REALITY CHECK for THRESHOLD Countries

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Author / Editor:

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Co-Editor Anna Lou Villena 🙂

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Let me go back to one of the questions in my interview with Circuit Surfers:

Q. 11:  Is preventive medicine more prevalent in Asia than in the West?

In my opinion, the prevalence of preventive medicine depends on the countries’ economical stability and governance because this solely rely on the implementation of rules on how to prevent diseases by the government’s support on the availability of vaccines for immunizations, proper dissemination on healthy practices like for instance breast feeding, hand washing and even prohibition on smoking and alcoholic beverages.

Based on my experiences in these 3 different countries, some patients only seek medical help if their heart problem is already severe since annual check-ups and early symptoms are just being ignored due to financial incapacity.

My answer was a generalized observation about the healthcare system coming from a Third World country. On the other hand, narrowing down the idea into Cardiac surgery specifically for Rheumatic Heart Disease, Dr. Peter Zilla, an Austrian Cardiac Surgeon and is currently the Chief of Christian Barnard Cardiothoracic Surgery Department in Cape Town, South Africa gave a clearer manifestation that it is indeed through government’s support and literacy uplifting that we would be able to prevent diseases.

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**The Surgeon’s Perspective

Dr. Zilla was one of our speakers in Jilin Heart Hospital Summer Workshop and gave an exemplary talk regarding his perspective for Rheumatic Mitral Valve Disease working in a Threshold Country. Living in South Africa for over a decade is more than enough for him to share an experience-based disparity between the causes of valvular heart disease from the 1st world countries and from the third world or developing countries.

Generally, degenerative heart valve diseases are common in first world-developed countries with patients in the mean age group of 65-70 years old while Rheumatic Heart Disease (RHD) is predominant among third world countries with patients in the mean age group of 15-20 years old and mostly seek surgical option during the severity of the disease in the age of 40-50 years old.

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**The Choice

Mechanical Valve- an artificial heart valve that last indefinitely but require lifelong treatment with anticoagulants (blood thinners) e.g. Warfarin /Coumadin which requires monthly blood tests for INR (International Normalized Ratio) to ensure adequate yet safe dose in order to prevent bleeding or thrombo-embolic events. Target INR for patients with one or more mechanical heart valves is 2.5 – 3.5 (or over 3.0- 4.5).

Biological / Tissue Heart Valve – limited life span; 15 years expectancy but less for younger patients. Do not require the use of anticoagulant drugs due to the improved blood flow dynamics resulting in less red cell damage and hence less clot formation.

Mechanical or Biological Heart Valves is not an issue for the developed countries as much as health insurances are available. Patients have their choices as enlightened by their surgeons.

However, significant choices should have underlying considerable factors for patients with RHD in a developing / third world countries. For instance, implanting a mechanical valve to a 20 years old patient, living in a rural area where hospital or clinic is not easily accessible for a monthly INR monitoring and the family’s source of income will even lead to a crucial decision making whether to buy food, pay the bills or purchase the daily maintenance of Coumadin leads to a deliberate discussion among surgeons working in a threshold region.

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**The Perfusionist’s Perspective in a Threshold Country

The surgeons make the deliberate decision making as to the choice of valve considering the patient’s way of living and socio-economic status and whatever their decision may be, the perfusionist take charge of the whole pump run, keeping the physiological function of the heart and lungs and adequately perfusing the systemic circulation during cross clamping. The success of the surgery is basically a team effort and whether we like it or not, we work in a concentric plan of restoring a life with QUALITY for patients after heart surgery and subjectively human enough if we hear that after a month or two the patient had stroke or even worst- died due to lapses of INR monitoring.

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** The Reality Check

Rheumatic Heart Disease starts from a Rheumatic fever, an inflammatory disease that occurs following a Streptococcus pyogenes infection- streptococcal pharyngitis or scarlet fever. Prevention of recurrence is achieved by eradicating the acute infection and prophylaxis with antibiotics.

An antibiotic such as Penicillin would only cost $ 0.49 – $ 0.81 / pill whereas an estimate cost for a heart surgery would range from $5000-7000 or even higher. This should be the government’s role in a threshold country – to increase the literacy of the people in this kind of disease or even in a wider scope of preventing other diseases and providing an easy and cheaper access of medicines especially in the rural and slum areas.

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