2129 CardioPulse the additional training. This makes sense as other procedures such as stenting are not applicable for their country at this stage’. Transferable medical skills are also used in other areas. She says: ‘We are training obstetricians who work with us at the Groote Schuur Hospital, Cape Town weekly cardiac maternity clinic to perform screening echocardiography. Obstetricians learn very fast because they are already trained in the ultrasound they perform on pregnant women. By doing this, we can find out if a woman has a lung or heart problem instead of trying to get one of the few cardiologists or pulmonologists to have a look at the heart’. This approach not only goes some way to solving the shortage of cardiologists but also saves time and resources. Judy Ozkan MA j.ozkan@btinternet.com Conflict of interest: none declared. doi:10.1093/eurheartj/ehy264 CATHCHAT CATHCHAT at Red Cross Children’s Hospital, Cape Town, South Africa: a novel, live online teaching and learning platform for interventional paediatric cardiac catheterization Background and statement of the problem Heart disease is an emerging global health priority for children across the world. For those living in Africa, it is a condition overshadowed by a global commitment to basic primary care and communicable disease. Under-researched and under-funded, data are limited, but evidence suggests that the burden is vast. Focusing specifically on congenital defects, with birth incidence rates consistent at 1% worldwide, improved diagnosis, and rapid population growth mean that the number of African children born with congenital heart disease (CHD) is both underestimated and set to grow. Extrapolating this incidence figure further, suggests that of Africa’s approximately 50 million annual live births, as many as 500 000 babies Downloaded from https://academic.oup.com/eurheartj/article/39/23/2129/5037140 by guest on 27 February 2023 doesn’t happen and for those wishing to undertake a PhD, Sliwa insists that they do the project in their own country. ‘I go to their county, see how I can find a good project and then they learn to do research in their system, with all the advantages and disadvantages. It works very well and ensures that they all stay there, so it’s a good training model’. Kenya has capacity to train its own cardiologists and surprisingly Sudan has 17 cardiac cath labs in Khartoum—more than many other places in Africa. ‘It’s not well known that Sudan is a training hub for neighbouring countries like Nigeria. They also undertake referrals from the other countries for angiograms’. Sliwa notes that this sort of high concentration of expertise is a blip and the entire continent of Africa only has about 2000 cardiologists for the entire continent of 1.2 billion people. With only 22 cardiothoracic centres in existence there remains a lack of expertise and infrastructure. Improvisation and support for specialist programmes to train noncardiologists to implant pacemakers is one example of the type of improvisation being applied to fill the gap. The Pan African Society Pacing Programme provides a 6-month training programme for physicians to learn how to implant a pacemaker—as opposed to undergoing full cardiology training. ‘Trainees come from Tanzania and Mozambique, and other places and learn only how to implant the pacemaker without 2130 CardioPulse will be born with significant CHD every year! With limited access to treatment of any kind, their prognosis is bleak. Left untreated, half of those infants born with significant CHD will die in infancy or early childhood, as many as one-third in their first month of life. There is a shortage of cardiac catheterization laboratories in Africa, the majority being distributed in the far south (South Africa) and the far north (Egypt). A growing number of catheterization laboratories are beginning to appear but are often not fully operational due to shortages of skilled cardiologists and consumables. However, there is an even greater, dire shortage of facilities for paediatric congenital heart surgery, and in particular: cardiac surgeons, cardiac surgical operating theatres, and post-operative intensive care facilities. Interventional cardiac catheterization holds the promise of starting to address the need of non-complex CHD repair. By using interventional catheterization techniques, cardiac surgical or intensive care facilities are not required to correct many of the common, ‘simpler’ congenital heart defects, such as coarctations of the aorta, ASDs, PDAs, pulmonary and aortic valvar stenoses, and even some VSDs. These few non-complex lesions comprise approximately 30% of the overall paediatric heart disease burden. In South Africa, paediatric cardiologists receive training in general cardiac catheterization during their subspecialist cardiology training. Expert interventional knowledge and skills are usually only gained over an extended period by undergoing Fellowship training at overseas centres and regularly attending costly interventional Congresses internationally. Consequently, there is a shortage of fully trained, specialist interventional paediatric cardiologists in Africa and only limited opportunities for such training exist in sub-Saharan Africa. Furthermore, it should be remembered that teams, and not individuals, perform these procedures and that all members of the team need to be trained in the skills required for interventional catheterizations. In addition, once a high level of interventional skills has been attained, it is imperative that such teams remain current with the new skills, techniques and equipment that are constantly developing for this burgeoning field of corrective cardiology. Training to perform such interventional repairs is not arduous and methods for the development and maintenance of these skills do exist in some centres in Africa. Interventional cardiac catheterization cases are routinely broadcast via satellite from remote cardiac catheterization laboratories to large international conferences. The exorbitant costs of satellite transmissions, as well as the technical demands of transmitting several high-definition outputs have limited this modality as a routine teaching tool in South Africa. CATHCHAT, by overcoming these limitations, aims to assist significantly in the development of interventional cardiac catheterization capacity, at Red Cross Hospital as well as further afield in South Africa and Africa. CATHCHAT is a novel system whereby cardiac catheterization procedure is transmitted live via the Internet from our catheterization laboratory. We have successfully managed to resolve the costly technical demand for high quality transmissions and are able to broadcast cases live over the Internet, for free. CATHCHAT: what is it and how does it work? At the Red Cross Children’s Hospital in Cape Town, interventional cardiac catheterization is well developed, and the team can perform, and are experienced with most procedures of a modern catheterization laboratory (Figure 1). Downloaded from https://academic.oup.com/eurheartj/article/39/23/2129/5037140 by guest on 27 February 2023 Figure 1 A view into the cardiac catheterisation laboratory at the Red Cross War Memorial Children’s Hospital, Cape Town. 2131 CardioPulse CATHCHAT. Figure 3 The ‘producer’ busy mixing seven outputs for live broadcasting, as well as interacting with the online audience. In addition, since 2014, we have developed and used CATHCHAT, a system whereby interventional cardiac catheterization procedure can be transmitted live online. The unique feature and power of CATHCHAT is that a renowned interventional expert is invited to log in and observe the procedure live as it is performed. The expert (or ‘guru’) is able to see all the visual imaging available to the catheterizing team and is in live voice contact with them. We have had several cases where the guru has guided the operators step-by-step from a remote setting, usually from Europe. When transmitted online, local and international audiences are invited to log in to witness the procedures in real time, including the live interaction with the guru. The online audience can follow the procedure in high-definition, step-by-step detail (Figure 2). The transmitted images are controlled by a ‘producer’ who can select any or all of the images available to the operators, i.e. fluoroscopy, echocardiography (e.g. transoespohageal echocardiography), haemodynamic data, and electrocardiography (Figure 3). In addition, a camera in the cath lab transmits high-resolution live images of the activity in the cath lab. By typing questions into the online platform, the online audience is also able to ask questions that are monitored and replied to by the ‘producer’ who interacts directly with the operators in the cath lab. A world-first, CATHCHAT is therefore a simultaneous teaching and learning tool to the Red Cross interventional team as well as for the logged-in audience: an observed master class, at no cost. CATHCHAT originated from our first live broadcasts to the 2013 Paediatric Cardiology World Congress in Cape Town and has been growing steadily during the past 4 years. We have broadcast more than 104 live cases to date, illustrating more than 17 different procedures, on 31 different days in 9 multi-day sessions (Table 1). All paediatric cardiac centres in South Africa, as well as centres in Africa, Australia, India, and Europe have viewed CATHCHAT, often simultaneously. CATHCHAT has enjoyed the pleasure of ‘guru expertise’ from Birmingham, London, Istanbul, Ho Chi Minh City, and Perth. Downloaded from https://academic.oup.com/eurheartj/article/39/23/2129/5037140 by guest on 27 February 2023 Figure 2 The triangular model of the interaction between the RXH cath lab team and online guru witnessed by an online audience, enabled by 2132 CardioPulse All cases are transmitted anonymously without identifying views of the patient (who is under drapes), and with full informed consent from the parents. A cut-off switch ensures that the producer may immediately cease transmission in the event of possible resuscitation procedures (although this has never been required). Assessing impact and growth of capacity in Africa Table 1 Interactive CATHCHAT sessions since November 2014 Dates Days Cases Rik De Decker, Associate Professor Consultant Paediatric Cardiologist Director: Cardiac Catheterisation Laboratory & CATHCHAT Department of Paediatrics and Child Health University of Cape Town Red Cross War Memorial Children’s Hospital Cape Town, South Africa Tel: +27(0)21 658 5111/5251 Email: rik.dedecker@uct.ac.za Website: https://cathchat.co.za ................................................................................................... 3–7 November 2014 5 16 28–31 July 2015 4 16 15–18 March 2016 14–16 November 2016 4 3 15 9 31 January to 2 February 2017 3 8 14–16 March 2017 17–19 May 2017 3 3 11 9 24 May 2017 1 1 13–17 November 2017 Total 9 sessions 5 31 days 19 104 cases Acknowledgements Technical infrastructure for CATHCHAT transmissions has been developed and refined since 2014. The audio-visual equipment is currently available on a cost-free loan from Extron (South Africa) while the technical expertise has been offered free of charge by Kathea in Cape Town, under the leadership of Mr Andre Gouws. Now well developed and tested, it is soon to be installed permanently into the cath lab, incorporating several technical advances. An upgraded CATHCHAT should be back online in the third quarter of 2018! Conflict of interest: none declared. Figure 4 The interactive circle of cardiac cath labs in Africa facilitated by CATHCHAT. The importance of a registry to monitor the growth of cathing capacity is emphasized. Downloaded from https://academic.oup.com/eurheartj/article/39/23/2129/5037140 by guest on 27 February 2023 By following the growth of interventional cardiac catheterization in Africa, we hope to contribute to capacity development by encouraging African audiences to log in and learn from our procedures (Figure 4). At recent CSI (Catheter Interventions in Congenital, Structural, and Valvar Heart Disease) Africa conferences (2015 and 2016), CATHCHAT has been introduced to pan-African interventional cardiologists, where it was received with enthusiasm. The first-ever live cases seen at CSI Africa were broadcast from Red Cross Hospital to the CSI Africa 2017 Congress in Nairobi, Kenya, using CATHCHAT. To assess the effectiveness of CATHCHAT—whether it is able to make a significant contribution to the development of interventional cardiac catheterization capacity in Africa—we are developing a research project. Teaching for those with more enthusiasm than expertise!