Early experience with open heart surgery in a pioneer private hospital in West Africa: the Biket medical centre experience

Introduction More than forty years after the first open heart surgery in Nigeria, all open heart surgeries were carried out in government-owned hospitals before the introduction of such surgeries in 2013 at Biket Medical Centre, a privately owned hospital in Osogbo, South-western Nigeria. The aim of this paper is to review our initial experience with open heart surgery in this private hospital. Methods All patients who underwent open heart surgery between August 2013 and January 2014 were included in this prospective study. The medical records of the patients were examined and data on age, sex, diagnosis, type of surgery, cardiopulmonary bypass details, complications and length of hospital stay were extracted and the data was analysed using SPSS version 16. Results Eighteen patients comprising of 12 males and 6 females with ages ranging between 8 months and 52 years (mean= of 15.7 +/- 15 years) were studied. Pericardial patch closure of isolated ventricular septal defect was done in 7 patients (38.9%) while total correction of isolated tetralogy of Fallot was carried out in 5 patients (27.8%). Two patients had mitral valve repair for rheumatic mitral regurgitation. Sixty day mortality was 0%. Conclusion Safe conduct of open heart surgery in the private hospital setting is feasible in Nigeria. It may be our only guarantee of hitch free and sustainable cardiac surgery.

Also there has been a paradigm shift from the training of the cardiothoracic surgeon to the training of cardiac surgical teams [6]  The post-operative hospital stay was 9.1 +/-2.4 days (Table 3) and the 60 day mortality was 0%. There was one late death at 13 months after surgery due to chronic renal failure in the child with double outlet right ventricle and sub-aortic membrane.

Discussion
The median age of patients (5.25 years) reflects our focus on congenital heart disease and would have been much lower but for one 52-year-old man with symptomatic ventricular septal defect and mild pulmonary hypertension. It is essential to operate children with congenital heart disease as quickly as possible and feasible before the onset of severe pulmonary hypertension and severe cardiac decompensation which are time dependent so, most of our patients were highly selected with few co-morbidities. This decision is well supported by other previous pioneers [7] in open heart surgery to achieve success thereby boosting the morale of the staff and the general population. Ventricular septal defect is the most common congenital cardiac defect seen in Nigeria [8][9][10] while tetralogy of Fallot is the commonest cyanotic heart disease [9]. This was our repair in these patients with favourable mitral valve apparatus is recommended [11] as it precludes the adverse complications associated with prosthetic mechanical valves and anticoagulation including prosthetic valve thrombosis and embryotoxicity of warfarin [11][12][13][14].
The two patients were symptom-free at the 6-month follow-up clinic visit and trans-thoracic echocardiography done then did not show any deterioration in the degree of mitral valve regurgitation. Long term follow-up is being done on these patients. All cases were done using bicaval cannulation and antegrade cold blood cardioplegia and Page number not for citation purposes 4 the aortic cross-clamp and cardiopulmonary bypass periods were noted to be slightly longer in patients with tetralogy of Fallot (TOF) compared with patients with non-cyanotic heart disease though the difference was not statistically significant. This is not unexpected since the complexity of repair in TOF is greater than for the noncyanotic surgeries that were carried out in our series. Postoperatively, the patients were transferred to the intensive care unit and most had early extubation and weaning from mechanical ventilation after adequate recovery from anaesthesia using a fasttracking approach which is recommended even in the paediatric population by various authors [15][16][17]. This approach resulted in over 75% of our patients being discharged from the hospital within 8 days of surgery (Table 3). Re-exploration for bleeding was carried out in 1 patient-a 20 year old man with classic tetralogy of Fallot. At re-exploration, diffuse oozing was seen from the pericardial and pleural edges and a few bleeding points along the right atriotomy suture line that required diathermic coagulation, use of surgicel® (Ethicon Inc. San Lorenzo, Puerto Rico) and re-suturing over the suture line on the right atrium. Several researchers have previously discussed the defective coagulation in patients with cyanotic heart diseases, highlighting inferior clot formation occasioned by defects in both the intrinsic and extrinsic coagulation pathways [18][19][20].
This impairment in the clotting mechanism gets worse with time so that older patients with cyanotic heart diseases manifest worse clotting abilities than younger children hence the increased bleeding seen with this 20-year old man with tetralogy of Fallot.

Conclusion
The

Competing interests
The authors declare no competing interests.

Authors' contributions
Uvie Ufuoma Onakpoya designed and conceptualized this study. In addition, he was involved in acquisition, interpretation and analysis of data as well as preparing the manuscript. Adebisi David Adenle was involved in study design, acquisition and interpretation of data as well as preparing the final version of this manuscript. Anthony Taiwo Adenekan was involved in the study design, interpretation of data as well as in preparing the final version of this manuscript.