Original Article

World Journal for Pediatric and

Congenital Heart Surgery
Pediatric Cardiovascular Surgery in 1(3) 321-327
ª The Author(s) 2010
Reprints and permission:
South America: Current Status and sagepub.com/journalsPermissions.nav
DOI: 10.1177/2150135110381391
Regional Differences http://pch.sagepub.com

Nestor Sandoval, MD1, Christian Kreutzer, MD2, Marcelo Jatene, MD3,

Thomas Di Sessa, MD4, William Novick, MS, MD5, Jeffrey Phillip Jacobs, MD6,
Pierre-Luc Bernier, MD7, and Christo I Tchervenkov, MD7

Abstract
Very little information is available about the epidemiology of congenital heart disease in developing parts of the world, including
South America. This article describes the incidence of congenital cardiac disease, the different treatment rates among countries,
and future solutions for achieving improved coverage for the children with cardiac diseases in South America. An incidence of
congenital cardiac disease of 8 per 1000 live births appears to be a fair approximation for the population of the world and
also the population in South America. Nevertheless, a wide variation exists in the observed incidence of congenital cardiac
disease in South American countries, which can be partly explained by inequalities in the access to diagnosis, differences in the
diagnostic criteria, and true regional variations. It is estimated that 58,718 children are born yearly with congenital heart
disease in South America. Brazil, Colombia, and Argentina have the highest number, followed by Peru, Venezuela, Chile,
Ecuador, Bolivia, Paraguay, Uruguay, and Guyana. It is also estimated that in South America, 24,081 children per year with a
new diagnosis of congenital cardiac disease do not receive any treatment. This paper provides strategies for improving the
access to and quality of pediatric cardiac surgery in South America.

Keywords
pediatric cardiac surgery, congenital heart disease, rheumatic heart disease, Chagas disease, developing nations, medical
volunteerism, humanitarian outreach, globalization, quality assurance

Submitted June 17, 2010; Accepted July 21, 2010.

A paucity of data exists regarding the causes of disease and the
rates of mortality in the various populations of the globe. Knowl-
edge of the epidemiology of diseases is fundamental for the devel-
opment of national and international policies of prevention and
control. It is important for national governments and systems of
health care to assess the epidemiology of diseases that affect the
population of their country. Such epidemiological data must
include information about the incidence of the disease and the out-
come of the various associated treatments. These data must be
obtained for multiple diseases in children and adults, including
cardiovascular disease, cancer, diabetes, mental illness, trauma,
malnutrition, infection, and morbidity and mortality resulting from
consumption of tobacco. This information is vital for governmen-
tal planning and proper allocation of funds for delivery of services.
Global Burden of Disease in Latin America
and Worldwide
Latin America is a region of the Americas where languages
derived from Latin, or Romance languages, are primarily
spoken. This region is typically considered to include countries
whose population speaks Spanish, Portuguese, and variably
French. Latin America, therefore, may include part of North
1
Fundación Cardioinfantil, Instituto de Cardiologı́a, Bogotá, Colombia
2
Hospital Nacional Alejandro Posadas, Hospital Universitario Austral, Buenos
Aires, Argentina
3
Instituto Corazón INCOR, Sao Paulo, Brazil
4
University of Kentucky, Lexington, Kentucky, USA
5
International Children Heart Foundation, University of Tennessee, Memphis,
Tennessee, USA
6
The Congenital Heart Institute of Florida (CHIF), All Children’s Hospital,
Children’s Hospital of Tampa, University of South Florida College of
Medicine, Cardiac Surgical Associates of Florida (CSAoF), St Petersburg and
Tampa, Florida, USA
7
Division of Pediatric Cardiovascular Surgery, The Montreal Children’s
Hospital of the McGill University Health Centre, Montréal, Quebec, Canada
Corresponding Author:
Nestor Sandoval, MD, Division Pediatric Cardiac Surgery, Fundacián
Cardioinfantil, Calle 163 A # 13 B-60, Bogotá, Colombia
Email: nestorsandoval@cable.net.co

321
322
America (Mexico), Central America, the Caribbean, and South
America. Although the focus of this article is South America,
many of the themes and lessons related to South America are
also applicable to Mexico, Central America, and the Caribbean.
In the future, we hope to publish papers similar to this article
that focus on these other regions and nations of Latin America.
In 1990, the World Bank sponsored a study performed by
Harvard University and the World Health Organization (WHO)
in which researchers identify the ‘‘global burden of disease.’’
This study provides a standard epidemiological measure of dis-
ability (‘‘disability-adjusted life year’’ [DALY]). Measurement
of DALY enables the evaluation of the effect of diseases not
only in terms of life expectancy but also in terms of quality
of life, that is, health during life.1 The main causes of morbidity
in DALYs were respiratory disease, followed by diarrhea, peri-
natal disease, major depression, and cardiac ischemia. How-
ever, the epidemiology of disease appears to be changing,
and by 2010, the leading cause of morbidity and mortality
worldwide is cardiac ischemia, followed by major depression,
traffic accidents, cerebrovascular events, and chronic obstruc-
tive pulmonary disease.
Currently, the major causes of morbidity and mortality in
Latin America are cardiovascular disease and type II diabetes
mellitus. These 2 diseases are responsible for 46% of all deaths.
By 2020, cardiac ischemic disease will be the number one
cause of morbidity and mortality in Latin America according
to DALY measures. Meanwhile, 98% of all deaths in the world
that occur in children younger than 15 years were in the devel-
oping world, while 83% and 59% of deaths at 15 to 59 years
and 70 years, respectively, also occurred in the same areas.2,3
Recent projections of mortality and morbidity for 2030 esti-
mate that the population with disability due to cardiovascular
disease will change dramatically depending on the degree of
development of the region. Life expectancy will increase, while
the mortality in children younger than 5 years will decrease, and
the number of people dying due to nontransmissible diseases
such as cardiac disease and cancer will increase. Disease associ-
ated with human immunodeficiency virus (HIV) will continue to
increase, but the new projections suggest that more people will
die due to diseases related to consumption of tobacco.4
The life expectancy in Latin American countries such as
Colombia has changed from 55 to 72 years in the last 50 years.5
Meanwhile, the change to a more Western lifestyle has contrib-
uted to an increase in obesity, hypertension, diabetes mellitus,
metabolic syndromes, and cardiovascular disease. In addition,
studies suggest that the lack of nutritional elements during preg-
nancy cause a genetic predisposition to the development of an
inadequate metabolic response when the newborn is subjected
to changes in diet and lifestyle in adult life, a phenomenon
termed ‘‘inadequate epigenetic programming.’’6 This phenom-
enon could lead to increased morbidity and mortality in older
children and adults with congenital cardiac disease.
In Latin America, congenital heart disease represents the third
most common cause of neonatal mortality. Therefore, increasing
the access to care, and establishing quality cardiac surgical pro-
grams, could lead to a substantial drop in neonatal mortality.7
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World Journal for Pediatric and Congenital Heart Surgery 1(3)
Congenital and Pediatric Cardiac Surgery in
South America and the Global Scientific
Community
Numerous pioneers in pediatric cardiac surgery are from South
America, including Zerbini, Jatene, Kreutzer, and Barbero
Marcial. Nevertheless, most publications about pediatric
cardiac surgery performed in developing countries come from
the humanitarian efforts that originate in North America8 and
Europe.9 These programs carry out both sporadic and program-
matic missions. Some of these programs are designed to be
sustainable in a variety of geographical locations worldwide,
including in South America. Few such efforts originate purely
from South American groups. Unfortunately, the work in
smaller areas, especially in the Andean region, is largely
unknown. These small regions have managed to establish
adequate results for their type of population and their adverse
conditions, and their results could provide interesting information
for those caring for patients in difficult areas.10
Some professional organizations, such as the Society for
Thoracic Surgeons (STS), have incorporated surgeons from
developing countries in their membership and committees and
have established a formal structure and process to develop and
support international relationships. STS facilitates the admis-
sion of ‘‘international members,’’ and hence, a large number
of surgeons from Latin America are members of STS. STS
allows access to and use of the STS Congenital Heart Surgery
Database (STSCHDB) by international participants, but the use
of the STSCHDB is associated with a fee that not everyone can
afford. STS is currently exploring methodologies to increase
the global accessibility of the STS database.
In contrast, the European Association for Cardio-Thoracic
Surgery (EACTS) Congenital Heart Surgery Database offers
free access for all participants. Currently, some South
American centers record their procedural results in the EACTS
Congenital Heart Surgery Database, but in some settings,
difficulties with the acquisition of data lead to incomplete data
in the database.
The World Society for Pediatric and Congenital Heart Sur-
gery (WSPCHS) was established in 2006. The vision of the
WSPCHS is that every child born anywhere in the world with
a congenital heart defect should have access to appropriate
medical and surgical care. At the World Summit on Pediatric
and Congenital Heart Surgery Services, Education and Cardiac
Care in Children and Adults with Congenital Heart Disease,
hosted by the WSPCHS in Montreal, Canada, in June 2008,
representatives gathered from 52 countries from all continents
except Antarctica so that the world would learn about the status
of pediatric cardiology and pediatric cardiac surgery in all parts
of the planet.
Incidence of Pediatric Cardiac Disease and Its
Relationship to Poverty
The origin of congenital heart disease (CHD) in the world is
multifactorial. It is related to chromosomal and genetic
Sandoval et al
alterations, consanguinity, viral infections, fetal drug and radia-
tion exposure, and even external and environmental factors.11
These variables could explain the variation in the reported inci-
dence of congenital cardiac disease, which ranges from 0.5% to
1% of the live births. These variables also impact the manifes-
tation of congenital cardiac disease early in life, especially in
undeveloped countries.12 The risk of having a child with CHD
increases from 8 in 1000 to 16 in 1000 if one of the parents or
the siblings has congenital cardiac disease.13
In addition to CHD, infectious diseases that can cause
acquired cardiac disease in children, such as Chagas disease
and rheumatic fever, are quite prevalent in developing coun-
tries. Rheumatic fever affects 15.6 million people worldwide,
and 230,000 of these citizens of the world die every year, many
of whom are young adults under 35 years of age.14 Rheumatic
heart disease is found infrequently in the population of students
in developed countries such as the United States, with an inci-
dence 0.02 per 1000 (0.002%), but in developing countries, its
incidence can be as high as 3.5 per 1000 (0.35%), as it is the
case for Brazil.15
The population of the world in 2008 was almost 6.6 billion
people, and 133 million children are born worldwide every
year.16 There are approximately 1 064 000 children born with
CHD every year, and unfortunately, 90% of these children are
born in underserved countries. Hence, 957,600 of these chil-
dren will not have access to modern treatment. Seventy percent
of these children will require medical or surgical treatment dur-
ing their first years of life. Poverty, however, impedes delivery
of appropriate therapy, and 30% of these children will die in
their first years of life. It is estimated that 1 billion people in
the world live under the international poverty index, with less
than $1 per day.17 Furthermore, the number of undernourished
people in the world increased to 925 million in 2008 due to the
50% increase in the cost of food in the first 7 months of 2008, as
per a report from the Food and Agriculture Organization
(FAO).17,18
The mortality of children under the age of 5 years in the
world is approximately 10,000,000 per year, and 90% of these
deaths occur in developing countries. Two percent of this mor-
tality occurs in South America. However, in South America,
childhood mortality appears to be improving. In 1970, the rate
of mortality for children in Latin America was 150 per 1000
live births, and it decreased to 70 per 1000 live births by
2005. In fact, Latin America and the Caribbean have shown a
greater improvement in childhood mortality in comparison to
the remainder of the world.5,19
In 2000, the United Nations established the Millennium
Development Goals (MDGs) in order to define the global need
to impact the poverty of men, women, and children on the pla-
net. The plan is to meet these goals by the year 2015.20 In order
to accomplish these objectives, health care professionals, and
especially those working in the pediatric area, must have an
impact on 3 of these 8 goals. The first of these goals necessitat-
ing the involvement of health care professionals (no. 4) is to
‘‘reduce the mortality in children’’; obviously, this goal has a
direct relationship to the services provided by health care
323
professionals in the fields of pediatric cardiology and pediatric
cardiac surgery. The second goal (no. 5) is to ‘‘improve the
health of mothers,’’ which should lead to a decrease in the inci-
dence of both congenital cardiac disease and acquired heart dis-
ease. Finally, the third goal (no. 8) is to ‘‘establish global
partnerships to promote continued education, scientific growth,
and technical advancements with all countries.’’
Epidemiology of CHD and Pediatric Cardiac
Surgery in South America
A paucity of publications exists in the peer-reviewed literature
about the incidence of congenital cardiac disease in South
America. A large registry named ECLAMC, the Latin
American Study of Congenital Malformations, records, on a
voluntary basis, since 1967, congenital anomalies diagnosed
at member centers. Whereas ECLAMC has a large and varied
study population, it only includes defects diagnosed at birth
and therefore excludes many congenital heart defects. An
analysis of ECLAMC reveals an incidence of congenital
cardiac disease of 1.2 per 1000 live births, which is a value
significantly lower than in many other studies.
A review of the literature reveals only a few studies about
the observed incidence of congenital cardiac disease in the
South American population. A report by Baltaxe and Zarante
identifies an incidence of 1.2 per 1000 live births in the Colom-
bian population.21 Two publications specific to the populations
of Brazil reveal higher incidences. A study by Guitti22 reports
an incidence of 5.94 per 1000 live births, and a study by
Amorim and colleagues23 identifies an incidence of 9.58 per
1000 live births. This wide variation in the observed incidence
of congenital cardiac disease in South American countries is
not surprising and is seen in other areas of the world. Indeed,
a significant variation (1.2-17 per 1000 live births) exists across
studies of the incidence of congenital cardiac disease in various
regions of the globe. The etiology of this variation is obviously
multifactorial. It can be partly explained by inequalities in the
access to diagnosis, differences in the diagnostic criteria, and
true regional variations. Nonetheless, when looking at all the
studies available in the literature, an incidence of 8 per 1000
live births appears to be a fair approximation of the true global
incidence of congenital cardiac disease. This value also seems
to be applicable to the population of South America.24
Except for Chile and Uruguay, 6% to 20% of the people in
South American countries live under the international poverty
line. As per WHO, the population in South America is more
than 385 million. Brazil has 192 million inhabitants (half the
population of South America), followed in descending order
by Colombia, Argentina, Peru, Venezuela, Chile, Ecuador,
Bolivia, Paraguay, Uruguay, and Guyana.16
The annual birth average in South America is 7.5 million per
year, which accounts for approximately 3.7 million births per
year in Brazil, 800,000 in Colombia, and 700,000 in Argentina.
Peru and Venezuela have an annual birth average of 600,000.
Ecuador, Bolivia, and Chile have an annual birth average of
323
324
approximately 270 000. Lower numbers are observed in Para-
guay, Uruguay, and Guyana.16
Different formulas have been used to calculate the incidence
of congenital cardiac disease in children. One of these formulas
is as follows:
Population  birth rate  incidence of congenital cardiac disease
¼ number of births at risk for congenital cardiac disease per year:
However, in order to obtain more realistic estimates of new
children with CHD, the infant mortality rate must be subtracted
from the annual birth rate, and then the remainder must be mul-
tiplied by the incidence of CHD. This more precise formula is
as follows:
Population  ðannual birth rate  infant mortality rateÞ  0:008 ¼
number of new children born with congenital cardiac disease per year:
Using this mathematical approach, it is estimated that
58 718 children are born yearly with CHD in South America;
Brazil, Colombia, and Argentina have the highest number,
followed by Peru, Venezuela, Chile, Ecuador, Bolivia,
Paraguay, Uruguay, and Guyana.16
Approximately 70% of these newborns with congenital car-
diac disease will require some type of medical or surgical treat-
ment in the first year of life. Therefore, in South America,
41,000 new children per year need medical or surgical treat-
ment for congenital cardiovascular disease.
It is not known how many children in the world have conge-
nital cardiac disease. However, in a recent publication, Sidi25
states that approximately 50% of children with congenital car-
diac disease will die during their first 5 years of life before they
receive any proper treatment.
Important changes in health care policies have occurred in
South America in recent years. Many of these changes affected
access to care for children who have congenital cardiac disease.
Hence, in Chile and Uruguay, almost 80% to 90% of the
children with congenital cardiac disease who require surgery
will undergo surgery, and in Argentina, the coverage is close
to 80%.
Although the health care coverage has improved in Colombia
since 1991, no more than 40% of children who need an operation
will ultimately undergo surgery. The goal to perform surgery on
all children with congenital cardiac disease (who require surgery)
is not met due to various medical, political, financial, and social
issues, such as lack of knowledge of the disease and lack of oppor-
tunities for poor people to travel to referral centers. Colombia
has centers in 8 cities where pediatric heart surgery is performed.
No centers in Colombia are dedicated exclusively to pediatric
cardiac surgery, but 5 have a special program for pediatric cardiac
surgery in 4 different cities. Of these, 2 centers are performing
about 230 cases per year, one center is performing 364 cases,
and another center (Fundación Cardioinfantil) is treating more
than 450 patients annually, with yearly improved results.26
The coverage in Brazil is almost 40%, and Brazil is a Latin
American reference in this specialty. Venezuela has made
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World Journal for Pediatric and Congenital Heart Surgery 1(3)
efforts to cover more children by supporting private institutions
and with the creation of a national specialized referral center.
Two large referral centers exist in Peru, and a high volume
of very complex procedures are performed at each center.
Ecuador distributes the service to various private and state-
funded hospitals. In Paraguay, a small number of surgeries are
performed with great difficulty, and Bolivia concentrates most
of its surgical efforts in a center outside the capital city. This
approach may be due to the high altitude of the capital city.
Most of the South American countries do not keep an offi-
cial record of the number of pediatric cardiac surgeries per-
formed each year. Hence, different surgeons were contacted
in each country to find out an approximate number of surgeries
performed, number of centers, how many surgeries are per-
formed per center, and how many surgeons perform this type
of surgery in each country. Besides the demographic data sup-
plied by the Pan-American Health Organization for each coun-
try, it was established that in South America, more than 17 000
surgical procedures are performed per year, and each year,
more than 41 000 new children with congenital cardiac disease
require some type of procedure. In South America, 138 centers
perform cardiac surgery, and over 195 surgeons perform these
procedures. (These surgeons are not exclusively dedicated to
operating on only children with cardiac disease.) Therefore,
in South America, one center exists for every 2.9 million peo-
ple, and an average of 42 (range, 19-76) operations per million
people is performed. These numbers show a slight improve-
ment with respect to the Latin American average published
in the past (Table 1).27,28
The survey also established that in South America, 24 081
children per year with a new diagnosis of congenital cardiac
disease did not receive any treatment. This estimate demon-
strates a continental deficit of 58% (range, 12%-86%) due to
lack of opportunities or to the precarious economic situation
of each country (Table 2).
Many factors exist that can affect the results of pediatric and
congenital cardiac surgery in South America and other devel-
oping countries, such as late diagnosis of the disease, marked
cyanosis, polycythemia, and coagulopathy, which can be asso-
ciated with major myocardial dysfunction, arrhythmias, and
neurological complications. Secondary pulmonary vascular
disease is frequently seen and is difficult to manage, especially
in the high-altitude cities in South America. Also, factors of
noncardiac origin can impact the results, such as malnutrition
and infection. Nutritional problems have led to the evaluation
and implementation of ‘‘fast nutrition programs,’’ which so far
have demonstrated a short-term impact, and the results to date
are favorable.29
Strategies for Improving the Access to and
Quality of Pediatric Cardiac Surgery in South
America
Future goals can include potential advances in multiple
domains:
Sandoval et al 325

Table 1. Demographic and Descriptive Data of the Population/Pediatric Cardiovascular Surgery Ratio in South America

No. of Surgeries PCVC No. of

Born Alive No. of New Surgeries Performed per No. of No. of No. of per Surgeries per
Country Populationa per Yeara Required per Yearb Yearb Surgeonsb Citiesb Centersb Million Million

Brazil 191 791 000 3 697 000 20 247 8113 83 46 81 2.3 42

Colombia 46 156 000 890 000 4905 2434 24 8 20 2.3 52
Argentina 39 531 000 696 400 3853 3000 31 8 10 3.9 76
Peru 27 903 000 586 000 3189 600 8 1 2 13.9 21
Venezuela 27 657 000 597 800 3293 871 15 4 7 3.9 31
Chile 16 635 000 251 000 1394 1200 9 1 3 5.5 73
Ecuador 13 341 000 281 000 1538 215 7 2 5 2.6 16
Bolivia 9 525 000 262 000 1387 250 6 3 3 3.1 26
Paraguay 6 127 000 153 000 842 116 5 1 4 1.5 19
Uruguay 3 340 000 50 500 277 220 6 1 2 1.6 73
Guyana 2 500 000 32 000 175 — 1 1 1 2.5 —
Total 384 506 000 7 496 700 41 100 17 019 195 76 138 2.7 44
PCVC ¼ pediatric cardiovascular center.
a
Source: World Health Organization report, 2007.16
b
Source: Group of pediatric cardiovascular surgeons in South America.

Table 2. Surgeries Not Performed per Year in New Patients With 6.

the maintenance of the education programs;
Congenital Cardiac Disease in South America 7.
the furthered development of partnerships with North
American or European institutions that emphasize a com-
No. of Surgeries Not Performed % Lack of Coverage
Country per Year per Year mitment to programmatic education and development
rather than sporadic visitation;
Brazil 12.134 59 8. the furthered development of partnerships between South
Colombia 2.471 50 American institutions that similarly emphasize a commit-
Argentina 853 22
Perú 2.589 81
ment to programmatic education and development rather
Venezuela 2.513 73 than sporadic visitation;
Chile 194 13 9. the implementation of ‘‘comparative effectiveness
Ecuador 1.323 86 research’’ to ‘‘define which interventions are effective
Bolivia 1.137 81 in specific populations, as for example the Latin American
Paraguay 726 86
ones, because the effect of the interventions could differ
Uruguay 57 20
Guyana a
? ? according to socioeconomic and environmental factors’’6;
Total 24.081 58 and
a
10. the development of strategies to improve access to health
The information from Guyana was not easy to obtain because many patients
are referred to European countries like France, Holland, and England or to
care and transportation for patients with congenital and
South American countries. pediatric cardiac disease who live in remote underdeve-
loped and impoverished areas.

Such strategies have been successful at many centers and

1. the standardization of methodologies to track, document,
and assess the regional and global epidemiology of CHD;
2. the universal implementation of databases that span
geographic, subspecialty, and temporal boundaries and track
the outcomes of patients with congenital cardiac disease;
3. the establishment of standards of quality for the results of
treatment given to patients with congenital cardiac dis-
ease in different regions of the world;
4. the standardization of the training of the cardiac surgeons
to the international level;
5. the creation of partnerships with North American or
European institutions, which would have governmental
support to create sustainable programs focusing on initial
training of the medical and paramedical personnel;
established programs throughout the world, especially in Asian
countries.28,30 It seems reasonable that some Latin American
countries could follow.28,30
A review recently published reveals that most underserved
areas of the world face similar challenges in regards to the
treatment of their population with congenital cardiac disease.
It is true that developing nations have many common chal-
lenges when trying to provide care for patients with pediatric
and congenital cardiac disease. However, the situation in each
country is unique. All politics are local. Each hospital and
country will have unique political, medical, and economic chal-
lenges. In order to help any developing nation meet the chal-
lenges of providing care for patients with pediatric and

325
326
congenital cardiac disease, one must first understand the unique
local challenges of that nation and its individual hospitals.
A coordinated approach of bringing together the various
global projects would likely be beneficial.24,31-34 The creation
of a Global Federated Multispecialty Congenital Heart Disease
Database that links extant databases from pediatric cardiology,
pediatric cardiac surgery, pediatric cardiac anesthesia, and
pediatric critical care will create a platform for improving
patient care, research, and teaching related to patients with con-
genital and pediatric cardiac disease.35 This database must span
geographical, subspecialty, and temporal boundaries.35
Furthermore, such a database must be structured to allow par-
ticipation of developing nations and can provide the framework
for achieving many of the goals described in this paper. Imple-
mentation of these strategies will improve care for the children
of the world.24,31-35
Data presented in this paper have some limitations. These
data are the best possible estimates based on the current knowl-
edge. These data remain to be validated. We hope that in the
future, we will be able to collect prospectively accurate data
on the incidence of, and level of care for, congenital cardiac
disease, not only in South America but across the world. A need
exists to standardize reporting, the use of various epidemiolo-
gical terms, and the methodology to collect these data.
Conclusion
In order to improve coverage, outcome, and quality in pediatric
cardiac care in South America, it is crucial to draw a profile of
congenital cardiac disease. This process provides useful infor-
mation that will help assess where to start. From the data gen-
erated from this analysis, we can create documents that can
help the private sector and the local governments to develop
national programs of congenital heart surgery. This process
should ultimately reduce infant mortality by funding the
already established pediatric cardiac care programs and creat-
ing new ones. The international collaboration channeled to
these programs, and the ability to share knowledge and obtain
training positions for South American physicians in centers of
the developed world, will play an essential role in achieving the
goals of reducing the mortality associated with CHD.
Acknowledgments
The authors thank the following group of South American cardiovas-
cular surgeons for their valuable information and effort, which made
the creation of this article possible: Christian Kreutzer, Gabriel
Santiago, and Roque Cordoba from Argentina; Marcelo Jatene and
Walter Vicente from Brazil; Juan Pablo Barrenechea from Bolivia;
Pedro Becker, Stephan Haecker, and Miguel Navarro from Chile;
Rafael Arcos from Ecuador; Alfredo Lora from Peru; Jose Corvalan
and Santiago Gallo from Paraguay; Jose Luis Filgueira and Dante
Picarelly from Uruguay; Igor Donis and Telma Ruiz from Venezuela;
and Victor Caicedo, Jorge Alberto Zapata, Victor Castillo, Juan
Fernando Velez, Eduardo Cadavid, Diego Piñeros, Oscar Sanchez,
Sergio Perafan, Pier Lombardi, and Miguel Mantilla from Colombia.
326
World Journal for Pediatric and Congenital Heart Surgery 1(3)
Declaration of Conflicting Interests
The author(s) declared no conflicts of interest with respect to the
authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
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