World's major heart surgery organizations call for effective strategies to treat rheumatic heart disease

Experts from the world's major heart surgery organizations-;including The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), and the European Association for Cardio-Thoracic Surgery (EACTS)-;are calling for urgent action to develop and implement effective strategies for treating rheumatic heart disease (RHD), which affects 33 million people and kills 320,000 annually. The joint statement, known as the "Cape Town Declaration," was published online today in The Annals of Thoracic Surgery and eight other journals.

The statement originated during a December 2017 conference in Cape Town, South Africa, arranged to commemorate the 50th anniversary of the world's first successful heart transplant operation. The conference was attended by representatives from STS, AATS, ASCVTS, and EACTS, as well as from numerous other national and pan-national heart surgery organizations, including the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the Brazilian Society of Cardiovascular Surgery, and the World Heart Foundation.

"The Cape Town Declaration represents the first truly worldwide initiative on rheumatic heart disease and involves every major cardiothoracic surgical organization throughout the globe," said STS President Keith S. Naunheim, MD. "While this may only be the first step, we look forward to a joint effort that involves not just surgical organizations but industry, regulatory agencies, legislative bodies, and charitable foundations. Only through such a coordinated effort can we hope to roll back the tide of global rheumatic heart disease."

RHD accounts for a major proportion of cardiovascular disease in children and young adults in low- and middle-income countries. It most often begins in childhood as strep throat. Left untreated, strep can progress to rheumatic fever and then RHD, which is characterized by one or more damaged heart valves. Although virtually eliminated in Europe and North America, RHD remains a leading cause of cardiovascular mortality in Africa, the Middle East, Central and South Asia, the South Pacific, and impoverished pockets of developed nations.

"The global burden of mortality from what is essentially a treatable disease remains underrecognized by different factions of society, including many health care providers," said AATS President David H. Adams, MD. "The Cape Town Declaration is a call to arms to work together to treat those currently suffering from RHD and hopefully to one day shift the focus to prevention through access to appropriate antibiotic treatments of streptococcal infections."

Currently, the only effective treatment for RHD is open heart surgery; however, this life-saving operation is not readily available in the affected regions. In those populations most vulnerable to RHD, the need for heart surgery is estimated at 300 operations per 1 million people. However, there is a serious shortage of both heart surgeons and hospitals that perform cardiac surgery in those areas most susceptible to the disease; for example, there is only one cardiac center per 33 million people in Africa. Furthermore, valve reconstruction as opposed to valve replacement in rheumatic disease is often possible and associated with better survival after surgery, and these techniques need to be broadly expanded through educational efforts in affected regions.

"The majority of people in the developing world are still lacking access to quality cardiac surgery," said Friedhelm Beyersdorf, MD, Editor-in-Chief of the European Journal of Cardio-Thoracic Surgery. "The recent 50th anniversary of the world's first heart transplantation in Cape Town should be the turning point."

ASCVTS President Shinichi Takamoto, MD, PhD, agreed. "We need a coordinated international effort, which draws upon the experience of fighting this disease in Asia, Africa, and elsewhere in the world, to make true progress in eliminating RHD."

Previous efforts to address RHD have focused on prevention and, while important, have failed to eradicate the disease, meaning that surgery likely will remain an integral part of RHD treatment for several generations. The declaration signatories are proposing a comprehensive solution with two principal aims:

• To establish an international coalition of individuals from cardiac surgery societies and representatives from industry, cardiology, and government to evaluate and endorse the development of cardiac care in low- to middle-income countries.

• To advocate for the training of cardiac surgeons and other key specialized caregivers at identified and endorsed centers in low- to middle-income countries.

More specifically, the declaration sets forth that the proposed international coalition should include two representatives each from STS, AATS, ASCVTS, and EACTS, along with one person from the device manufacturing industry and another from the World Heart Foundation. This group will be responsible for establishing criteria for the clinical care and training centers, as well as selecting and endorsing the centers. In addition, the declaration states that providers should receive training relevant to the conditions and resource-constrained settings that they can expect to encounter in their own countries. The statement also calls for the identification and endorsement of up to three clinical care and training centers to form a program nucleus as quickly as possible.​