Humanitarian Congenital Cardiac Surgery: Late is better than never

Because of the progresses made in pediatric cardiology and cardiac surgery over the past 40 years, most patients born with a congenital heart defect can now be prenatally diagnosed and treated in neonatal age, with the result that, in Western Europe or North America, over 90% of these children can expect to reach adulthood. Unfortunately, this is not true everywhere, because there is a dramatic disproportion in medical access and healthcare services between developed and developing countries [1].

More than 4 millions of children with congenital heart disease (CHD) are waiting for cardiac surgery around the world. Theoretically, the majority of them could be operated, saved, and have a good quality of life. However, most of them are doomed to die because they receive suboptimal care or have no access at all to lifesaving treatments [2,3].

Few of these patients are treated only thanks to the support of many non-governmental organizations (NGOs).

Currently, there are different organizational models of cooperation (OMC) to help children with congenital heart disease from low- and middle-income countries (LMIC), and all of them have their own limitations [1].

The first and most popular OMC is to send patients needing treatment abroad, to experienced centers with well-developed programs [1]. An interesting example of this experience is reported, with good surgical and clinical results, by Damien Schaffner et al. [4], from the Centre Hospitalier Universitaire Vaudois of Lousanne, Switzerland. The main limitation of this model is numerical, since only few lucky patients can benefit from this approach, because of resources and logistic constraints. The COVID pandemic, in addition, has strikingly emphasized the system shortcomings and how still far away we are from the claimed goal of autonomy and sustainability [1].

A second OMC is to perform surgical missions overseas in a hosting local Institution. As for the first model, the limitations of the latter are financial availability and, more importantly, the shortage of trained care givers.

Finally, the most complex OMC, but the one with higher potential, establishes a long-term collaboration between a local hospital and a well-known experienced international partner, in order to create stable and autonomous local services. To be successful, this model needs to involve international bodies (World Health Organization, World Bank, Charity Foundations) and International Scientific Societies that play a leadership role in coordinating large and strongly funded projects in selected geographical areas.

The paper from Shaffner et al. [4] reports the excellent outcomes of 165 patients operated for Tetralogy of Fallot (TOF) repair at an average age of 4.5 years, much higher than the usual 4–6 months age limit recommended in western countries, providing unique insights and afterthoughts on the feasibility of care within uncommon surgical timing. A late referral, in fact, is frequent for patients coming from LMIC, due to many reasons, such as late diagnosis in the Country of origin, prolonged visa times, patient's socio-economic issues, etc.

In support of good surgical results despite late referrals, we recently analyzed the data from a population of 45 consecutive foreign patients who underwent late arterial switch operation (ASO) for TGA-IVS over a 3-year period in our institution [5]. The mean age range was 23–121 days. Despite a more frequent use of ECMO support (3-5-fold higher incidence, compared to the literature) we have shown how ASO for TGA-IVS can be performed with excellent results, in terms of mortality and morbidity, even in late referrals and in less favorable patients with severely deconditioned left ventricles [5]. The results obtained were extremely useful and, transposed into our daily clinical practice, led us to the total abandonment of the 2-stage operation for late TGA-IVS.

Patients arriving from LMIC are often complex, for anatomical substrate and physiology, but also for the timing of referral, and are an authentic therapeutic challenge. The results obtained, however, even if sometimes unexpected, provide important scientific information.

Very often, the late referral for these unfortunate patients represents a unique chance of survival, and therefore, with due attention, we should remember that “late is better than never”.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.