Development and current status of Interventional cardiology in Sudan.

Sudan is located in North-eastern Africa, with a population of 41.8 million and a GNI per capita of 1560 US dollars and a life expectancy of 65 years. It has an area of approximately 1.8 million sq.km. , making it twice the size of France and Germany combined. The first cardiac catheterization laboratory (cath lab) in Sudan was installed in Alshab Teaching Hospital in 1974 and the first case of left and right heart catheterization was performed in 1976. Routine work started in January of 1980 with cases mostly left and right heart catheters for valvular heart disease, cardiomyopathies, and congenital heart disease. At the turn of the century, several cath labs were installed performing percutaneous coronary interventions (PCI), pacemaker implantations, and valve interventions as a routine procedure (Figure 1). There are currently 18 cath labs in the country, though not all are fully functional, with 13 located in the capital Khartoum. There are 141 cardiologists registered at the Medical Council in Sudan with only 90 actively practicing. Lack of cardiologists is a major issue across the African continent and even in South Africa, which is considered a leader in the continent, some provinces lack any cardiologists. Of note, there are 26 active cardiac surgeons and 14 paediatric cardiologists. There is no special register for cardiac sub-specializations such as interventional cardiology or electrophysiology and privileges to perform interventional procedures are usually decided at the hospital level. A local cardiology Fellowship training program of 4 years was set up by the Sudan Medical Specialization Board in 2011 to train and graduate cardiologists to fill the much-needed gap in the country. The program has graduated 43 cardiologists so far. There remains no formal subspeciality training in interventional cardiology in Sudan. Cardiovascular disease (CVD) especially coronary artery disease is one of the major causes of mortality in lowand middle-income countries and Sudan is no exception. In April 2018, the government launched a program to fully support all coronary interventions as well as selected valve interventions including percutaneous mitral valvotomy and paediatric congenital interventions. These interventions were only partially supported prior to this program and with full government sponsorship numbers have risen significantly especially in the main public centres. This has provided a great service especially to MI patients who present or are referred to PCI capable centres to receive free of charge coronary interventions usually after being thrombolysed and within 24 h. Of note, Sudan remains one of the very few countries in SubSaharan Africa that provides free thrombolytic therapy for all patients with myocardial infarction and free access to the cath lab in PCI capable centres. An editorial by Prof. Khalil in Sudan Heart Journal highlighted the main aspects of this program and that despite the rise in volumes, the need for interventional cardiology procedures is still grossly underserved. Maintaining a continuous supply of consumables and there are periods of time where supplies are short, and hospitals can only acquire from a specially dedicated government fund obviously affects patient care. The future of this program is also threatened by the difficult economic situation (Figure 2). A major challenge is transfer of patients with myocardial infarction to PCI capable centres as most of these centres are in a few major cities. A recent survey, presented as an abstract at The Acute Cardiovascular Congress 2019, involving a sample of 13 centres from all states of Sudan showed that 92% were 24 h electrocardiogram (ECG) capable while 69% and 31% of surveyed hospitals thrombolysis capable and PCI capable, respectively. The distance to the nearest PCI capable cath lab hospital ranged from 200 to 1200 km and the distance would be longer for patients in rural areas. It also showed poor knowledge of surveyed doctors on diagnosis and guideline endorsed reperfusion therapy for myocardial infarction The need to improve the availability of local resources especially ECG machines and life-saving medications including thrombolytic agents, referral systems, reliable ambulance service, physician training in managing acute coronary syndrome patients, and expansion of the cath lab network is essential to improve outcomes. The dilemma of late MI presenters is a daily issue in our cath labs and the debate of Figure 1 Photo of the first cath lab in Sudan. The photo was taken in 1984 with Dr Siddig Ibrahim Khalil performing a procedure on a Sudanese patient.