The continent is faced with a demographic challenge associated with increasing number of underserved patients with congenital and acquired cardiovascular disease among the current population of 1.4 billion (SSA: 1.1 billion) which will double by 2050. Similarly the pediatric population age <15 years comprising 387.6 million (43%), and students age <25 years comprising 884 milIion (60%) will double by 2050. ^, Population studies and data on prevalence of cardiovascular disease in Africa are limited, with most data obtained from out-patient clinical studies. The World Health Organization reports an estimated 19.8 million people died from cardiovascular disease in 2022, representing approximately 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke. ^, In large population studies by other authors cardiovascular disease claims about one million lives in SSA which constitutes 11.3% of deaths from all causes. About 67% of patients with coronary artery disease who die within 28 days of onset of symptoms, fail to reach the hospital. This poor preclinical result is not acceptable in modern medicine. Cost effective public health educational programs on primary prevention such as regular exercise, a healthy diet, recognizing early warning signs of heart attack and other cardiovascular emergencies, close monitoring of cardiovascular risk factors such as hypertension, diabetes, high cholesterol and obesity can help in preventing premature deaths.

About 1% to 30% of children in different regions of Africa are susceptible to developing preventable rheumatic heart disease caused by streptococcal throat infection associated with rheumatic fever. ^, It is estimated to affect 19/1,000 (range: 4-34/1,000) (1.9%: 0.4%-3.4%) individuals under 25 years old. ^, Affordable penicillin prophylactic therapy for school children in SSA has resulted in lower incidence of rheumatic heart disease in some subregions of Africa as evidenced by decreasing rate of juvenile rheumatic valve surgery which is as low as 7% to 15% of the surgical case volumes in Ghana and Namibia, it is as high as 21% to 66% in Cameroon, Ethiopia, Kenya, Mozambique, and Uganda, respectively (). The paradigm shift of prevalence of rheumatic heart disease in middle income countries of Africa was confirmed by the data obtained from Pan-African Society for Cardiothoracic Surgery’ (PASCaTS) screening studies in Ghana among 5000 school children (under 22 years of age) in collaboration with the German Heart Center Berlin, namely 1,75 per 1000 (0.2%), Odds Ratio: 95% CL (0.25-6.22). The studies were supported by Edwards Lifesciences under ethics committee review. The data were submitted to the Ministry of Health, Ghana in 2018. An estimated 1.4 million babies are born worldwide with congenital heart disease, of these 335,000 are in SSA which represent 2.3/1000 births.

Forty-eight percent of babies born with congenital heart disease will die from heart failure before their first birthday, and 76% of children who survive into adulthood will die in heart failure. This is due to limited access to complex surgical procedures in Africa, as tabled for discussion and action. Wealthy (self-funded) patients or sponsored patients have to travel to South Africa, India or United States of America for heart surgery or succumb to death in heart failure.

Over the past 60 years several charity heart teams supported by foundations from Europe, USA, Australia and recently, Qatar and Saudi Arabia have responded to the emergency calls to develop cardiac surgery programs and provide free congenital and rheumatic heart surgery services to the underserved populations in Africa. ^, In the absence of the visiting teams, patients pay out-of-pocket for expensive surgical procedures ranging from 6,000 to 8,000 USD as compared to half the costs for similar procedures in India, or else wait for the next charity mission. Applying Hoffman’s calculations, 817,000 children in sub-Saharan Africa (PASCaTS studies) require heart surgery for congenital and rheumatic heart disease but only 2% of them have access to the needed surgery (PASCaTS studies). ^,, Charity projects of PASCaTS—Global Heart Care and others in Africa aim at developing sustainable cardiac surgery programs to meet the cardiovascular disease burden in the subregions of Africa.

Rheumatic mitral valve repair/replacement with concomitant tricuspid annuloplasty for moderate tricuspid regurgitation (TR) is a well-established procedure in Africa, yet it is very expensive (ranging from 8,000 to 10,000 USD) and unaffordable to many patients. Mechanical and bioprosthetic valve replacement and repair of tetralogy of Fallot in SSA cost 3 and 4 times as much in India, respectively ( Figure 5 ).

Quotes for heart surgery, GDP/capita and health expenditure/capita (World Bank) in Sub-Saharan Africa (US$).

The rate of associated postoperative pacemaker implantation ranges from 1% to 14% in patients with degenerative and rheumatic mitral valve disease, posing an additional cost. ^,,, The prohibitive cost of cardiac surgery is a barrier for many patients, restricting access to complex congenital and acquired heart surgery, limiting growth of quality capacity building programs and upskilling of the next generation of surgeons. These challenging factors influence and adversely affect cardiac surgery practice in Africa, resulting in low volume surgery and increased medical tourism. ^,,

To date, 31 out of 54 countries of Africa run cardiac surgery programs with various degrees of surgical capacity and performance either independently or with support of international charity “surgical– safari” visiting teams Figure 1 . The current cardiac surgical volumes in Africa do not meet the requirements of WHO and PASCaTS for 400 and 40 open heart surgeries (OHS) per one million population/y, respectively to serve the general population ( Figures 2 and 3 ). ^,, It is encouraging that there is a positive trend for improvement in the surgical capacity (upskilling the local surgeons—training the trainers by visiting teams including the diaspora “ the brains in circulation”) and performance as compared to previous reports ( Figures 2 and 3 ). ^, Reports in 2020 and 2023 showed surgeon/population ratio of 1:4 million, open heart procedures/population ratio of 2:1 million, heart center/population ratio of 1:16 million). Although the cardiac surgery capacity has improved, the performance is still low to provide full access to all patients ( Figures 2 and 3 ). ^,

The rate of Juvenile rheumatic mitral valve surgical procedures is variable from region to region as compared to congenital heart surgery. Valve repair is still a challenging procedure in Africa due to late presentation, lack of screening program for early detection of reparable pathologies and lack of surgical expertise in valve repair. Recent studies demonstrated rheumatic mitral valve repair rates to be around 10% to 30%. ^, Aortic root surgery, excluding the Ross procedure, represents 2% of the annual surgical case volume of centers in SSA which perform 400 to 600 cases ( Figures 2 and 3 ). The frequency of coronary artery bypass surgery (CABG) surgery has increased from 5% to 16% of annual surgical volume in SSA and varies from center to center and clinical experience ( Figure 2 ). ^, Off-pump coronary artery bypass (OPCAB) surgery is practiced at a few centers in SSA ( Figure 2 ). Minimally invasive cardiac surgery and interventional catheter based procedures are undisputable trends that drive medical tourism in the absence of centers of excellence and expertise in SSA. These technologies are yet to be developed, established and practiced at centers of excellence. ^, Only a few centers in Africa, specifically Algeria, Ghana, Kenya and South Africa have simulation laboratories to provide hands-on skill training courses to teach cardiac trainees how to perform mitral and tricuspid valve repair, complex aortic root surgeries such as root enlargement techniques, valve replacement and reimplantation of the coronary arteries (Bentall-de Bono), reimplantation or remodeling techniques (David, Yacoub), homograft aortic root replacement, Ross procedures and coronary artery bypass graft anastomotic techniques. ^,,

Through concerted efforts and good planning an African Cardiothoracic Surgery Database was initiated by the Pan-African Cardiothoracic Surgery in 2020. ^, It serves as a useful resource for quality improvement including but not limited to the following: (1) Clinical and academic research for improving medical/surgical patient management. (2) Working instrument to evaluate burden of disease and to develop strategies for prevention and treatment of cardiovascular diseases and associated morbidities, (3) Developing useful guidelines for clinicians and policymakers to assist with planning appropriate cardiovascular disease prevention and therapy.

Other data in the manuscript were obtained from the coauthors and collated from PASCaTS studies. ^, The data presented in the histograms on cardiac surgery capacity and performance in SSA were obtained from 8 of the 11 centers in SSA which performed a total of 1,999 open heart procedures (range: 83-655 open heart cases) and completed AfriCaTS data form Figures 2 , 3 , and 4 . This manuscript did not require ethics committee/ institutional review board approval, as it did not represent human research. The coauthors are signatories of the declaration. Generative artificial intelligence (AI) and AI-assisted technologies were not required for the writing process of the Accra Declaration.