Global Cardiac Surgery Capacity Development in Low and Middle Income Countries

Foreword I: Duke Cameron
Foreword II: Thiery Folliguet
Preface
Acknowledgment
About the Book
Contents
About the Editor
Global Surgery as the Neglected Stepchild of Global Health
1 History of Global Surgery
Abstract
1.1 Introduction
1.2 The Foundations of Medical Missions
1.2.1 Faith-Based Missions
1.2.2 Short-Term Reconstructive Missions
1.2.3 Self-Contained Surgical Platforms
1.2.4 Specialty Surgical Hospital Missions: The Barsky Model
1.3 Early Institutional Global Surgery Efforts
1.3.1 The International Committee of the Red Cross
1.3.2 Médecine Sans Frontieres—The Beginnings
1.4 Early Policy Milestones
1.5 The Evolution of Academic Global Surgery
1.6 History of Early Ethics in Global Surgery
1.7 Recent Global Surgery Policy Shifts
1.8 National Surgical, Obstetric, and Anesthesia Plans
1.9 Regionalization of Surgical Strategy
1.9.1 Standardization of Metrics and Data Collection
1.10 Conclusion
Acknowledgements
References
2 Global Surgery: From Grassroots Movement to Global Momentum
Abstract
2.1 Introduction
2.2 Partnerships and Advocacy Organizations in Global Surgery
2.2.1 The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC)
2.2.2 The Lancet Commission on Global Surgery
2.2.3 The G4 Alliance
2.2.4 World Federation of Societies of Anaesthesiologist (WFSA)
2.2.5 South-South Partnerships
2.2.5.1 The West African College of Surgeons (WACS)
2.2.5.2 The College of Surgeons of East, Central, and Southern Africa (COSECSA)
2.2.6 Educational and Grassroots Partnerships in Global Surgery
2.2.6.1 Harvard Medical School’s Program in Global Surgery and Social Change (PGSSC)
2.2.6.2 Other U.S.-Based Educational Partnerships
2.2.6.3 Student Organisations
2.2.7 Ethical Considerations in Global Surgery Partnerships
2.3 National Surgical, Obstetric, and Anaesthesia Plans
2.3.1 Framework and Process
2.3.2 Principles and Purpose
2.3.3 Global Momentum
2.3.4 Regional Momentum Towards a Global Movement
2.4 Conclusion
References
3 UHC Surgery and Anesthesia as Essential Components of Universal Health Coverage (WHA 68.15)
Abstract
3.1 Introduction
3.2 Universal Health Coverage
3.2.1 History of UHC: A Transition from MDGs to SDGs and the Expansion of IHP + 
3.2.2 UHC as a Means to an End
3.3 Surgery as Part of UHC
3.4 Strategies to Achieve Universal Surgical Coverage
3.5 Health Financing and Surgery Under the Umbrella of UHC
3.5.1 Micro Health Insurance Systems
3.5.2 Innovative Financing
3.5.3 Universal Surgical Coverage and Financial Risk Protection
3.6 The Role of Academia in Achieving Universal Surgical Coverage
3.7 Barriers Towards UHC Coverage
3.8 Conclusion
References
4 Global Surgery Financing, Challenges and Possibilities
Abstract
4.1 Health as a Right and the Movement Towards Universal Health Coverage
4.2 Scarce Resources, Delivery Failure and the Global Cost of Lack of Access to Surgery
4.3 How Is Health and Surgical Care Paid?
4.4 The Spark: How Surgical Programs Can Advance in Low Resource Settings
4.5 The Long Run: How to Sustain Efforts in Surgical Services Delivery
4.6 The Ecosystem
4.7 Conclusion
References
5 Leveraging Data Science for Global Surgery
Abstract
5.1 Background
5.2 Global Health and Global Surgery
5.3 The Necessity of Data-Driven Strategies
5.4 Challenges of Data Collection in LMICs
5.5 Opportunities for Technology and Data Science Approaches in LMICs
5.6 Future Possibilities with AI
References
6 Global Surgery Innovation at Academic Medical Centers: Developing a Successful Innovation Ecosystem
Abstract
6.1 Introduction
6.2 Global Cardiac Surgery and the Need for Medical Innovation
6.3 Medical Innovation in Limited Resource Settings—An Overview of Relevant Terminology
6.4 Centers for Medical Innovation at Academic Medical Centers and Innovation Ecosystems
6.4.1 Trainees and Training Programs
6.4.2 Infrastructure
6.4.3 Partnerships
6.4.4 Funding and Innovation Networks
6.5 Common Challenges in Global Surgery Innovation—Manufacturing and Ethical Concerns
6.6 Conclusion
References
7 The Role of Social Impact Innovation and Entrepreneurship in Global Health
Abstract
7.1 Introduction
7.2 Healthcare Innovation Context
7.2.1 Emerging Market Operating Environments
7.2.2 Challenges for Emerging Market Healthcare Ventures
7.2.3 The Impact of the COVID-19 Pandemic
7.2.3.1 Balancing Local Resilience and Globalization
7.2.3.2 Necessity Spurs Technology Adoption
7.2.3.3 Consumer Power Rising
7.3 The Role of Innovation Ecosystems
7.4 Health System Innovation in Emerging Markets
7.4.1 Innovation in Action: Case Studies of Global Healthcare Innovators
7.4.1.1 Proximie—Winning Hearts and Minds with Industry Allies Around the Globe
7.4.1.2 Smart Medical Care Services—Finding the Right Investors
7.4.1.3 Bloomer Tech—Building Entrepreneurship Capacity at Academic Institutions
7.4.1.4 HM Habib Cardiac Endowment Fund—Measuring Quality for Sustainable Innovation
7.5 Blueprint for Social Impact Ventures and Ecosystem Players
7.5.1 Social Impact Entrepreneurs: Essential Ingredients
7.5.1.1 Resilience
7.5.1.2 Focus on Mission and Values
7.5.1.3 Systems Orientation
7.5.1.4 Personal Motivation
7.5.1.5 Local Ties
7.5.1.6 Global Reach
7.5.2 Innovation-Driven Ventures: Blending Ingredients for Success
7.5.2.1 Identify and Fill Systemic Gaps
7.5.2.2 Invest in Local Capacity
7.5.2.3 Blend Technology with Human Intervention
7.5.2.4 Focus on Business Models with Social Purpose
7.5.2.5 Blend Local and Global
7.5.2.6 Embrace Consumers
7.5.3 Accelerating Regional Innovation Ecosystems for Healthcare Innovation
7.5.3.1 Collaborate to Build Needed Capacities
7.5.3.2 Involve Stakeholders in a Collective Ecosystem Approach
7.5.3.3 Adopt New Mindsets
7.6 Conclusion: Collaborating for Sustainable Healthcare Impact
References
Cardiac Surgery as an Indispensable Component of Health Systems Strengthening
8 Global Cardiac Surgery and the Global Burden of Disease
Abstract
8.1 Introduction
8.2 Rheumatic Heart Disease
8.3 Congenital Heart Defects
8.4 Ischemic Heart Disease
8.5 Aortic Pathologies
8.6 Other Cardiovascular Diseases
8.7 Conclusion
References
9 Monitoring, Evaluation, and Disease Surveillance for Cardiovascular Surgical Disease
Abstract
9.1 Introduction
9.2 Disease Surveillance
9.2.1 Importance of Surveillance
9.2.2 Community-Level Screening
9.3 Monitoring and Evaluation
9.4 Diagnostics
9.5 Conclusion
References
10 Global and National Advocacy for Cardiac Surgery—Start with the Children
Abstract
10.1 Burden of Heart Disease in Children
10.2 What Is Advocacy
10.3 Global and National/Subnational Advocacy
10.4 Advocacy for Children with Heart Disease
10.5 Collaboration
10.6 Challenges
10.7 The Invisible Child Series
10.8 Conclusion
References
11 Costing and Health Systems Financing of Global Cardiac Surgery
Abstract
11.1 Introduction
11.2 Cost of Cardiac Surgery
11.3 Health Systems Financing
11.4 Innovative Financing Instruments
11.5 Cost Reduction Opportunities
11.6 Conclusion
References
12 The Global Cardiothoracic Surgery Workforce in 2020
Abstract
12.1 Introduction
12.2 Describing the Landscape
12.3 Changing the Landscape
12.4 Conclusion
References
13 Team-Based Care Along the Cardiac Surgical Care Cascade
Abstract
13.1 Introduction
13.2 Team-Based Approach to Care
13.2.1 Cardiologists
13.2.2 Internists and General Practitioners
13.2.3 Advanced Practice Providers
13.2.4 Pharmacists
13.2.5 Nurses
13.2.6 Community Health Workers
13.3 The Care Cascade
13.3.1 Chronic Disease Management
13.3.2 Primordial Prevention
13.3.3 Primary Prevention
13.3.4 Secondary Prevention
13.3.5 Tertiary Prevention
13.4 Health Systems Strengthening to Support Surgical CVD Care
13.4.1 Health Workforce
13.4.2 Health Service Delivery
13.4.3 Access to Essential Medicines
13.4.4 Health Information Systems
13.4.5 Leadership and Governance
13.4.6 Health Systems Financing
13.5 Summary
References
14 An Advanced Heart Team Model: Can It Be Adapted to Africa?
Abstract
14.1 Introduction
14.2 UOHI Advanced Heart Team Concept
14.3 Three Pillars–Clinical, Research, Education
14.3.1 Clinical Practice Initiatives
14.3.2 Research
14.3.3 Education
14.4 High Performance Teams
14.5 Heart Teams in Reducing the CVD Burden in Africa
14.6 Conclusion
References
Bioethics, Education and Role of Societies in Global Cardiac Surgery
15 Ethical Considerations in Global Heart Surgery
Abstract
15.1 Allocation of Scarce Resources to Cardiac Surgery: The Ethical Perspective
15.2 How Can I Help? Ethical Guidelines for Assisting in the Establishment of Cardiac Surgical Programs
15.2.1 Ethical Guidelines for Cardiothoracic Surgery Global Health Initiatives
15.3 Interaction with Local Providers
15.4 Navigating Differences in Cultural Norms
15.5 Conclusion
Conflict of Interest Disclosure
References
16 Role of Humanitarian Cardiac Surgery Missions in Developing the Next Generation of Global Surgeons
Abstract
16.1 Background
16.2 Challenges to Incorporating Medical Students
16.3 Surgical Mission Trips as an Investment into the Next-Generation of Global Cardiac Surgeons
16.4 How Best to Prepare for Mission Trips?
References
17 Role of Cardiothoracic Surgery Societies in Global Health Disparities
Abstract
17.1 Current State of Cardiac Surgical Disparities
17.2 Global Cardiac Surgery
17.3 Pitfalls of Humanitarian Surgery
17.4 Successful Programs
17.5 Future Perspective and the Role of CT Surgery Societies
References
18 Deconstruct One, Document One, Simulate Many, Assess Many. Role of Simulation in Cardiac Surgery
Abstract
18.1 Introduction
18.2 The Science of Learning
18.3 The Domains of the MVS Project
18.4 The Format of the MVS Project
18.5 The Simulators of the MVS Project
18.6 The Online Platform of the MVS Project
18.7 The Assessments of the MVS Project
18.8 The Profile of the Participants
18.9 The Future of Simulation Versus the Future of Cardiac Surgery
References
19 Utility of Simulation in Transthoracic and Transesophageal Echocardiogram-Based Training of a Cardiovascular Workforce in Low and Middle-Income Countries (LMIC)
Abstract
19.1 Introduction
19.2 Ultrasound
19.2.1 Point of Care Ultrasound (POCUS)
19.2.2 Training
19.3 Role of Simulators
19.4 Static Simulation
19.4.1 Workflow
19.4.2 Limitations
19.5 Live TEE Simulation
19.5.1 Modes
19.5.2 Limitations
19.6 3D TEE Simulator
19.7 Augmented Reality (AR)
19.7.1 Limitations
19.8 Curricula for Application of Simulation Technology
19.9 Future Applications
19.10 Conclusion
References
20 Developing a Web-Based Curriculum for Radiology Sub-Specialty Training in Emerging Countries
Abstract
20.1 Overview: The Greatest Problem
20.2 What to Avoid
20.3 The Digital Solution
20.4 Case Example: Ethiopia
20.5 A Note on Digital Colonialism
20.6 More Than eLearning: “Project Nobel”, A Model for Healthcare Workforce Capacity Building
20.7 Application to Cardiovascular Care (Cardiac Echo Curriculum) and Future Perspectives
20.8 Summary
Acknowledgements
References
Strategies for the Implementation of Sustainable Cardiac Surgery Programs
21 Echocardiography for Cardiac Surgeons
Abstract
21.1 Overview
Bibliography
22 Anesthesia Considerations in Global Cardiac Surgery Capacity Development in Emerging Countries
Abstract
22.1 Introduction
22.2 Preoperative Anesthetic Management
22.2.1 Preoperative History
22.2.1.1 Diabetes Mellitus
22.2.1.2 Systemic Hypertension
22.2.1.3 Atherosclerotic Disease of the Carotid Arteries
22.2.1.4 Pulmonary Disease
22.2.1.5 Renal Insufficiency
22.2.1.6 Anemia
22.2.2 Preoperative Medications
22.2.3 Physical Examination
22.2.4 Preoperative Laboratory Evaluation
22.3 Intraoperative Anesthetic Management
22.3.1 Premedication
22.3.2 Monitoring
22.3.2.1 Standard Monitors
22.3.2.2 Blood Pressure Monitoring
22.3.2.3 Cardiac Output Monitoring
22.3.2.4 Temperature Monitoring
22.3.2.5 Brain Monitoring
22.3.3 Induction and Maintenance of Anesthesia
22.3.4 Intraoperative Anesthetic Management Prior to Cardiopulmonary Bypass
22.4 Intraoperative Transesophageal Echocardiography
22.4.1 Training Requirements for TEE Certification
22.4.1.1 National Board of Echocardiography [46]
22.4.1.2 European Association of Cardiovascular Imaging [47]
22.5 Cardiopulmonary Bypass
22.5.1 Weaning from Cardiopulmonary Bypass
22.5.2 Intraoperative Problems After Cardiopulmonary Bypass
22.5.2.1 Problems with Cardiac Function
22.5.2.2 Hypotension and Hypertension
22.5.2.3 Excessive Hemorrhage
22.5.2.4 Metabolic Abnormalities
22.5.2.5 Pulmonary Dysfunction
22.6 Transport to ICU
22.7 Pain Control
22.8 Enhanced Recovery After Cardiac Surgery
22.9 Future Perspectives
References
23 Cardiopulmonary Considerations for Cardiac Surgery in Low and Middle Income Countries
Abstract
23.1 Brief History of CPB
23.2 CPB Hardware Including Oxygenator and Pump
23.3 Hemodilution and Priming Solutions
23.4 Conduction of CPB
23.5 Troubleshooting During CPB and Management
23.6 Deep Circulatory Arrest
23.7 Non-cardiac Use of CPB
23.8 Heparin-Protamine Axis
23.9 Perioperative Cell Salvage
23.10 Brief: Off Pump CABG Role of a Perfusionist
23.11 IABP, VADS, ECMO
23.12 Checklists
References
24 PEN-Plus Strategies I: Decentralizing and Integrating Preoperative Medical Management, Cardiac Surgery Screening, and Referral
Abstract
24.1 Introduction
24.2 PEN-Plus Model for Decentralizing NCD Care Including Heart Failure and Cardiac Surgical Screening
24.3 Preoperative Evaluation and Planning
24.4 Procedural Considerations
Acknowledgements
References
25 PEN-Plus Strategies II: Decentralizing and Integrating Postoperative Management and Anticoagulation
Abstract
25.1 Introduction
25.2 Routine Management
25.2.1 Heart Failure
25.2.2 Anticoagulation
25.2.2.1 Initiating Warfarin
25.2.2.2 Anticoagulation Monitoring and Titration in Rural LMIC Settings
25.2.3 Penicillin Prophylaxis
25.2.4 Family Planning
25.3 Management of Ongoing Complications
25.3.1 Endocarditis and Fever in Patients with Prosthetic Heart Valves
25.3.2 Sternal Wound Infection and Dehiscence
25.3.3 Pericardial and Pleural Effusions
25.3.4 Atrial Fibrillation
25.3.5 Valve Thrombosis
25.3.6 Valve Dehiscence
25.3.7 Hemolytic Anemia
25.4 Other Considerations
25.4.1 Cardiac Rehabilitation
25.4.2 Nutritional Support
25.4.3 Socioeconomic Support
25.4.4 Mental Health Support
Acknowledgements
References
26 Establishing and Expanding Cardiac Surgery Centers
Abstract
26.1 Introduction
26.2 Components of Cardiac Centers
26.3 Existing Models to Establish Center
26.4 Opportunities for New Models
26.5 Conclusion
References
27 Nuts and Bolts of Establishing a Contemporary Global Cardiac Surgery Program
Abstract
27.1 Introduction
27.2 Identifying Need: Rules of Engagement
27.3 Site Assessment and Scout Visit
27.4 Team Composition and Logistics
27.5 Before the First Surgery
27.6 After the First Mission
27.7 Conclusion and Key Points
Acknowledgements
References
28 Cardiac Surgery Capacity Development in Emerging Countries
Abstract
28.1 Introduction
28.2 The Global Burden of Cardiac Disease
28.3 Pulmonary Disease and the Unmet Need for Surgery
28.4 Proposed Way Forward for Global Cardiothoracic Surgery in Low-and-Middle Income Countries
28.5 Scaling Up Surgical Programmes
28.6 Cardiothoracic Anaesthesia
28.7 Continuity of Care
28.8 Fellowship Programs, Collaboration and Education
28.9 Research and Perioperative Databases
28.10 Prevention
28.11 Access to Care
28.12 Simulation Laboratory
28.13 Surgical Workforce, Diversity and Inclusion
28.14 Conclusion
References
29 Development of Sustainable Global Thoracic Surgery Programs in LMICs
Abstract
29.1 Burden of Thoracic Surgical Disease
29.1.1 Chronic Respiratory Disease
29.1.2 Pulmonary Infections
29.1.3 Malignancy
29.1.4 Trauma
29.2 Current Barriers and Solutions
29.2.1 Imaging Techniques
29.2.2 Anesthesia Techniques
29.2.3 Postoperative Care
29.2.4 Pathology
29.2.5 Workforce
29.3 Existing Models for Thoracic Surgery Program Building
29.3.1 Malawi Surgical Initiative
29.3.2 Tenwek Hospital—Bomet, Kenya
29.3.3 Human Resources for Health
29.4 Future Directions
References
Leveraging Digital Health Technologies in Augmenting Cardiac Surgery Capacity
30 Digital Technology’s Role in Addressing the Social Forces Impacting Cardiovascular Health
Abstract
30.1 Introduction
30.2 Defining the Social Determinants of Health
30.3 Factors Influencing Health Outcomes
30.4 Healthcare Access and Quality
30.5 Social and Community
30.6 Economic Stability
30.7 Education Access and Quality
30.8 Environment
30.9 Behaviour and Lifestyle
30.10 Digital Behaviour
30.11 Provider Perspectives on SDH
30.12 Conclusions
References
31 Emerging Opportunities for Sustainable Digital Health Enhanced Care Delivery Models for Improved Cardiovascular Surgery Outcomes
Abstract
31.1 Introduction
31.2 Digital Health Overview
31.3 Models of Digital Health Care Delivery
31.3.1 Avatars for Preceptorship and Mentorship
31.3.2 Portable Ultrasound and Hand-Held Electrocardiogram Imaging
31.3.3 Robotic Cardiac Surgery
31.3.4 Chronic Disease Management via Telehealth/ Telemedicine
31.4 Conclusions and Discussion
References
32 The Role of Technology and Innovation
Abstract
32.1 Introduction
32.1.1 The Value of Technology and Innovation
32.1.2 The Considerations and Challenges of Technology and Innovation
32.2 Human Resources
32.2.1 Improving the Minimum Quality Standard
32.2.2 New Training Methods
32.2.3 New Relationships
32.2.4 New Career Opportunities
32.2.5 Future Developments
32.2.6 Improving the Maximum Quality Standard
32.3 Physical Resources
32.3.1 Technology Development
32.3.2 Clues of Successful DevelopmentClues of Successful Development
32.3.3 Helpful Resources and Support
32.3.4 Where Does Development Occur?
32.3.5 Who Is Involved in Development?
32.3.6 How Does Development Occur?
32.3.7 Technology Implementation
32.3.8 Accreditation and Procurement
32.3.9 User Uptake
32.4 Summary
References
33 Augmented, Virtual and Robotic Capabilities in Cardiovascular Program Capacity Building
Abstract
33.1 Capacity Building as a Part of Overall Health System Strengthening
33.2 Examples of emerging technologies
33.2.1 Extended Reality
33.2.1.1 Extended Reality in Education and Training
33.2.1.2 Extended Reality for Surgical and Interventional Procedures
33.2.1.3 Robotics in Cardiovascular Care
33.3 Acceleration of Technology Adoption for Capacity Building During Pandemic
33.4 Technology Coupled with Ecosystem Partnerships
References
34 Establishing National Telehealth Service in a Lower Middle-Income Country—the Ghana Model
Abstract
34.1 Definition
34.2 Case Study One
34.2.1 Ghana Telemedicine Project (GTP)
34.2.1.1 Workflow of GTP
34.2.1.2 Opportunities for Increased Access
34.2.2 GHS Telehealth Program
34.2.2.1 System Strengthening Using Ghana Telehealth Services
34.2.2.2 Service Delivery Using Ghana Telehealth Services
34.2.2.3 Components and Range of Telehealth Services
34.2.3 Key Projects Under Ghana Telehealth Program
34.2.3.1 Modalities for Telehealth Service Delivery
34.2.3.2 Upgrade Implementation
34.2.3.3 Implementation of Telehealth Service Delivery Technology Upgrade
34.2.3.4 Clinical Decision Support System for Telehealth
34.2.4 Reimbursement
34.2.4.1 Health Insurance
34.2.4.2 Micro Insurance in Healthcare
34.2.5 The Way Forward in Telehealth Reimbursement
34.2.5.1 NHIS Reimbursement of Telehealth Services
34.2.5.2 Private Health Insurance Reimbursement of Telehealth Services
34.2.5.3 Telehealth Reimbursement with Micro Health Insurance
34.2.5.4 Reimbursing Telehealth with Payment for Services and Grant Support
34.2.6 Evaluation of Telehealth in Ghana
References
Cardiology and Cardiothoracic Surgery—A Global Perspective
35 The Story of Rheumatic Heart Disease in Rwanda: Capacity Building for Comprehensive Cardiovascular Care
Abstract
35.1 RHD as a Disease of Poverty
35.2 Scope of the Disease
35.3 The Genocide Against the Tutsi and the Rwandan Health System 
35.4 Strategic Direction for Eradicating RHD in Rwanda
35.5 Recommendations 
35.6 Challenges 
35.7 Innovation and Technology: Telemedicine as a Way Forward to Improve Cardiovascular Health in Resource-Constrained Settings 
35.8  Team Heart and Rwanda’s Race to Establish Cardiac Surgery to Address the Surgical Burden of RHD; It Is Not Just About Surgery
35.9 Conclusion
References
36 Telecardiology in Ghana: Perspectives from Korle Bu Teaching Hospital and Cardiovascular Diagnotics Clinic
Abstract
36.1 Introduction
36.2 History of Telecardiology in Ghana
36.3 Technology
36.4 Wearable Devices
36.5 Teleechocardiography with Kosmos Echonous
36.6 Artificial Intelligence Enabled Hand Held Tablet Echochardiography (KOSMOS ECHONOUS)
36.7 Future Perspectives
References
37 Developing a Sustainable High-End Cardiovascular Surgery Program in Emerging Economies: The Narayana Health (NH) Model Structured on Affordable, Accessible, Tertiary Level Care
Abstract
37.1 Introduction
37.2 Economies of Scale (Micro Health Insurance, Assembly Line Surgery)
37.3 Converting Atoms into Bytes (Telemedicine, Holter Monitoring and Portable EHR)
37.4 Data Intelligence
37.5 Electronic Health Systems (EHS)
37.6 Training for the Future
37.7 Scaling into Other Territories (the Caribbean Story)
37.8 Conclusion
Acknowledgements
References
38 Cardiac Surgery and Interventional Cardiology Capacity Development: Insights from Ethiopia and Côte d’Ivoire
Abstract
38.1 Introduction
38.2 Background: Ethiopia and Côte d’Ivoire at a Glance
38.3 A Brief History and Current Status of Cardiac Service in Ethiopia and Côte d’Ivoire
38.4 Implementation of a Team-Based Collaborative Capacity-Building Model
38.5 A Team-Based Collaborative Capacity-Building Model in Ethiopia
38.6 A Team-Based Collaborative Capacity-Building Model in Côte d’Ivoire
38.7 Lessons and Challenges
38.8 Future Direction
Acknowledgements
References
39 Global Cardiac Surgery in China: 23 Years of Mission Work
Abstract
39.1 Growth in China
39.2 Cardiovascular Disease Burden
39.3 First Visits
39.4 Expanding the Scope
39.5 Getting Organized
39.6 Training in Cardiac Surgery
39.7 Lessons Learned
References
40 Establishing a Congenital Cardiac Program-Pakistan Model
Abstract
40.1 Introduction
40.2 Burden of Disease
40.3 Screening
40.4 Diagnosis
40.5 Limitations
40.6 Current Model and Status of CHD Programs
40.7 Interventional Program
40.8 Cardiac Surgery
40.9 Financial Model
40.10 Brain Drain
40.11 Capacity Building
40.12 Challenge for the Future
Acknowledgements
References
Index