scan interpretation. Magnetic resonance imaging and positron emission tomography CT are limited and most closely accessible in Nairobi, 300 km away. At Tenwek, donated equipment from visiting teams, institutions, and industrial partners has greatly facilitated patient care.
A committed and reliable onsite workforce has been critical to success at Tenwek. We have developed a full complement of outpatient and inpatient services spanning pediatric and adult populations. Our general surgical residency program runs under the College of Surgeons of East, Central, and Southern Africa (COSECSA) accredited faculty. There are 2 full-time cardiac anesthesiologists, 4 full-time cardiac sonographers, and a robust group of cardiologists from the United States who support diagnostic interpretation and are part of visiting teams who frequent Tenwek.
Perioperative Outcome Analysis
A retrospective review of all patients who received cardiac surgical intervention at Tenwek Hospital, Bomet Kenya, was conducted from the initiation of a formal cardiac surgical program in 2008 until July 2021 after receiving ethics approval by the Tenwek Ethics and Research Committee. All pediatric and adult patients were included. Preoperative patient characteristics and disease characteristics were recorded in addition to the distribution of procedures performed, operative characteristics, and postoperative morbidity and mortality. Detailed postoperative follow-up was maintained in this cohort of cardiac surgical patients such that no patients were lost to follow-up. A survey of the operative surgical teams was conducted with specific focus on categorizing the operative team into 2 groups: (1) short-term volunteer surgical teams and (2) a local cardiac surgical team. This period included several important phases of development. First was the initiation of a cardiothoracic surgical training program in 2018, and the second was the onset of the COVID-19 pandemic with significant travel restrictions imposed in March 2020, preventing visitation by short-term surgical teams.
Patient demographics, operative characteristics, and outcomes were analyzed to allow for characterization of the extent of systemic and intrinsic cardiac pathology. Patient mortality data were collected for all patients including long-term follow-up with a specific focus on identifying cardiac-related deaths.
Results
During the study period, 817 cardiac surgical procedures were conducted at Tenwek Hospital. The age of these patients ranged from 3 months to 73 years. Congenital heart defects were present in 236 patients (28.9%), with the remaining patients most commonly having valvular RHD (Table 1). During the study period, overall annual case volume generally increased annually for both acquired adult procedures and congenital cardiac procedures. This increase was progressive including time periods after the development of the cardiothoracic surgical training program and during the early phase of the COVID-19 pandemic despite the absence of short-term visiting cardiac teams at Tenwek (Figure 2).
Table 1Distribution of case type during the study period
Figure 2Annual case volume at Tenwek Hospital categorized by the lead surgical team performing each procedure. Surgical volume steadily increased over the study period with local team volume overtaking visiting team volume in 2019.
During the study period, the proportion of cases being performed by the local surgical team steadily increased across both acquired and congenital procedures (Figure 2). During the first 5 years of program development, the local team performed 0% to 14% of acquired cases independently annually and 0% to 50% of congenital cases annually. In the subsequent 5 years, these rates increased to 11.1% to 97.0% annually for acquired procedures and 3.4% to 100% for congenital procedures.
Congenital procedures consisted primarily of repair of tetralogy of Fallot (67 patients, 28.3%), closure of ventricular septal defect (53 patients, 22.4%), closure of atrial septal defect (39 patients, 16.5%), ligation of patent ductus arteriosus (42 patients, 17.7%), and repair of coarctation of the aorta (11 patients, 4.7%). Acquired heart disease was dominated by rheumatic valvular disease (581 patients, 62.3% of all cases). Repair of thoracic aortic aneurysms and coronary arterial bypass procedures have been performed but are rare in our experience (Table 1). Thoracic aortic surgery has been a recent addition to our repertoire, with 31 of 32 cases (96.9%) performed in the last 3 years with 1 mortality observed after attempted repair of acute type A dissection. The majority of patients with RHD experience single valve pathology, with 43% having mitral disease alone; however, double and triple valve involvement are still common with 37% of patients having mixed mitral and aortic valve disease, and 19% of patients with triple mitral, aortic, and tricuspid valvular pathology. As a result, single valve intervention was most frequent, taking place in 54% of patients. Double and triple valve interventions occurred in 28% and 11% of patients, respectively, with commissurotomy or balloon valvuloplasty in 7% of patients too ill to undergo valve replacement. Valve replacement was more common than repair, with 66% of patients receiving mechanical valves and 13% receiving bioprosthetic valve replacements. Case complexity has been increasing over time, with a greater proportion of valvular cases undertaken being of a multivalve variety over the past 4 years (Figure 3).
Figure 3Annual case volume at Tenwek Hospital categorized by single valve and multiple valve procedures. Surgical volume steadily increased over the study period with a greater proportion of multi-valve procedures during recent years.
Long-term follow-up of all patients revealed an overall all-cause mortality of 8.6% in this cohort of patients over the 13-year study period. Perioperative 30-day mortality was 2.1% during the study period. Perioperative mortality was comparable between visiting teams (10/499, 2.0%) and local teams (7/318, 2.2%) during the study period. Perioperative morbidity was generally rare, with postoperative symptomatic pericardial effusion requiring drainage being most common in 12 patients. Progressive bioprosthetic valve restenosis was a severe complication requiring reintervention in 5 patients and progressive decline and death in 4 patients. Postoperative permanent pacemaker need was rare (5 patients, 0.6%), as were infectious complications of surgical site infection and mediastinitis (7 patients, 0.86%).
Cardiothoracic Training Program Outcomes
Structured cardiothoracic training has been in place at our institution since 2017 as part of a 3-year training fellowship after completion of general surgical training. A training curriculum was developed for these fellows under the auspices of COSECSA, which used the Society of Thoracic Surgeons Curriculum as a model from which the COSECSA Cardiothoracic Training program was based on, with accreditation guidelines provided by the College. Unique to the COSECSA training program are areas of emphasis that reflect the African epidemiological disease burden. Applications are made to COSECSA annually and competitive candidates interviewed by faculty at Tenwek Hospital.
A total of 4 surgeons have graduated from this program (1 in 2020, 3 in 2021), all of whom have successfully passed oral and written examination certified by COSECSA. Two of these graduates are retained as teaching faculty at Tenwek Hospital. Trainees have represented 3 different African countries and are trained broadly in both thoracic and cardiac pathology. Trainees complete 2 years of education at Tenwek Hospital and complete their final year of training through partnership with a sponsoring institution for greater exposure to senile valvular pathology and coronary arterial disease, as well as minimally invasive techniques not available at Tenwek.
Discussion
In the last 30 years, congestive heart failure has remained 1 of the top 10 causes of medical morbidity and mortality in our hospital and the country at large. In the pediatric population, RHD is the leading cause of congestive heart failure, followed by congenital lesions. In the adult population, it is the third leading cause of death after hypertension and diabetes.
This large burden of endemic RHD observed in the region led us to undertake the previously noted echocardiographic screening exercise of 120 patients with suspected RHD from clinical examination. Of these, 27 patients had normal echocardiography examination results, 54 patients had established RHD, 35 patients had congenital heart disease, 1 patient had tuberculous pericarditis, 1 patient had cor pulmonale, and 2 patients had cardiomyopathy. Of those who had RHD, 6 had pure mitral stenosis.
This survey brought acutely into focus the need for cardiac surgical care at Tenwek Hospital. We present our approach to development of a cardiac surgical program in sub-Saharan Africa. Our program has stabilized, with increased volume and complexity since its inception over 10 years ago. We have demonstrated consistency in 30-day mortality throughout the phases of program maturation, and we have been successful in our ultimate mission of facilitating knowledge transfer to local Kenyan cardiothoracic surgeons, allowing for independent provision of cardiac surgical care and establishment of a cardiothoracic surgery training program.
The establishment of a stable cardiac program in Kenya with surgical training capability is of great public health importance for the region and a crucial component of battling RHD. Over the past few decades, numerous international organizations have advocated for the establishment of permanent and accessible care and centers of excellence in the treatment of RHD.
They call for local training of providers as a core element in providing this care to the region and highlight the instability of “fly-in” cardiovascular care—especially after the COVID-19 pandemic resulted in significant travel restrictions. As a result of the pandemic, supportive fly-in teams were absent from Tenwek Hospital for an 18-month period, and all cases performed at Tenwek during that time were done by an independent local team. Unique circumstances like these highlight the need for deliberate efforts to emphasize knowledge transfer and develop independence of local surgeons and peri-surgical staff. This has long been the focus at Tenwek, and therefore surgical volume and quality were maintained during this critical time period.
Although access to cardiac surgical services in low-income countries is largely absent, low-middle income countries and middle-income countries like Kenya often offer cardiac surgical care but in a limited manner, with a steep urban-rural gradient in the availability of this care. This consolidation of care in urban centers leaves large swaths of the population in a desert devoid of cardiac surgical services.
Tenwek Hospital has been uniquely positioned to address this issue because it is notably rurally located and therefore can better serve those at highest risk for acquired RHD or late presentation of unrecognized congenital heart disease. Provision of cardiac surgical care in this environment is undoubtedly a costly endeavor; however, there are great long-term economic and societal benefits to providing this care.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
Repair of cardiac lesions in these young patients can allow for severely debilitated individuals with many productive years ahead of them to reintegrate into their families and society as able, productive contributors for many years. The disparity in services and steep rural–urban gradient is observable in Kenya, where 16 active cardiac surgeons service the population of 50 million people across 4 main institutions. Tenwek provides approximately half the surgical cardiac care in the region and has become a referral hub for Eastern Africa with patients traveling as far as Togo, Gabon, and Niger.
Cost of care is an ongoing challenge in this environment. Most patients are on the National Hospital Insurance Fund, which covers approximately half the cost of the open procedures. The patients are then largely responsible for the rest of the cost; however, there is considerable philanthropic humanitarian efforts made by the hospital for those who cannot afford to cover the remainder of the cost through community donation or personal wealth. Although philanthropy in care is a core tenant at Tenwek Hospital, sustainability of this model is an ongoing challenge. During the early years of this program, donated resources by visiting teams were central to providing care. We have since developed partnerships that allow for locally sourced prosthetic valves and supplies to allow for ongoing surgical care between visiting teams.
An important component to the current success at Tenwek undoubtedly has been the sequential nature of progression toward independent practice. This sequential progression has been critical to maintenance of high-quality care throughout the duration of the program, as evident by consistently low perioperative mortality rates through all phases of program development, consistent with similar programs in the region (2.0% with visiting surgeons, 2.2% with independent local surgeons).
Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: building a platform for ultimate sustainability in a resource-limited setting.
Maintaining high-quality care has been critical in establishing community trust, bolstering team and hospital staff morale in caring for critically ill patients, and building a regional reputation and referral base. Additionally, the maintenance of quality care has allowed for development of a cardiothoracic training program that further bolsters a culture of inquiry and commitment to learning throughout the institution, as it does in many other academic centers. The training of the past 4 cardiothoracic fellows with 2 current fellows at Tenwek Hospital, with a 100% board pass rate, is potentially the most impactful legacy of this program, because these surgeons go on to provide cardiothoracic care throughout the region. Unique to this program has been the progressive development of training of associated members of the cardiothoracic team, including establishment of a formal perfusionist training program in 2020 and evolving training in cardiac anesthesiology, critical care, and cardiology. These associated training effects have opened the potential to train entire Heart Teams at Tenwek Hospital who can serve other regional communities.
Study Limitations
Our study is limited by the retrospective nature of its design. Although concerted efforts at longitudinal follow-up for all patients are made, long-term postoperative follow-up is limited in this study due to the dispersed, rural character of the community that Tenwek Hospital serves and the inherent limitations in close follow-up monitoring and follow-up diagnostic testing in this resource-limited environment. Additionally, we recognize that the methodology used at Tenwek maay not be transferrable to other communities and countries within the region because there are vast cultural, economic, and political differences between countries in Sub-Saharan Africa that directly impact resource allocation, physician training, and financial support for specialized surgical care.
Conclusions
We present a model for establishment of cardiac surgical care in Sub-Saharan Africa that emphasizes transfer of surgical knowledge and establishment of a surgical training paradigm to foster sustainability. Emphasis on surgical quality of care has been critical to establishing regional trust in this program and has facilitated its growth as a regional referral center for cardiac surgical care in Sub-Saharan Africa.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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A glimpse of hope: cardiac surgery in low- and middle-income countries (LMICs).
Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: building a platform for ultimate sustainability in a resource-limited setting.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
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