Assessment of the financial gaps in cardiothoracic surgery in Africa

Abstract

OBJECTIVES

This study identified the challenges to financing cardiothoracic surgical care in Africa, highlighting the present state of funding and proffering probable solutions to adequate and effective funding in the region.

METHODS

In a literature review, the authors elaborated key points, such as areas of financial funding in cardiothoracic surgery; barriers to appropriate allocation of financial resources for cardiothoracic surgery in Africa; and the needs and available resources for cardiothoracic surgery in Africa. Multiple search engines and databases were used, including but not limited to PubMed, Medline, Cochrane, Scopus and Google Scholar. Sixty articles were identified, and 50 of the 60 were used for this review.

RESULTS

Operations to treat cardiovascular and thoracic diseases performed on the African continent are known to be expensive. They also tend to result in significant morbidity and mortality among the affected individuals because payment is largely out of pocket and the coverage by health insurance providers is low. The establishment of cardiothoracic surgical centres and the delivery of cardiothoracic surgical care are expensive endeavours that limit access to care of patients without comprehensive health insurance or philanthropic support. These poor outcomes are attributed mainly to inadequate funding.

CONCLUSIONS

We therefore have recommended advocating for increased funding and for support of policies designed to support the prioritization of cardiothoracic care within national and regional healthcare agendas in order to include cardiothoracic surgery in global and national healthcare plans. Non-governmental organizations and major industries (foreign and local) should be encouraged to invest substantial funds in building and developing cardiothoracic surgery centres in Africa.

Globally, cardiovascular disease is the leading cause of mortality and morbidity, with about 17.9 million deaths reported in 2019 [1].

Graphical Abstract

INTRODUCTION

Globally, cardiovascular disease is the leading cause of mortality and morbidity, with about 17.9 million deaths reported in 2019 [1]. The issue of the cost of care is always at the forefront of discussions in all the world's healthcare systems [2, 3]. Over 5 billion people globally lack access to affordable quality surgical and anaesthetic care, with a heavy burden being paid by low- and middle-income countries (LMICs) [4]. Sub-Saharan Africa had 0.08 and 0.12 paediatric and adult cardiac surgeons per million population, respectively, in 2017 [5].

Whereas surgically treatable congenital heart defects account for about 63,302 disability-adjusted life years in Sub-Saharan Africa, about 1,692,728 disability-adjusted life years are accounted for in North Africa and the Middle East [6]. There has been a significant increase in the burden of cardiovascular diseases in Africa (about 50%) within the last 3 decades, although a good number of cases remain unreported [7]. In fact, a published article by Vosloo reported that only 2 countries, South Africa and Egypt, have independent cardiac surgical programmes and perform more than 500 operations per year [8]. The continent lacks significant infrastructure [9, 10]. As a result, millions of people lack access to cardiac surgical care in a competitive situation in which the poorest suffer the most [4, 5]. A closer look reveals that this inequality of opportunity to access surgical care affects both adults and children. Of the 335,000 children born with congenital heart disease in Africa each year, only a minority have families that can afford adequate care [9, 11, 12]. Fewer than 20% of patients in West Africa are able to finance their cardiac surgery [13]. In 2013, the cost of open-heart surgery in Nigeria ranged from USD($)6230 to $11200, whereas the gross domestic product (GDP) per capita income of the country was $1248 [14]. In Kenya, $899 is required for 2.5 heart operations per 1,000 inhabitants for congenital and rheumatic diseases [15], but even with this estimate, the true cost (taking into account the large number of non-public sector operations performed as well as indirect costs) is of course much higher. Sources of healthcare funding include government expenditures, which encompass government spending across all levels; estimated development assistance for health; prepaid private health spending; and out-of-pocket spending [16]. Financing of cardiothoracic surgery, which is an out-of-pocket expense, is the root of financial disasters [4, 12, 17]. Some lucky patients are cared for by philanthropic missions, non-governmental organizations and visiting teams [9, 18, 19]. The Democratic Republic of the Congo, home to 99 million people, had its first experience of cardiothoracic surgery in 2012 through a mission run by the Association of Friends and Former Students of the Faculty of Medicine at the University of Kinshasa [20]. In 2015, a total of 207 patients, including 92 children, were waiting for operations in the same country.

Today, 11 years after that first experience, there is still no equipped cardiothoracic centre in this country. Namibia, Uganda and Zambia have cardiothoracic surgery centres and partial state subsidies for the care of affected patients, but 30% of the affected population are unable to co-finance this care [21]. In that context, most African families will never be able to afford these types of operations. In Rwanda, patients who were operated on from 2011 to 2016 were financed by private insurance .up to 61% and by community-based health insurance [22]. In many African countries, patients still die of conditions for which an operation is the only option to save their lives [20]. Other patients wait desperately for an operation because cardiothoracic surgery is not a priority for their country's government [21, 23].

The goal of this study was to understand the challenges associated with financing cardiothoracic surgical care in Africa; to identify the unmet needs in cardiothoracic surgical capacities; to analyse the methods of raising funds for care and the different systems for financing cardiothoracic surgical care; to showcase bottlenecks to the adequate allocation of the much-needed resources for cardiac and thoracic surgical interventions; and to highlight measures that can be put in place to proffer solutions and areas of intervention to reduce brain drain, redundancy and disease burden and to deliver better services.

Areas of financial funding in cardiothoracic surgery

Cardiothoracic surgery involves a wide range of financially demanding procedures designed to address diseases and conditions affecting the heart, lungs and chest cavity. Remarkable advancements in surgical techniques, research and patient care have been made in past years in the world, particularly in developed countries; however, these advancements come with significant financial implications that weigh heavily on LMICs [12], in particular to ensure improvement in patient care. Over 93% of the world’s population lacks access to safe, timely and affordable cardiac surgical care, most likely due to geographical location, lack of surgeons, inadequate infrastructure and, most importantly, financial barriers [24]. Over the years, the National Institutes of Health has contributed massively to financing research grants and projects within the health field; however, within this context, Africans receive minimal attention, with very few African cardiac surgeons and researchers receiving financial support [25, 26].

The different areas of financial funding that are crucial for the successful delivery and growth of cardiothoracic surgery programmes in Africa include the following:

Government grants

Government funding plays a vital role in supporting cardiothoracic surgery programmes. Federal agencies and institutions provide grants for research, education and infrastructure development in the field. In 2001, all African countries agreed to participate in the Abuja Declaration, whereby 15% of the annual government budget of each participating nation was to be allocated for healthcare within their nation; however, not all signatories implemented and respected this agreement [24]. The National Institutes of Health and other government bodies are prominent sources of funding, supporting research projects, clinical trials and training programmes [25]. These grants not only foster innovation but also aid in the dissemination of scientific knowledge.

Private foundations

Private foundations contribute significantly to cardiothoracic surgery funding. Organizations such as the American Heart Association, the Thoracic Surgery Foundation and the Children’s Heart Foundation offer grants specifically directed towards cardiac and thoracic research [26, 27]. These foundations often prioritize projects with clinical significance, potential for breakthroughs and benefits for patient outcomes, with some directed only towards paediatrics [28, 29]. Endowments and donations from philanthropic individuals also contribute financial support through grants and fellowships. Additionally, several cardiac surgery units have been established in Africa with input from United States cardiac surgeons and foreign organizations. Worthy of note is the National Heart Lung and Blood Institute established in 2009 in Kenya by Duke University. This institute currently has a robust cardiac outpatient clinic, a 10-bed cardiac care unit, an echocardiographic and an electrocardiographic laboratory and cardiac surgery clinics, among others [30]. Another clinic worthy of note is the Maputo Heart Institute in Mozambique established by the Chain of Hope organization in 2000. Maputo currently performs about 130 operations and 10,000 consultations annually in between the visiting training missions. They handle different cardiac cases and have specialist training missions that focus on rare and neglected cardiac diseases, including rheumatic heart disease and endomyocardial fibrosis [31].

Industry support

The medical device and pharmaceutical industries play a significant role in providing financial support to cardiothoracic surgery programmes. Companies sponsor research projects, clinical trials and educational programmes. However, it is necessary to ensure ethical practices, transparency and avoidance of conflicts of interest when receiving industry support.

Insurance reimbursement

Insurance reimbursement is a critical aspect of financial funding for cardiothoracic surgery. Adequate coverage and reimbursement policies for surgical procedures ensure that medical centres can sustain their programmes. However, the complexities of insurance systems, coverage limitations and pre-authorization requirements present challenges for surgeons and patients alike.

Patient contributions

Patient contributions, including copayments and deductibles, also form a part of the financial funding for cardiothoracic surgery. It is important to consider the financial burden placed on patients, because only up to 20% of patients in West Africa can fund their surgical procedure within a year; all others must explore alternate avenues for financial assistance or support programmes [24]. Patient satisfaction surveys, financial counselling and assistance with insurance navigation can help mitigate the financial stress associated with cardiothoracic operations. Thus, securing financial funding is a critical component for the development, success and sustainability of cardiothoracic surgery programmes in Africa. This comprehensive review has explored various areas of financial funding, including government grants, private foundations, industry support, insurance reimbursement and patient contributions. By understanding the available funding sources, stakeholders in cardiothoracic surgery can work towards optimizing financial support for research, education and clinical care in the field.

Funding of cardiothoracic interventions in Africa: the journey so far

Despite the financial and systemic deficits facing their use on the continent, cardiothoracic surgical interventions so far have adopted several ways to meet the needs of Africans. These include the following:

Philanthropic organizations and missions

Funding from philanthropic initiatives, such as medical and surgical missions, constitutes an essential tool that makes cardiovascular care accessible to resource-limited settings. These foreign-based missions, such as Team Heart and Chain of Hope, receive grants in aid and equipment support from many other foundations. They also set up a cardiac team to undertake cardiothoracic surgical interventions in African countries [32]. In Nigeria, for example, the Vincent Obioma Ohaju Memorial foundation (VOOM foundation) provides localized care to patients in rural areas where the healthcare system is poorly developed. This foundation organizes dozens of surgical missions each year, strengthens relationships with Nigerian hospitals and establishes new teaching programmes to further their mission. It also partners with local organizations to provide heart operations. These partnerships have been important in establishing a stable cardiac surgical care network [33].

Government subsidies and health insurance

Government health budgets and public health insurance systems in some African countries shoulder the cost of providing and maintaining basic facilities required for cardiothoracic surgery. Government funding of cardiothoracic centres is critical for the survival of cardiac surgical interventions in Africa, because it provides and maintains health facilities for the use of foreign missions and lessens a large portion of the full cost of cardiothoracic surgical care, which may be out of reach of patients who must pay out of pocket. Yet, more lethal population-wide diseases like malaria, tuberculosis and human immunodeficiency virus successfully wrestle government health funding priorities from advanced surgical healthcare disciplines such as cardiothoracic surgical care. Cardiac surgery is a complex discipline that necessitates a significant financial investment. Unfortunately, because most African countries are LMICs, such medical procedures are often unaffordable. The main impediments to expanding surgical intervention in Africa are a lack of administrative capability and poverty [21, 34]. Despite some government investment in tertiary cardiac surgical centres, the maintenance and expansion of said centres still constitute a financial burden to the countries in question. To cut costs, a lot of African countries, including Uganda, Namibia and Zambia, have implemented copayment fees for public health services such as cardiac surgery [21]. However, only 30% of individuals can afford this fee. Furthermore, recent studies in Kenya, Uganda, Tanzania, Cameroon and Zimbabwe also showed that, for a substantial proportion of the families of infants requiring congenital heart surgery, the cost was the most substantial barrier to their treatment [35, 36].

Additionally, some public health insurance systems in African countries do not completely bear the full cost of specialized surgical cases such as those requiring cardiac surgery. Thus, out-of-pocket payments to supplement the cost of an operation persist even for patients who are covered by health insurance. This is the situation in Malawi, where government-owned hospitals do not charge fees for surgery but patients incur significant costs, beyond their monthly incomes, to access general surgical care [2]. For example, the total cost of surgical treatment for congenital heart disease for just 1 child in Malawi could be at least $20,000. This cost is well beyond the means of most families [37]. Out-of-pocket expenditures for these operations may involve payments for consultation, medicines or examinations or even payments by patients and their relatives for transportation, accommodations and food. Some of these patients may be referred to other centres that have the capacity to carry out these operations; hence, they may be required to pay for ambulance services [38]. The same situation exists in Ghana, where more than half (60%) of insured surgical patients risk spending about 40% of their annual income on surgical care. However, this situation is dwarfed by that of their uninsured peers, who lose up to 90% of their annual income [39].

Barriers to appropriate allocation of financial resources for cardiothoracic surgery in Africa

At present, current funding for cardiothoracic surgery in Africa depends mainly on foreign aid, philanthropy and private sector funding, out-of-pocket expenditures that are not sustainable [40]. Given that cardiothoracic operations require a high level of specialization, a lot of resources and highly skilled personnel in most aspects of medicine, adequate government assistance is needed in terms of both material and human capital development in health institutions to sustain and successfully run an affordable cardiac surgery programme [41].

Vervoot et al. reported that, due to the low concentration of workers in Sub-Saharan Africa (0.12 cardiac surgeons per 1 million people), few training programmes exist within the continent. It is common for senior surgeons to be trained outside the continent whereas junior surgeons have opportunities to be trained in Northern Africa, South Africa, Ghana or Kenya with varying levels of support [40].

Falase et al. reported that the delivery of cardiothoracic surgery within the continent occurs essentially via 3 models: (i) In the first model, a senior local surgeon successfully sets up a centre, as seen in Ghana. (ii) In the second model, humanitarian operations are performed over a short period by visiting surgeons. (iii) In the third, less frequently practiced model, foreign surgeons are employed on a contractual basis to develop a cardiac programme, as was done successfully in Kenya [10]. These models require significant financial investments and expenditures to be run successfully.

The limitations to the appropriate allocation of resources for capacity building and service delivery in cardiothoracic surgery include the following:

Patient-related Factors

Direct and indirect financial costs and the total cost of care borne by the patients have been found to determine the choice of treatment, patient adherence to treatment, access to care and timing of presentation. Indirect costs to patients encompass income lost during the perioperative and rehabilitation periods as well as transportation costs [42]. Insufficient transportation cost reimbursements have also contributed to the loss of patients during follow-up, thereby hindering the collation of data on surgical outcomes.

The funding structure is poorly developed, with most patients self-funding their healthcare. This situation restricts the number of procedures performed [10], with the cost for repair of simple defects like atrial septal defects being between $4,000 and $6,000 in Zimbabwe and some other African countries. In comparison, in countries with higher patient volumes, such as India, the cost of procedures such as atrial septal defect closure is between $4900 and $5500 [43]. Because the field of cardiothoracic surgery is not so highly developed in African countries, patients prefer to travel abroad for cardiac or thoracic surgical management. This has been the case in the past, where only the rich and the affluent travelled to the United States and Europe for healthcare. With India emerging as one of the medical hubs of the world, patients from Africa also go to India for all heart-related issues [44, 45]. Zilla et al. recommended that African countries purchase medical consumables in bulk to help reduce the cost of care [43].

Physician-related factors

Capacity building in surgery, educational investments and regular skills training and maintenance are important for the sustainability of cardiothoracic systems. The shortage of healthcare workers, inadequate skilled staff and poor remuneration of healthcare workers in comparison to their counterparts in other parts of the world have further fuelled the vicious cycle of brain drain and the underdevelopment of cardiothoracic systems. Zimbabwean surgeons who train abroad in South Africa as supernumerary registrars are often not paid and require their own or external funding due to the debts incurred during the course of training; many have to seek jobs in high-income countries to compensate [40].

Institutional barriers

The sustained investment required to effectively provide quality care is hampered by economic and political restraints on healthcare institutions. Most equipment and consumables used for cardiac operations are imported from other continents and require foreign currency, usually United States dollars. This foreign currency is a scarce resource in most African countries, which is a reflection of the economic difficulties being faced by these countries [43]. For a majority of countries, the percentage of the budget spent on healthcare, including the growth of cardiac surgery, is dependent on the GDP. High-income countries spend 11.8% of their GDP on health whereas low- and middle-income countries spend just 5.8% of their GDP on health, which severely limits essential health service priorities in these countries [5]. Insufficient political will and competing priorities have made most African countries fail to honour the Abuja Declaration of 2001, which was to commit 15% of government budgets to healthcare [24].

Emphasis is placed on the treatment of communicable diseases such as HIV/AIDS, malaria and diarrhoea [7]. Most government-funded interventions, policies and international aid are geared towards the treatment and eradication of these to the detriment of non-communicable diseases, which include cardiovascular diseases.

Increasing poverty levels, poor leadership and governance, corruption and an absence of universal healthcare coverage in most African countries hamper the delivery of cardiothoracic surgery care. Most African countries also struggle to provide primary healthcare services such as vaccinations; hence, cardiothoracic surgery in general is considered a luxury [46]. Even in global health, cardiothoracic surgery is considered a luxury and hence not prioritized in low- and middle-income countries [13]. Political conflicts, armed conflicts and continuous and persistent rebellions, which lead to political instability, prevent financial investments, which further leads to problems such as a lack of a proper medical infrastructure [7].

Health insurance programmes in low-income countries are non-existent or underdeveloped; hence, the majority of costs are paid out of pocket, with most patients who present being indigent [43] and institutions not intending to run at a loss opting to provide care with lower cost implications.

Governmental funding is often politicized spending on short-term initiatives that are popular but do not essentially meet the needs of the population at large. Poor fiscal returns, lack of sustainability and insufficient audits of donations have led to the waste of much-needed resources. Innovative financial instruments should be looked into to upgrade cardiac surgical capacity.

Bridging the gaps: the need and available resources for cardiothoracic operations in Africa

Despite these challenges, several initiatives and resources are available to support the development of cardiothoracic surgery in Africa, such as the Pan-African Society for Cardiothoracic Surgery, whose main objective has been to enhance collaboration among African cardiothoracic surgeons and to establish a sustainable cardiothoracic surgical care plan in Africa [47]. Partnerships with international organizations for capacity building, such as the Cardiac Surgery Intersociety Alliance and the Thoracic Surgery Foundation, just to name a few, will go a long way to improve the collaboration, not forgetting the African Association for Thoracic and Cardiovascular Surgeons, because it is a continental association whose aim is to improve the standard of cardiovascular and thoracic care within Africa [48]. Advocacy efforts to raise awareness about the importance of investing in cardiothoracic care should become another priority, especially advocacy using the Association of Future African Cardiothoracic Surgeons, which is a group of young students and early-career medical doctors who plan to undertake a career in cardiothoracic surgery, because such an organization is crucial to implement sustainable cardiac surgery in Africa [49]. Additionally, some African countries have made progress in establishing specialized cardiothoracic surgery centres and training facilities, contributing to the growth of the field in Northern Africa, Southern Africa, East Africa and Western Africa [21] (Table 1) [50].

Table 1:

The types of cardiothoracic operations performed and the number of cardiothoracic surgery centres in each African country with its corresponding population

S/N	Country	Types of cardiothoracic surgery procedures performed	Number of cardiothoracic surgery centres	Corresponding population
1	Nigeria [50]	Open-heart operations, heart valve operations, congenital heart defect repairs, CABG, thoracic tumour resections and lung operations	15	230,842,743
2	Cameroon [50]	CABG, open-heart operations, heart valve operations, congenital heart defect repairs	3	30,966,105
3	South Africa [50]	Open-heart operations, heart valve repair/replacement, CABG, congenital heart defect repairs, lung operations and thoracic tumour resections, minimally invasive cardiac and thoracic operations	27	62,027,503
4	Egypt [50]	CABG, thoracic tumour resections, lung transplants, minimally invasive cardiac operations, repairs of congenital defects within the thorax (tracheoesophageal fistula), heart valve operations, heart transplants, thoracic tumour resections	15	107,304,000
5	Ghana [50]	Valvular operations, congenital heart defect repairs, thoracic operations, open-heart operations and CABG	10	34,612,532
6	Gabon [50]	Thoracic operations, vascular operations, congenital heart operations	2	2,397,368
7	Congo-Kinshasha [50]	Congenital heart operations, open-heart operations, thoracic operations	2	109,717,326
8	Zambia [50]	Open-heart operations, valvular operations, congenital heart operations	2	20,216,029
9	Uganda [50]	Open-heart operations, valvular repair/replacement, CABG, coronary angioplasty, heart transplants, minimally invasive operations, congenital heart operations	5	49,283,041
10	Kenya [50]	CABG, heart valve operations, congenital heart defect repairs, thoracic operations and open-heart operations	7	52,428,290
11	Zimbabwe [50]	Open-heart operations, congenital cardiac operations, valvular repairs/replacements	5	16,868,409
12	Burkina Faso [50]	Open-heart operations, valvular repairs/replacements	3	22,489,126
13	Senegal [50]	Open-heart operations, congenital repair operations, vascular operations, valvular repairs/replacements	7	18,847,519
14	Ivory Coast [50]	Congenital heart operations, valvular repairs/replacements, vascular operations, open-heart operations	2	30,900,000
15	Rwanda [50]	Thoracic operations, cardiac operations, valvular repairs/replacements	2	13,623,302
16	Namibia [50]	Congenital cardiac operations, open-heart operations	1	2,803,660
17	Ethiopia [50]	Open-heart operations, congenital heart operations	2	132,900,000
18	Mali [50]	Open-heart operations, valvular repairs/replacements, congenital heart operations	2	21,990,607
19	Tanzania [50]	CABG, open-heart operations, minimally invasive heart surgery, valvular repairs/replacements, thoracic surgery, congenital heart surgery	4	67,462,121
20	Morocco [50]	Open-heart operations, valvular repairs/replacements, thoracic surgery	11	37,493,18
21	Algeria [50]	Open-heart operations, CABG, congenital heart surgery	18	46,700,000

CABG: coronary artery bypass grafting

Again, to improve the sustainability of cardiothoracic surgery within Africa, the needs of cardiothoracic surgeons should be met so that they can work more effectively and improve patient care within the continent. This goal involves strengthening cardiothoracic surgery education and training programmes, increasing the number of training programmes available for cardiothoracic surgeons in Africa and increasing the chances for Africans to get into cardiothoracic training programmes abroad, because all of these factors will help expand the pool of skilled cardiothoracic surgeons on the continent. Medical undergraduate programmes should have a cardiothoracic surgery rotation integrated within the medical curriculum, so that medical students are exposed to cardiothoracic surgical practice in the hope that this exposure will encourage them to become cardiothoracic surgeons and eventually increase the ratio of cardiothoracic surgeons to patients in Africa.

Investing in cutting-edge cardiothoracic surgery technology and the establishment of dedicated cardiothoracic surgery units and other infrastructures within the African region will improve the cardiothoracic surgery capacity and provide better patient care within the continent. These goals could be achieved by grants, partnerships and loans granted to heart centres.

Promoting research and innovation is another solution that can improve patient care and advancement in cardiothoracic surgery practice in Africa, because research is the key to modern medicine. Cardiothoracic surgeons and aspiring cardiothoracic surgeons, i.e. medical students and early-career doctors, should be encouraged to become involved in cardiothoracic surgery research to improve their skills.

Advocating for increased funding and policy support to prioritize cardiothoracic care within national and regional healthcare agendas will give cardiothoracic surgery firmer grounding in global and national healthcare plans because surgery is an integral part of patient care.

Offering standard quality cardiothoracic surgery care in Africa requires collaborative efforts from healthcare professionals, policy makers and the global community. By addressing the existing gaps, leveraging available resources and implementing strategic interventions, it is possible to improve access to life-saving cardiothoracic interventions and reduce the burden of cardiovascular and thoracic diseases in the region.

CONCLUSION

The issue of healthcare costs is a worldwide problem. Access to surgical care, particularly cardiothoracic surgery, remains limited, especially for the African population, but opportunities exist for African countries and international organizations to sustainably and innovatively finance local cardiothoracic surgery centres in their countries, drive down costs and support patients requiring this specialty care. Advocacy efforts are required to improve access to cardiothoracic surgical care by influencing governments and major industries to invest substantial funds in cardiothoracic surgery. These efforts must occur while minimizing opportunity and productivity costs for patients requiring cardiothoracic surgery, which can ultimately promote socioeconomic growth through health system-wide ripple effects. Even with all of these efforts, preventive medicine is still a very cost-effective way to bring down future costs of many cardiovascular diseases.

Glossary

ABBREVIATIONS

GDP

gross domestic product

LMICs

low- and middle-income countries

FUNDING

None declared.

CONFLICT OF INTEREST

All authors declared no conflict of interest.

DATA AVAILABILITY

No new data were generated or analysed in support of this research.

ETHICS APPROVAL STATEMENT

Ethical approval was not required.

Author contributions

Cynthia Nwalibe: Conceptualization; Writing—original draft. Victory Bassey Effiom: Writing—original draft; Writing—review & editing. Achanga Bill-Smith Anyinkeng: Writing—original draft. Michael Anayo James: Writing—original draft. Eben-Ezer Genda: Writing—original draft. Wambui Irungu: Writing—original draft. Frank-Awat Abaiweh: Writing—original draft. Kelechi E. Okonta: Supervision; Writing—review & editing

Reviewer information

Interactive CardioVascular and Thoracic Surgery thanks Shahab Nozohoor, Kerem M. Vural, Samuel Heuts, Amit Bhargava, Frank A. Baciewicz Jr and the other, anonymous reviewer(s) for their contributions to the peer review process of this article.