REVIEW

Cardiac Surgery in Low- and Middle-

Income Countries: A State-of-the-Art
Review
Dominique Vervoort, MD, JaBaris D. Swain, MD, MPH, A. Thomas Pezzella, MD, and
Jacques Kpodonu, MD
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery,
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; International Children’s Heart Fund, Boca Raton, Florida; and
Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Background. Six billion people in low- and middle- million population compared with low-income coun-
income countries (LMICs) lack timely or ready access to tries. There are more than 4000 cardiac centers world-
safe and affordable cardiac surgical care when needed, wide, but less than 1 center per 10 million population
which remains a low priority on the global public health in LMICs. Approximately 1.5 million cardiac opera-
and global surgery agenda. Here, we report the results of tions are performed globally, of which a dispropor-
a state-of-the-art review of cardiac surgical care in LMICs tionally low number are in LMICs. Despite the high
to highlight the important milestones and current prog- costs associated with cardiac operations, recent data
ress as well as the challenges associated with the expan- suggest the favorable cost-effectiveness thereof in
sion of sustainable global cardiac surgery for those in LMICs. Opportunities arise to sustainably integrate
need. cardiac surgery in holistic health systems strengthening
Methods. A literature review was performed searching interventions.
the PubMed/MEDLINE and Google Scholar databases Conclusions. Skepticism underlying the need, feasi-
using a combination of cardiac surgery, global health, bility, and cost-effectiveness of cardiac surgery in LMICs
and LMIC keywords. The Institute for Health Metrics prevails, but recent advances, successful case studies, and
and Evaluation Global Burden of Disease Results Tool existing data illustrate the potential of expanding cardiac
REVIEW

was used to assess the global burden of disease related to care globally.
cardiovascular surgical diseases.
Results. High-income countries are estimated to have (Ann Thorac Surg 2021;111:1394-401)
more than 100 times as many cardiac surgeons per Ó 2021 by The Society of Thoracic Surgeons

G lobal cardiac surgery can be defined as a platform

“that places a priority on improving health out-
comes and achieving health equity for all people world-
To date, 93% of people living in low- and middle-
income countries (LMICs)—nearly 6 billion people
worldwide—are estimated to lack access to cardiac sur-
wide who are affected by cardiac surgical conditions or gical care when needed.4 In light of the growing burden
have the need for cardiac surgical care.”1 Surprisingly, of of CVD around the world, including the epidemiologic
all the surgical subspecialties included in the discourse transition from communicable to noncommunicable dis-
surrounding the global burden of disease, global cardiac eases in LMICs, recognition thereof is vital to move to-
surgery is the one subspecialty that is most often omitted. ward the Sustainable Development Goals and universal
Much of the disregard, however, is believed to be a result health coverage. In this state-of-the-art review, we
of the perceived difficulty of introducing cardiac surgery comprehensively describe cardiac surgical care in LMICs
in low-resource settings given its complex follow-up, its to highlight the important milestones and current prog-
demand for intensive human resource training, and the ress as well as the challenges associated with the expan-
required capital funding necessary to establish widely sion of sustainable global cardiac surgery for those in
available and sustainable cardiovascular services. Unfor- need.
tunately, this disregard undermines the parallel attempts
to ameliorate the global burden of cardiovascular disease
(CVD), a known cause of significant morbidity and mor- Material and Methods
tality of all noncommunicable diseases worldwide.2,3
Global Burden of Disease
The Institute for Health Metrics and Evaluation Global
Address correspondence to Dr Kpodonu, Division of Cardiac Surgery,
Beth Israel Deaconess Medical Center, Harvard Medical School, 110
Burden of Disease Results Tool was used to assess the
Francis St, Ste 2A, Boston, MA 02215-5501; email: jkpodonu@bidmc. global burden of disease related to cardiovascular surgi-
harvard.edu. cal diseases in disability-adjusted life years (DALYs) and

Ó 2021 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2020.05.181
Ann Thorac Surg REVIEW VERVOORT ET AL 1395
2021;111:1394-401 GLOBAL CARDIAC SURGERY

deaths.3 DALYs are a morbidity measure reflecting the discussing the state of cardiac surgical care in LMICs for
years of healthy life lost due to disease, disability, or the first time on an international stage: “As thoracic sur-
death, whereby 1 DALY equals 1 year of healthy life lost. geons, we must recognize that we as a specialty have failed
Table 13 summarizes the estimated morbidity and mor- the international community, and we should place the task
tality due to cardiovascular surgical diseases in propor- of correcting that failure at the top of our agenda.”11-13
tion to all-cause mortality and morbidity and that from Despite the strong call to action, little societal efforts took
common global and public health priorities, including place in the nearly 2 decades that followed.
trachea, bronchus, and lung cancers, road injuries, More recently, The Society of Thoracic Surgeons, the
tuberculosis, malaria, and HIV/AIDS. American Association for Thoracic Surgery, the European
Association for Cardio-Thoracic Surgery, the Asian So-
Literature Review ciety for Cardiovascular and Thoracic Surgery, and the
A state-of-the-art literature review was performed World Heart Federation jointly established the Cardiac
searching the PubMed/MEDLINE and Google Scholar Surgery Intersociety Alliance (CSIA).14 The CSIA was
databases using a combination of variations of cardiac established after the 50-year celebration of the first hu-
surgery, global health, and LMIC keywords. Search re- man heart transplant by Dr Christiaan Barnard in Cape
sults were categorized as history, workforce, infrastruc- Town, South Africa. During the gathering, which
ture, service delivery, financing, information convened societal leaders from around the world, the
management and technology, and governance. “Cape Town Declaration on Access to Cardiac Surgery in
the Developing World” was developed, with a pro-
nounced emphasis on rheumatic heart disease.15
Results The focus of this coalition was to corral “all relevant
entities within the international cardiac surgery, industry
Global Burden of Disease
and government sectors to commit to develop and
Approximately 17.65 million people die from CVD every implement an effective strategy to address the scourge of
year, with more than 80% of deaths taking place in rheumatic heart disease in the developing world through
LMICs.2 Estimates project an increase in CVD mortality increased access to life-saving cardiac surgery.”15
to more than 20 million per year by 2030, with the most Although in its infancy, the initiative has already begun to
substantial increase in LMICs. One in 100 children is born identify and support fledgling training programs and care
with congenital heart defects (CHD), of which 70% delivery systems that might serve to enable cardiac sur-
require medical or surgical treatment to survive or live in gery services to larger catchment areas.
good health before their first birthday.5 Nevertheless,

REVIEW
more than 90% of individuals with CHD in LMICs fail to Workforce
receive the care they need. As a result, nearly 300,000 Recent data estimated that high-income countries possess
individuals continue to die from CHD every year.6 approximately 7.15 adult cardiac surgeons per 1 million
Rheumatic heart disease, in turn, affects 33.4 million population and 9.51 pediatric cardiac surgeons per 1
people worldwide, slowly progressing to heart failure and million pediatric population.16 In stark contrast, low-
eventually death as a result of mitral valve calcification income countries have approximately 0.04 adult and
and failing valves.7 To a lesser extent, endemic CVD in- 0.07 pediatric cardiac surgeons per 1 million (pediatric)
cludes endomyocardial fibrosis in the equatorial African population. In addition to differences between countries
region and Chagas disease in Central and South America. and regions, most LMICs face substantial in-country
Endomyocardial fibrosis affects as many as 20% of heart disparities limiting specialty services for large parts of
disease patients referred for echocardiography in coun- their population. For example, the western, northeastern,
tries at risk, although exact prevalence estimates are un- and rural regions in China see low densities of cardiac
available.8 Chagas disease has been estimated to be surgeons and low surgical volume per surgeon, leading to
prevalent in 8 to 12 million people, of whom only 1% have a mean cardiac surgery volume per surgeon per year of
access to timely diagnosis and treatment, risking pro- only 23 procedures nationwide.17 In addition, critical
gression to chronic Chagas cardiomyopathy.9 shortages in the number of anesthesiologists, intensivists,
and nurses specifically trained to manage cardiac surgical
History patients, as well as perfusionists and technicians, further
As of the late 20th century, mission trip models were limits the ability to provide safe and high-quality cardiac
responsible for most of the cardiac surgical care delivery surgical care in many countries.
in LMICs due to a lack of overall surgical infrastructure In line with substantial variation in the cardiac surgical
and financial resources in LMICs. While still common to workforce around the globe, specialty training markedly
date, a shift from fly-in–fly-out missions to more sus- differs from country to country.18 A standardized, inter-
tainable models is occurring, encouraging the establish- national cardiac surgical certification seems far removed,
ment and expansion of locally driven cardiac centers.10 whereas cardiac surgery training pathways for medical
In 2001, Dr James L. Cox, informed by Dr Felix Unger’s graduates from low- and lower-middle-income countries
global survey from 6 years prior, delivered his Presidential are lacking. Some graduates are able to seek training in
Address “Changing Boundaries” at the Eighty-first Annual larger LMICs (eg, South Africa, India, China) or, less
Meeting of the American Association for Thoracic Surgery, frequently, high-income countries (eg, United Kingdom,
 1396 REVIEW VERVOORT ET AL Ann Thorac Surg
GLOBAL CARDIAC SURGERY 2021;111:1394-401

Table 1. The Global Burden of Disease in 20173

Deaths Disability-Adjusted Life Years

Cause Number Proportion of Total (%) Number Proportion of Total (%)

All causes 55,945,730 100.00 2,499,292,056 100.00

Ischemic heart disease 8,930,369 15.96 170,275,348 6.83
Rheumatic heart disease 285,517 0.51 9,393,560 0.38
Congenital heart defects 261,247 0.47 22,223,897 0.89
Cardiomyopathy and myocarditis 368,536 0.66 10,247,081 0.41
Atrial fibrillation and flutter 287,241 0.51 5,976,005 0.24
Aortic aneurysms 167,249 0.30 3,039,858 0.12
Endocarditis 83,391 0.15 2,228,363 0.09
Stroke 6,167,292 11.02 132,051,366 5.29
Peripheral artery disease 70,169 0.13 1,432,443 0.06
Trachea, bronchus, and lung cancers 1,883,066 3.37 40,928,668 1.64
Road injuries 1,243,068 2.22 67,798,033 2.72
Tuberculosis 1,183,672 2.12 44,997,359 1.80
Malaria 619,827 1.11 45,014,578 1.80
HIV/AIDS 954,492 1.71 54,446,184 2.18

Germany). However, little standardization of such path- sustainability, applicability, and a reduction in costs.
ways is currently present around the world and between Some countries, such as China and India, now produce
governments. Although the involvement of industry has equipment, disposables, and devices in-country to reduce
shown the potential for improving technical skills by costs and shorten the supply chain. Additionally, LMIC
surgeons from a distance through virtual simulation teams have developed important innovations relevant to
models and centralized (eg, at conferences) skills work- low-resource settings. For example, Scherman et al23
shops, the short-term nature and lack of direct, physical introduced the hollow balloon for transcatheter valve
mentorship currently limits the expansion thereof to replacements in South Africa, reducing the need for
substantially increase the cardiac surgical workforce ventricular pacing by maintaining cardiac output through
REVIEW

density around the world. However, long-term (eg, 6 to 12 the balloon. Matte and del Nido24 developed a low-cost,
months) models embedding experienced cardiac sur- easy-to-make cardioplegia solution, costing LMICs less
geons—ranging from sabbatical years and academic col- than $10 per dose compared with conventional car-
laborations to retired surgeons—in nascent or growing dioplegia solutions costing hundreds of dollars. Portable
international cardiac centers have demonstrated success echocardiography has further allowed for increased dis-
in accelerating the institutional learning curve.19,20 ease detection in communities and underresourced pri-
mary and secondary care facilities in LMICs and has
recently shown high accuracy even among trained
Infrastructure nonphysician personnel.25
In 1999, it was estimated that approximately 4000 centers
performed cardiac surgery around the world.11 Where
North America possessed 1 center per 120,000 population Service Delivery
and Europe and Australia reportedly had 1 center per 1 An estimated 1.5 million cardiac operations are per-
million population, Asian countries had only 1 per 16 formed around the world every year, although the
million population and the African continent 1 per 33 exact number in LMICs remains unknown. Zilla and
million population. Recent global numbers are lacking, colleagues26 estimated a need for 400 cardiac opera-
but country-specific data are increasingly emerging. A tions per 1 million population per year in low-income
cardiac center assessment tool was recently developed countries, between 500 and 1000 per 1 million in
and piloted in Namibia, Uganda, and Zambia, which can middle-income countries, and more than 1000 per 1
be implemented in other countries to comprehensively million in high-income countries.26 The increase was
assess cardiac surgical infrastructure.21 largely attributed to the exponential increase in
Owing to inefficient and often costly surgical supply ischemic heart disease incidence amid the epidemio-
chains for LMIC facilities, equipment (eg, heart-lung logic transition of (mostly) middle-income countries to
machines, surgical tools) and consumables (eg, heart date and the high incidence and prevalence of non-
valves, drugs) are commonly donated by centers in high- communicable diseases, such as ischemic heart dis-
income countries. However, this may occur without ease, in high-income countries.
regulation, leading to a donation of defective, expired, or While a growing number of local cardiac centers are
otherwise unusable equipment.22 As a result, locally being established, annual volumes commonly remain low
sourced and low-cost solutions are necessary to ensure due to a lack of funding and inefficient surgical supply
Ann Thorac Surg REVIEW VERVOORT ET AL 1397
2021;111:1394-401 GLOBAL CARDIAC SURGERY

chains. As a result, nongovernmental organizations in the United States. China has similarly leveraged local
(NGOs) fill a substantial gap, ranging from traditional fly- economies of scale and local industry to provide high
in–fly-out mission trips to long-term academic partner- surgical volume at low costs in Shanghai and Beijing.36
ships established with the specific intent of building local Innovative financing mechanisms are necessary to
capacity. Among cardiac surgical NGOs, pediatric cardiac ensure funding of surgical services on a regional, national,
surgery missions have been the most common focus of and individual level. Expanding surgical services in LMICs
international NGOs. In 2014, Nguyen and colleagues27 to meet the surgical volume target of 5000 procedures per
identified 80 NGOs providing pediatric cardiac surgical 100,000 population was initially estimated at an investment
services in 92 LMICs. Encouragingly, 74% of partner sites of approximately $350 billion by 2030.37 However, recent
were reported to perform pediatric cardiac surgery dur- developments suggest that the investments may be much
ing times when NGOs were not in-country, illustrating lower.38 Introducing innovative financial models, such as
the gradual expansion of services worldwide. public-private partnerships, fiscal space expansion, and
Favorable postcardiac surgery outcomes in several nonearmarked development aid for health, is necessary to
LMICs further suggest the feasibility of performing achieve the required investments. Currently, however, less
complex cardiac operations in low- and lower-middle- than 1% of health aid from high-income countries to
income countries in the context of late-stage presenta- LMICs is directed to surgical care, partly as a result of
tion and lower Human Development Index. In earmarking of funds to existing global health priorities as
Mozambique, 30-day postoperative mortality rates were opposed to the LMICs’ domestic priorities.39 Concurrently,
6.1%, whereas 2-year mortality was 9.7%.28 In Cambodia, introducing national health schemes to provide financial
30-day mortality rates were 3.1%, whereas 1-year mor- risk protection for countries’ poorest populations and
tality rates were 5.8%.28 In Samoa and Fiji, early (30-day) reduce out-of-pocket expenditure is necessary to improve
mortality rates were 3.9%, including 1.0% in-hospital access to cardiac surgical services. The “Poor Patients Re-
mortality rates.29 Because higher surgical volumes are lief” program was started in Nepal in 2003, ensuring free
associated with better outcomes, the expansion of ser- cardiac surgical care for children aged younger than 15
vices in LMICs may, in turn, lead to further reductions in years, the elderly older than 75 years, and the poorest
postoperative mortality rates.30,31 Furthermore, opportu- populations in Nepal.40 As a result, more than 100 valve
nities arise for the improvement of nontechnical skills for replacements are done free of charge in low-income Nep-
surgeons in cardiac surgery and variable-resource con- alese patients every year.
texts to improve communication skills, leadership, and
decision making within the operating room.32,33 Information Management and Technology
Professional societies in North America (eg, The Society

REVIEW
Financing of Thoracic Surgeons) and Europe (eg, European
Cardiac surgery is an expensive and complex interven- Congenital Heart Surgeons Association) have developed
tion due to its reliance on health services spanning the robust, international databases to monitor the quality
entire care continuum, most notably with regards to heart and, by proxy, volume of procedures done in the catch-
transplantation, mechanical circulatory support, and ment areas. However, LMICs are grossly lacking in the
complex congenital heart operations. Despite the high databases, largely due to a lack of information manage-
procedural costs, however, cardiac surgery has been ment infrastructure, workforce available to enter data,
shown to be cost-effective due to the large impact on financial constraints, and lack of validation mechanisms.
individuals’ and populations’ lives. For example, pediatric To date, the World Society of Pediatric and Congenital
cardiac surgery in LMICs has shown cost-effectiveness at Heart Surgery has become the first and only society to
$171 per DALY, indicating more favorable cost- comprehensively include a large number of LMIC cardiac
effectiveness than many common global public health centers.41 In parallel, the International Quality Improve-
interventions such as oral rehydration therapy for diar- ment Collaborative stemming from Boston Children’s
rhea and antiretroviral therapy for HIV/AIDS.34,35 Hospital has grown to include 64 cardiac centers in 25
Several opportunities may arise to reduce the costs of LMICs, providing regular quality improvement, distance
cardiac surgery in LMICs as well as to cover the out-of- learning, and in-person data validation to all collabo-
pocket expenditure by patients. In India, Narayana rating centers.42 However, national databases for cardiac
Health, for example, established and expanded under the surgery as a whole are lacking in LMICs, limiting our
leadership of Dr Devi Shetty, is a multihospital network knowledge of the outcomes, techniques, and volume to
spanning the country and providing specialty care at low the literature coming out of these centers.
costs. The network’s largest facility, in Bangalore, started Meanwhile, the introduction of digital health technol-
with performing cardiac surgery at high volumes, build- ogies allows for improved access to preoperative, peri-
ing a local economy of scale in collaboration with the local operative, and postoperative health care services through,
industry. Through a cofinancing model, higher-income for example, telemonitoring, mobile health smartphone
patients pay higher charges to allow the hospital to treat applications, and anticoagulation monitoring and adher-
lower-income patients at lower to no charges. As a result ence.43 With the expansion of mobile application systems
of these innovative approaches, the hospital is now able and technologies such as 5G connectivity going main-
to perform coronary artery bypass grafting (CABG) at stream, as well as artificial intelligence platforms in health
approximately $1500 compared with more than $100,000 care and quantum computing, the future outlook of
 1398 REVIEW VERVOORT ET AL Ann Thorac Surg
GLOBAL CARDIAC SURGERY 2021;111:1394-401

medicine in LMICs holds promise with improved docu- further contributing to one-third of the global burden of
mentation and patient follow-up, which should cumula- disease.51 Without timely investments in surgical ser-
tively add to sustainability in many of these regions. vices, LMICs are projected to face a loss of $12.3 trillion in
economic growth by 2030.37 Given these striking statistics,
Governance a call to action was invoked on May 26, 2015, when the
To move away from fly-in–fly-out cardiac surgery mission World Health Organization and its 194 Member States
trips and build toward sustainable, local-led and local-bred unanimously adopted the World Health Assembly
cardiac centers, long-term, multidisciplinary planning and (WHA) Resolution WHA68.15, “Strengthening emer-
political buy-in is required. Many models exist to develop gency and essential surgical care and anesthesia as a
local programs, ranging from the Ghana-Germany model component of universal health coverage.”52,53 The his-
in Ghana—the first Ghanaian cardiac surgeon trained in torical significance of this critical moment lies in the fact
Germany and returned to Ghana to establish a program— that this proposition was the first public, high-level
to sustainable, capacity building-oriented support by an meeting acknowledging surgical care as an essential
NGO in Rwanda.44-46 Further, National Surgical, Obstetric, and cross-cutting component of well-functioning health
and Anesthesia Plans (NSOAPs) are long-term health systems.54 As such, there has been a growing priority
systems strengthening strategic plans embedded within toward augmenting surgical services around the world
countries’ national health plans. The NSOAP framework across all surgical and anesthetic specialties. However,
has been laid forth by the Lancet Commission on Global one may argue that exception has been taken in regards
Surgery to holistically strengthen entire health systems to global cardiac surgery—where progress still lags
through a focus on workforce, infrastructure, service de- behind—especially in LMICs, where the expansion of
livery, financing, information management, and gover- cardiovascular services is needed most.
nance, and is increasingly being developed by LMICs Several challenges and opportunities exist within
around the world.47,48 To date, 6 countries (Senegal, global cardiac surgery. Despite the progress made,
Ethiopia, Zambia, Tanzania, Rwanda, and Nigeria) have skepticism underlying cardiac surgical services in LMICs
developed NSOAPs, whereas several dozen are in progress prevails.55 The misperception of cardiac surgery as a
of doing so. However, owing to a lack of CVD stakeholders luxury within global health stands in contrast with CVD
during the planning processes, no NSOAP has included as the world’s leading cause of death and the need of
cardiac surgical services so far.49 surgical care in 33% of CVD cases, as well as the clear
cost-effectiveness on an individual level.34,56 Cardiac
surgery can be scaled, as illustrated in India and China,
Comment whereas the establishment of such services enables
REVIEW

Five of the nearly 8 billion people worldwide lack access noncardiac health services to be scaled. Holistic cardiac
to safe, timely, and affordable surgical, obstetric, and surgical care encompasses the availability of timely
anesthesia care when needed.50 As a result, 18 million outpatient disease detection, referral mechanisms, imag-
people die of surgically treatable conditions each year, ing, laboratory services, blood banks, intensive care,

Figure 1. Comprehensive cardiovascular

care, including cardiac surgery and inter-
ventional cardiology, strengthen the entire
care continuum as cross-cutting health
services.
Ann Thorac Surg REVIEW VERVOORT ET AL 1399
2021;111:1394-401 GLOBAL CARDIAC SURGERY

anticoagulation and essential medicines, and dialysis, 5. Zheleva B, Atwood JB. The invisible child: childhood heart
among others. As a result, it can result in overall health disease in global health. Lancet. 2017;389:16-18.
6. GBD 2017 Congenital Heart Disease Collaborators. Global,
systems strengthening (Figure 1). regional, and national burden of congenital heart disease,
While moving toward the expansion of sustainable 1990-2017: a systematic analysis for the Global Burden of
global cardiac surgery, lessons ought to be drawn from Disease Study 2017. Lancet Child Adolesc Health. 2020;4:
other surgical subspecialties successful in transcending 185-200.
7. Watkins DA, Johnson CO, Colquhoun SM, et al. Global,
preexisting myths underlying the care delivery thereof in
regional, and national burden of rheumatic heart disease,
low-resource settings. For example, the global neurosur- 1990-2015. N Engl J Med. 2017;377:713-722.
gery community has been successful in catalyzing a 8. Bukhman G, Ziegler J, Parry E. Endomyocardial fibrosis:
global movement with the involvement of the World still a mystery after 60 years. PLoS Negl Trop Dis. 2008;2:
Health Organization and all neurosurgical societies, e97.
9. Mora G. Chagas cardiomyopathy. e-J Cardiol Pract. 2016;
creating an opportunity for cardiac surgery to follow
14(31).
suit.57 In this context, cardiac surgeons from all countries 10. Polivenok I, Gelatt M, Cardarelli M. Cardiac surgical mis-
alike are to be encouraged to raise their voices regarding sions: what works, what does not, where we need to go from
disparities in domestic and international care and to here. Curr Opin Cardiol. 2020;35:76-79.
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Cardiovasc Surg. 2001;122:413-418.
through health policy discussions and pertinent advo- 12. Unger F, Ghosh P. International cardiac surgery. Semin
cacy. This entails, among other actions, calling on gov- Thorac Cardiovasc Surg. 2002;14:321-323.
ernments and policymakers to include the establishment 13. Unger F. Worldwide survey on cardiac interventions 1995.
or expansion of cardiac surgery services in national health Cor Eur. 1999;7:128-146.
14. Boateng P, Bolman RM III, Zilla P, on behalf of CSIA. Car-
plans, for example, through integration in budding
diac surgery for the forgotten millions: the way forward.
NSOAPs. Moreover, in an era in which nearly half of the Cardiac Surgery Intersociety Alliance (CSIA) site selection
world’s population owns a smartphone and mobile net- criteria. Ann Thorac Surg. 2019;108:653.
works provide instant and asynchronous global connec- 15. Zilla P, Bolman RM, Yacoub MH, et al. The Cape Town
tivity, the use of social media to build networks, Declaration on access to cardiac surgery in the developing
world. Ann Thorac Surg. 2018;106:930-933.
disseminate scholarly work, and foster medical education 16. Vervoort D, Meuris B, Meyns B, Verbrugghe P. Global car-
is clear.58 diac surgery: access to cardiac surgical care around the
Ultimately, the expansion of services and development world. J Thorac Cardiovasc Surg. 2020;159:987-996.e6.
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allows for the introduction of such practices in high-
JAMA Cardiol. 2019;4:952-953.
income countries alike. Such trickle-up or reversed

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18. Nissen AP, Smith JA, Schmitto JD, et al. Global perspec-
innovation in particular benefits countries and pop- tives on cardiothoracic, cardiovascular, and cardiac
ulations faced with substantial socioeconomic and health surgical training. J Thorac Cardiovasc Surg. 2021;161:168-
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19. Pezzella AT. Model 5-year cardiothoracic surgery residency
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21. Forcillo J, Watkins DA, Brooks A, et al. Making cardiac sur-
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of access to cardiac surgical care for billions of people Uganda and Zambia. J Thorac Cardiovasc Surg. 2019;158:1384-
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Cardiac Surgery in Low- and Middle-income Countries: Can We Move the Needle?

Invited Commentary: remains an outlier in that it is often deemed too

complex or too expensive to perform in austere set-
Despite the relatively recent acknowledgement of the tings. In this piece, in which the authors have per-
importance of surgical diseases in attempts to address formed a state-of-the-art review, Vervoort and
public health at a global level, the article by Vervoort colleagues1 survey the brief history, current landscape,
and colleagues,1 in this issue of The Annals of Thoracic and future of cardiac surgery in low- and middle-
Surgery, correctly points out that cardiac surgery income countries (LMICs).

Ó 2021 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2020.06.132