Introduction

Congenital Heart Disease (CHD) refers to structural heart or intra-thoracic great vessel abnormalities, and it is one of the most common birth defects, impacting 8 to 12 newborns out of every 1000 live births. There have been few studies of the prevalence of CHD in Libya and no community-based data for the incidence and prevalence of CHD in the entire country. In a study on the frequency and patterns of Congenital Heart Disease (CHD) in South Libya by Mansour’s AM, et al. [1], VSD was the most common CHD (14.8%), and TOF was the most common type of CCHD (13.2%). According to the results of another study Mahmmed R, et al. [2] in a single center in the middle of Libya, the incidence of ASD (40.4%) and VSD (30.8%) and the prevalence of CHD also were observed to be slightly higher in males than females (M: F ratio of 1:0.9). The advanced level of pediatric cardiology and cardiac surgery care provided to children with CHD in developed and highincome countries has allowed for the treatment of the majority of cases of CHD, including complex CHD, and these patients have a good chance of surviving to adulthood. The majority of children in low- income and developing countries do not have access to such advanced CHD care. The variety of defects ranges from a single, minor defect, such as an ASD, PDA, or VSD, which doesn’t need immediate attention, to numerous, major defects, such as a single ventricle, significant aortic stenosis, severe coarctation, pulmonary Artesia, a hypoplastic left heart, and Truncus arteriosus, which need early intervention ,untreated neonates with critical CHD in eastern part of Libya die ,and a few of these newborns are transferred to Tripoli, which is about 1,150 km from Benghazi and takes about two hours by plane, and the parents transported their children there themselves. The exact number of these children who pass away from lack of treatment is unknown because there are no local studies to quantify them. When a child is diagnosed with CHD in one of our hospitals in the eastern region of Libya, the parents usually face difficulties, especially if the lesion is severe and requires immediate treatment because there are no available surgeons. Due to our reliance on cardiac surgical missions from other countries and the resulting delayed timing of cardiac surgery for all types of CHD, the number of cases requiring surgery increased significantly, and critical cases requiring urgent surgery have passed away. Timing is critical for cardiac surgery in children with CHD since delayed surgical intervention can cause a variety of morbidity and mortality, including AVC and VSD, there is a risk of developing early pulmonary hypertension, which raises the possibility of a longer stay in the intensive care unit and an increased mortality rate. A number of factors have been implicated in the delayed timing of cardiac surgery in Libya, including an insufficient continuous cardiac surgery program and the delayed detection of CHD in the periphery cities due to a lack of a competent pediatric cardiac survey. The local team must be capable of managing CHD patients on their own, as these patients require extensive care. To be able to manage a child with CHD independently, we need a comprehensive program, and the government must facilitate an atmosphere that encourages local teams to receive training.

Patients and Methods

This is a prospective descriptive study of (91) CHD patients who underwent cardiac surgery (between May 2022 to March 2023) to analyze demographics, age and sex distribution, and the type of congenital heart abnormality. The operations were performed at the Benghazi National Heart Center is a Referral center in Eastern region of Libya formerly Benghazi Cardiac Center (BCC) offers service to the whole of children with CHD from different cities of Libya. Patients from various parts of Libya have been referred by neighborhood pediatric cardiologists, or the patient has traveled to Benghazi from a remote location for diagnosis or medical followup. Patients from the southern region of Libya experienced delays in diagnosis and have been referred due to a lack of pediatric cardiac services in this area. Age ranged from 33 days to 28 years old for such old patients considered Adult with Congenital Heart Disease (ACHD). Physical examination, a pulse oximeter, a chest X-ray, an ECG, and echocardiography were used to confirm the diagnosis. In some cases, cardiac CT or diagnostic catheterization were also indicated. This study excludes operations including thoracic duct ligation, pacemaker installation, pacemaker removal, fixing an unstable sternum. Following 30 days of open-heart surgery, death was included in this study. Patients from Benghazi and Jebel Akadar area, which includes Derna, Jabal al-Akhader, Marj, and Albeda. Ajdadia, the southern region including Sabha, Alkofra, Jalu, and Awjilah; and the western region including Tripoli and nearby cities, as well as the Western Mountain. Due to the excessive number of pediatric patients with CHD on the waiting list for surgery, patients from the Western Area who had a single local cardiac surgery at Tripoli Medical Center came to this visiting team. These missions caring on by Italian team from Ospedale Pediatrico Bambino Gesù to resume surgery on CHD patients after it was stopped in 2012 which was depended on mission visits. This mission will also serve to train the local team. The local population appreciated these trips. Many success stories involving children and their families exist, some sad ones involving those whom we were unable to assist and whose families had to wait for the following visit for their children. By bringing up the destinies and sufferings of their children six of whom died while their families hoped for any surgical solution we revived their sadness, and all we could find for them were our sincere regrets and condolences. We hope that this work will be successful and that the local team will be able to treat these patients independently in the near future. The descriptive data was analyzed in Microsoft Excel and presented as percentages in tables and charts.

Results

Ninety-one CHD patients had heart surgery. There were females (48%) and males (52%). (Table 1, Figure1). The operating age ranged from 33 days to 28 years. (Table 2). 85% of the patients were normal children, and 12% had Down syndrome. (Table 3).

Table 1: Total Gender Distribution

Figure 1: Total Gender Distribution.

Table 2: Total Age Distribution at time of operation.

Table 3: Genetic condition in operated patients with CHD.

Most patients come from Benghazi (52%) then Jebel Akadar (22%). (Table 4) Jebel Akadar including: Derna, marj, Albeda. Western Region including: Tripoli and city near to it, and Western mountain. Southern region including: Sabha, Alkofra, Jalu, Awjilah.

Table 4: Total Region Distribution.

32 surgeries were performed during the first mission. TOF (n = 9, 28%) was the most common type of CHD, followed by VSD (n = 7, 21%). Males outnumbered females 53% to 47% (Table 5). The mortality rate was 9% (Tables 6 and 7).

Table 5: Gender distribution throughout the workshops

The second mission included 24 surgeries, with TOF accounting for 41.6% and VSD accounting for 29.1% of the total. With a male-to-female ratio of 1.6:1 (Table 5). The mortality rate was 13%. (Table 7) The third mission included 35 surgeries, with VSD accounting for 34.2% and TOF accounting for 17.1%. with a male- female ratio of 0.9:1 (Table 5). and an 8.5% mortality rate. (Table 7)

Over the course of a year, three separate missions performed 91 cardiac surgeries (Table 8,9). VSD (n=26, 29%) and TOF (n=25, 27.4%) were the most common types of surgery (Table 9). The 30day post- operative mortality rate was 9/91 (9.8 %) (Table 7).

The most common post-surgical complications were wound infection (n=6, 6.6%) and sepsis (Table 6). Sepsis is a significant factor that has a negative impact on the outcomes of the second mission. (Table 7)

Table 6: Post-Operative Complications.

Table 7: Total Patients, Mortality Rate.

Table 8: Total Operative Corrections.

Table 9:  Distribution of CHD, Mortality rate.

Discussion