Establishing an Indigenous Cardiac Anaesthesia Service in Enugu: Report of two cases of Atrial Septal Defect (ASD) closure

Background: Open heart surgery program require enormous resources and commitment to establish. In low and middle income countries like Nigeria it is quite a difficult task. The surgery requires highly sophisticated equipment and specially trained professional teams. The training is done abroad and requires long term planning. Case report: We report two cases of two patients, aged 20 and 30-years diagnosed with Atrial Septal Defect (ASD) scheduled for surgical closure under general anaesthesia and cardiopulmonary bypass carried out by a completely indigenous team. The anaesthetic management and the strategy necessary for developing a sustainable open heart program are discussed.


Introduction
Congenital heart disease (CHD) account for nearly one-third of all major congenital anomalies worldwide and the birth prevalence of this disease 1 has increased overtime.Survival of this diseased has increased dramatically due to improvements in the field of cardiothoracic surgery and anaesthesia.The same cannot be said about countries of low and middle incomes such as Nigeria.Nigeria relies on foreign cardiac missions for management of its cardiac surgical burden as only very few patients who can afford it seek medical treatment abroad.Major challenges in establishing a viable and sustainable open heart surgery services in this part of the world require adequate funding, manpower training, team building and staff retention.Over the years our centre (University of Nigeria Teaching Hospital UNTH Ituku-Ozalla Enugu) has engaged in manpower training and also collaborated with 2 foreign cardiac missions.The Open Heart Surgery (OHS) services is slowly but steadily being established in our centre and we report two cases of Atrial Septal Defect (ASD) c l o s u r e u n d e r g e n e r a l a n a e s t h e s i a a n d cardiopulmonary by-pass carried out by a completely local team.
Case report: 1. JAA was a 30 year old male (body weight 71kg, 1.76m height) patient referred to University of Nigeria Teaching Hospital (UNTH) Ituku Ozalla Enugu, from a tertiary hospital on account of Atrial Septal Defect.The patient was asymptomatic; an incidental findings of a heart murmur on routine medical examination resulted in a follow up echocardiography.The mummur was a grade 2 ejection systolic murmur loudest at the pulmonary area (P2) and fixed splitting of P2.An echocardiography showed ASD (ostium secundum), with left to right shunt but no significant pulmonary hypertension.Bi-atrial dilation, Left Ventricular (LV) diastolic and Right Ventricular (RV) systolic functions were preserved.Overall left ventricular systolic function was preserved (Left  OHS.This accounted for the use of ionotrope in both cases in the immediate post-operative period to improve cardiac contractility.
Treatment of this condition is expensive, and in our environment where patients pay directly from their pocket, it becomes difficult to get treatment for indigent patients and also sustain the programme.
Establishing an OHS programme is capital intensive.Provision of infrastructure and training of a complete cardiac team require huge funding and takes a long time.Maintenance of equipment and provision of consumables is equally important.To achieve all these, the hospital management must be committed to providing the funds necessary and enact policies that will create the enabling environment for the programme to thrive.Open heart surgery programme is multidisciplinary and cardiac anaesthesia service is an integral part of it.Team building is important as every member of the cardiac team is relevant and must be carried along for success to be achieved.

Conclusion
Congenital heart diseases are a significant group of diseases in our environment.There is however limited room for definitive intervention in the management of these lesions in the country.Efforts should be made to establish a sustainable OHS programme.

Establishing an Indigenous Cardiac Anaesthesia Service in Enugu: Report of two cases of Atrial Septal Defect (ASD) closure
then intubated using a 7.5mm ID cuffed endotracheal tube and the cuff inflated.Correct endotracheal tube placement was confirmed by the presence of equal breath sounds over the lung zones using a stethoscope and also by capnography (end tidal carbon dioxide EtCO ).The tube was then 2 secured using adhesive tape.Anaesthesia was maintained using sevoflurane 2%vol, and 50%O in air mixture.Arterial line was 2 secured with 20G arterial cannula (Teflon) in the left radial artery (for Invasive Blood Pressure IBP monitoring; blood sampling for arterial blood gas ABG and electrolyte monitoring using I-stat Analyzer ABBOTT 2010 USA).Central venous pressure was monitored using a central venous catheter size 7.5 FG (multi lumen) placed in right internal jugular vein.Patient's body temperature Ibom Med.J. Vol.13 No.3 Sept.-Dec., 2020 Ibom Med.J. Vol.13 No.3 Sept.-Dec.

, 2020 also
carried out in the ICU.The operation time, aortic cross clamp time and the pump time were very high in both cases and this must be improved upon as prolonged surgery time is a major factor increasing morbidity and mortality in 7