South African Heart Association

Abstract Background TAVI implants have been available for >10years in SA and data has been collected since 2014 in a national registry. Objectives Evaluating local TAVI outcomes against international best practice using data captured in the SHARE TAVI registry, can provide an evidence base to inform appropriate patient selection in subgroups such as females. Method Clinical and demographic data of 4249 Aortic stenosis patients(pts) has been captured into a national web-based prospective registry, outcomes are reviewed at 30d and annually (to 10 years) post-implant (VARC2 definitions). From Sept 2014 – June 2024 2996 of these patients received TAVI implants, aggregated procedural and 30-day outcomes data from all 31 participating sites has been analysed by sex. Results Patient populations and outcomes are similar to other registries and studies (GARY, Corevalve, PARTNER 1) in early TAVI programs. Female pts are less represented in TAVI implant data in SA 41.45% (n=1242/2996), and the percentage of females has gradually dropped from 52.94% in 2014 to 39.9% in 2023. Females are on average slightly older than males 79.964 vs. 78.854 years, have higher STS risk score 6.139% vs 5.329% and are more often frail 28% vs 19% of men. Most comorbidities occur similarly between sexes, exceptions are: Females: Prior CABG 9.18%, Permanent Pacemaker 6.84%, Extracardiac arteriopathy 9.02%, DM 20.13% Males: Prior CABG 27.31%, Permanent Pacemaker 11.97%, Extracardiac arteriopathy 16.99%, DM 26.97% Females have higher Mean gradient across valve (49.25 vs 46.62mmHg), and more pts in NYHA class III+IV (61.22% vs 55.75%) Lower Procedural Success in females (96.86%) vs 97.95% in males is partly due to higher female Intraprocedural mortality 1.93% vs 0.68%, and similarly 30-day mortality 6.04% vs 3.71% is higher in females. The higher female intraprocedural mortality is related to bleeding & vascular complications with larger profile earlier generation valves. Mortality outcomes by 1-year (11.93% vs 12.71%) and 2-year (22.10% vs 23.16%) favour females. Conclusion Differences in baseline Echo measurements, risk scores, comorbidities and periprocedural outcomes between sexes do not always track to obvious changes in longer term outcomes. Women come for treatment later than men, presenting with worse symptoms and aortic stenosis. Poorer procedural outcomes in females were driven by vascular & bleeding complications with larger profile earlier generation valves. Newer generation smaller profile valves result in fewer bleeding and vascular complications related to females' smaller vasculature and anatomy. By 1-year the higher burden of co-morbidities in males drives a relatively higher sex-related mortality difference and mortality outcomes favour females.

Background: Pulmonary hypertension (PH) disproportionately affects those residing in low- and middle-income countries (LMICs). Given that these countries also have a high prevalence of infectious diseases, many cases of PH are either directly or indirectly related to infectious etiologies. Despite this correlation, the precise burden of infectious disease-associated PH is largely underappreciated due to a lack of diagnostic resources, a shortage of clinical expertise to carry out right heart catheterization and poor access to healthcare facilities in many low- and middle-income settings. Methods: In this narrative review, we highlight the significant burden of infectious disease-associated PH in LMICs, outline the technical challenges faced by LMICs when diagnosing PH, and propose possible solutions for diagnosing PH in resource-constrained settings. Conclusions: Low-cost and sustainable solutions for infectious disease-associated PH in LMICs should be prioritized. Meaningful solutions require collaborative efforts and capacity building in LMICs.

Background:Heart failure (HF) affects approximately 64.3 million people worldwide. Despite notable progress over the past two decades in advancing the understanding of heart failure in Africa–a condition often more lethal than many cancers–important knowledge gaps persist. These include outdated data on access to care and a lack of information regarding the incidence, aetiology, availability, and affordability of HF medications.Objectives:To prospectively characterise the contemporary incidence, epidemiology, clinical presentation, and health outcomes of acute HF among a large, representative cohort of patients presenting to hospitals across diverse communities in Africa.Methods:The Sub-Saharan Africa Survey of Heart Failure (THESUS-HF II) is a pragmatic, multicentre, observational cohort study coordinated by the Pan-African Society of Cardiology (PASCAR). All 27 PASCAR member countries were invited to participate, along with over 5,000 clinicians from the PASCAR database. The survey comprises two components. First, a platform collecting data on each hospital’s catchment population, human resources, presence of specialised cardiology services, availability of diagnostic tools, and access to essential heart failure treatments. Second, a prospective observational study capturing all acute heart failure presentations to participating hospitals over seven weekdays within an 8-week period (from the start of surveillance). Data were collected on clinical characteristics and outcomes to discharge, 30 days, and six months. The study commenced in mid-2024 and includes approximately 50 hospitals across 16 countries spanning all major regions of the African continent.Conclusions:When completed, THESUS-HF II will be the largest and most comprehensive study of acute HF to date in Africa. It will provide invaluable insights into the contemporary characteristics and burden of acute HF in Africa, whilst indicating what is needed to improve health care planning and, ultimately, patient outcomes.

Background and AimsHypertension has a high prevalence in heart failure with preserved ejection fraction (HFpEF), which can be controlled, uncontrolled, or even resistant. The effects of empagliflozin on systolic blood pressure (SBP), time in target range, incidence of hypertensive urgencies, and studied cardiovascular and renal outcomes in different hypertension categories and after treatment with empagliflozin in the EMPEROR-Preserved trial were explored.MethodsA total of 5533 patients were studied and the population was separated into resistant (resHTN), uncontrolled (uctrHTN), and controlled (ctrHTN) hypertension. The effect of SBP on outcomes and treatment effects of empagliflozin were explored. Analyses were done with Cox regression analyses adjusted for demographic and clinical confounders and with a mixed model for repeated measures.ResultsEmpagliflozin reduced SBP in resHTN slightly more than in the other categories in the first weeks, while thereafter there were no significant differences. The modest reduction in SBP resulted in a moderate increase in time at target and reduced hypertensive urgencies. The primary endpoint was more prevalent in resHTN (P = .0358), but the treatment effect of empagliflozin on the primary endpoint was similar in resHTN, uctrHTN, and ctrHTN (P for interaction = .92) as was the improvement of the estimated glomerular filtration rate slope (P for interaction = .95) and change in quality of life by empagliflozin.ConclusionsIn HFpEF, the prevalence of resHTN is high and is associated with frequently higher outcome rates compared with ctrHTN and uctrHTN. The treatment effect was not modified by hypertension categories. This indicates that in HFpEF, moderate modifications of blood pressure do not affect overall outcomes and treatment effects of empagliflozin.

This case study describes the successful short-term outcome of staged minimally invasive pectus excavatum correction and endoscopic mitral valve repair in a patient with severe mitral valve regurgitation and pectus excavatum.

BackgroundThere is still a paucity of evidence on the outcomes of coronavirus disease 2019 (COVID-19) among people living with human immunodeficiency virus (PWH) and those co-infected with tuberculosis (TB), particularly in areas where these conditions are common. We describe the clinical features, laboratory findings and outcome of hospitalised PWH and human immunodeficiency virus (HIV)-uninfected COVID-19 patients as well as those co-infected with tuberculosis (TB).MethodsWe conducted a multicentre cohort study across three hospitals in Cape Town, South Africa. All adults requiring hospitalisation with confirmed COVID-19 pneumonia from March to July 2020 were analysed.ResultsPWH comprised 270 (19%) of 1434 admissions. There were 47 patients with active tuberculosis (3.3%), of whom 29 (62%) were PWH. Three-hundred and seventy-three patients (26%) died. The mortality in PWH (n = 71, 26%) and HIV-uninfected patients (n = 296, 25%) was comparable. In patients with TB, PWH had a higher mortality than HIV-uninfected patients (n = 11, 38% vs n = 3, 20%; p = 0.001). In multivariable survival analysis a higher risk of death was associated with older age (Adjusted Hazard Ratio (AHR) 1.03 95%CI 1.02–1.03, p < 0.001), male sex (AHR1.38 (95%CI 1.12–1.72, p = 0.003) and being “overweight or obese” (AHR 1.30 95%CI 1.03–1.61 p = 0.024). HIV (AHR 1.28 95%CI 0.95–1.72, p 0.11) and active TB (AHR 1.50 95%CI 0.84–2.67, p = 0.17) were not independently associated with increased risk of COVID-19 death. Risk factors for inpatient mortality in PWH included CD4 cell count < 200 cells/mm3, higher admission oxygen requirements, absolute white cell counts, neutrophil/lymphocyte ratios, C-reactive protein, and creatinine levels.ConclusionIn a population with high prevalence of HIV and TB, being overweight/obese was associated with increased risk of mortality in COVID-19 hospital admissions, emphasising the need for public health interventions in this patient population.

There is no conclusive evidence to guide surgical management in the presence of multiple colonic injuries as opposed to a single colonic injury, and whether multiple colonic suture lines are associated with worse outcomes than single suture lines. We reviewed the outcomes of penetrating colonic trauma in relation to whether patients had single versus multiple colonic suture lines (primary repair or anastomosis) following laparotomy. A retrospective study was conducted at a major trauma centre in South Africa from 2012-2020 for all patients over 18years who had sustained penetrating colon injury. 541 cases were included: 409 with single suture line and 54 with multiple suture lines. There were no differences between groups in terms of mechanism of injury (gunshot vs stab; p = 0.328), Injury Severity Score (p = 0.071), or Penetrating Abdominal Trauma Index (p = 0.396). Admission lactate was worse for multiple suture line patients (p = 0.049), but no other blood gas parameters were different, and there was no higher incidence of damage control surgery (p = 0.558) or ICU admission (p = 0.156) for this group. There was a higher rate of diversion in the multiple suture line group (p < 0.001). Univariable logistic regression did not show an increased risk of gastro-intestinal complications, suture line leak rate, or mortality for multiple suture lines compared to single. It appears that there is no appreciable difference in outcome between patients with a single colonic suture line compared to patients with more than one suture line following trauma laparotomy. In light of this, each injury should be treated on its own merit, in the context of the patient's overall physiological condition, without undue fear of leaving the patient with more than one colonic suture line. However, judicious use of diversion remains advisable.

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2–3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.