It is difficult to be a dispassionate observer at a PCR Course organised by Europa Organisation. Sessions are designed to stimulate audience participation and dialogue, and AfricaPCR 2015 exemplified that approach.
Held from the 26 – 28 March at The Forum, The Campus, in Bryanston, Johannesburg, the 2015 Course had an audible buzz with delegates being as interactive as the presenters, making for highly stimulating and informative sessions, with much take-home value.
Case studies were particularly interesting because they were not presented as “show and tell” exercises. Speakers presented the images pertaining to their respective cases, identified the challenges, but did not disclose how they had handled them. Instead, they invited the delegates to comment and debate how they would have treated the patient. Audience consensus or divergence regarding recommended strategies inevitably led to lively discussion, resulting in a “Yes” or “No” vote for specific procedures. Case studies were rounded off by the speakers disclosing how they actually treated their respective patients, with the chairman of the session summarising the learning points.
Special focus on congenital heart disease
An informative 90 minute session for allied professionals on congenital heart disease was guided by faculty members, Dr Kenny Govendrageloo, Dr Colin Schamroth, cardiac clinical technologist, Bev Leahy, and radiographer Jeni Chick.
In his address on ‘Foetal developments and changes at birth’, Dr Govendrageloo pointed out that the heart is the first organ to be formed during embryogenesis. He highlighted that as the oxygen saturation levels in the foetus are lower than the mother’s level, the foetus lives in a hypoxic environment. More specifically, the saturation at the placental level is 80%, but drops to 62% in the foetus. He pointed out that cessation of placental blood flow takes place at birth, with closure of patent foramen ovale (PFO) usually taking place within the first 12 months of life. Should the PFO not close, then there will be a persistent shunt from the left to right side of the heart.
In his talk on ‘Treating Atrial septal defect: hole in the heart’, Dr Govendrageloo commented that atrial septal defects (ASDs) are usually asymptomatic and often missed clinically, but that they can be diagnosed when a heart murmur is detected. There are three potential locations for ASDs in the atrial septum and their location and size will determine the manner in which they are treated – either surgically with an autologous graft, or with a device. He stressed that it is crucial to close an ASD early as this allows for remodelling as the child develops.
In his talk on ‘Patent foramen ovale: to close or not to close’, Dr Colin Schamroth identified that up to 30% of all patients have a PFO, with many being asymptomatic. However in younger patients presenting with stroke or transient ischaemic attack, the incidence is much higher. He listed four treatment options for PFOs which included: doing nothing; medicating the patient; intervening surgically or using a closure device.
According to the meta-analysis shown by Dr Schamroth, closure devices are better than medical treatment, but he did point out that there may still be a residual shunt or thrombus formation following the procedure. It is therefore extremely important to exclude clotting factors in patients with PFOs. He closed his talk by stating that healthcare providers should treat patients after the first thrombotic event and not wait for a second event.
In the last talk of the session, Bev Leahy and Jeni Chick discussed the important factors associated with the ‘Clinical interpretation of congenital heart defects’. Leahy commented that heart murmurs in paediatric patients are usually detected by a general practitioner who then refers the patient to a paediatric cardiologist who will perform an ECG and chest X-ray to determine if an ASD is present.
Due to the nature of this condition, the paediatric cardiologist will request a colour Doppler to visualise the ASD, and transoesophageal echocardiography (TEE) will be used to determine the size of the ASD and its suitability for treatment with a closure device instead of surgery. The patient then undergoes cardiac angiography to confirm the diagnosis of an ASD.
When PFO is suspected in a patient, contrast echocardiography is used to diagnose a PFO, with TEE, however, being the gold standard. The paediatric cardiologist may also perform a bubble test on the patient when a PFO is suspected, but no obvious flow is detected on the contrast echo.
Setting up new cath lab in Africa
Another highlight at the Course was a special focus on the necessity for setting up more cath labs in Africa. Discussion centred on what the basic requirements were for paediatric and adult cardiology diagnostic and interventional procedures in the cath lab.
A few major challenges were identified. A shortage of equipment, or inadequate maintenance of equipment, appeared to be a common problem in some African countries. There are currently 14 cath labs in Sudan, for example, but none with the equipment needed to do FFR.
Angola has four cath labs, with only two being functional. The reason is that the equipment suppliers and technicians are based in another country. Thus, it is clearly imperative to secure the servicing and maintenance of equipment as a contractual obligation when signing a deal with an industry partner based elsewhere.
Securing the funding to establish additional cath labs was clearly a challenge throughout the continent. Based on personal experience, Prof Mpiko Ntsekhe from UCT Medical School recommended engaging with politicians in order to advocate for the establishment of new cath labs. He cited the opening of Namibia’s first cath lab a few years ago as an example, where politicians had been actively lobbied for support, with both Presidents Thabo Mbeki and Sam Nujoma having attended the opening ceremony.
Dr Bourlon drew on his experience in Mauritania in order to identify what the basic requirements were for setting up a functional cath lab. These included having enough space and sufficient ventilation, adequate cooling for the equipment, no toilets near the lab, and adequate after-sales service. There was also consensus amongst delegates about access to echocardiograms being imperative.
Dr Bourlon recommended having cardiothoracic surgery on site, but pointed out that many cath labs operated in Europe without them, with interventionists having accommodated themselves to a higher risk environment.
The 2016 AfricaPCR Course will expand on the 2015 edition and course director, Dr Farrel Hellig says that “It will aim to be even more inclusive with participation from as much of the African continent as possible. Education and resource development in the continent is clearly needed and AfricaPCR serves as a springboard.”