Acute rheumatic fever (ARF), also known as Bouillaud’s disease, remains a major public health issue worldwide [1] [2] . It is a delayed autoimmune inflammatory response secondary to an untreated group A streptococcal pharyngitis [1] - [3] . ARF is a post-streptococcal syndrome that can affect the skin, joints, nervous system, and most importantly, the heart [3] [4] .

Rheumatic heart disease (RHD) represents the most serious complication of ARF and the principal cause of mortality associated with it [1] . Globally, it is the leading cause of acquired heart disease in children and young adults [5] . RHD is the result of damage to the cardiac valves following one or several episodes of ARF [1] [4] [6] . According to WHO estimates, this disease caused 305,000 deaths in 2015, 60% before age 70, and led to the loss of 11.5 million DALYs [7] . In 2017, around 30 million people worldwide were affected, with the highest burden in Africa, Southeast Asia, and the Western Pacific [7] [8] .

Although largely preventable, RHD remains a serious health challenge not only in low- and middle-income countries but also among marginalized populations in high-income settings where the disease had once been nearly eradicated [1] [6] [7] [9] . The Pacific region reports the world’s highest incidence rates [10] ; for instance, in New Caledonia, the prevalence was 8.1% in 2020 [11] .

As the most significant acquired cardiac disease in children and young adults, RHD is responsible for an estimated 223,000 to 492,000 deaths annually in low-and middle-income countries [7] . In sub-Saharan Africa, it represents a major public health challenge [12] . A multicenter retrospective study conducted between 2004 and 2008 across seven countries reported high mortality rates associated with rheumatic valvular disease, coupled with very limited access to surgical treatment [13] . In Burkina Faso, Kinda et al. (2013) found that RHD accounted for 20.8% of all pediatric heart disease and 75.6% of acquired pediatric cases, with a hospital prevalence of 0.24% [14] .

In South Africa, the incidence of RHD among children under 14 years in Soweto was 23.5 per 100,000 in 2010 [15] . In Senegal, Ba Ngouala et al. (2012) observed RHD in 25.6% of a predominantly young and female patient population [16] . This figure may even underestimate the true prevalence, as systematic echocardiographic screening is not routinely performed—a practice shown by Marijon et al. (2008) to reveal substantially higher prevalence rates [17] .

More recently in Cameroon, RHD was found in 13.1% of 1020 schoolchildren screened by cardiac echography [18] .

Several preventive and therapeutic strategies have been developed to reduce the prevalence of rheumatic heart disease, repair valve lesions, improve quality of life, and decrease mortality.

Primary prevention relies on prompt antibiotic treatment of suspected streptococcal pharyngitis and tonsillitis, improvement of living conditions, and raising awareness among both patients and healthcare professionals [1] - [10] .

Secondary prevention consists of the regular administration of benzylpenicillin to prevent relapses, and systematic school-based echocardiographic screening programs [1] - [10] [17] .

Tertiary prevention aims to limit the complications of established cardiac involvement. This requires coordinated multidisciplinary management by general cardiologists, interventional cardiologists, and cardiac surgeons.

Severe rheumatic valvular disease may require surgical intervention. Indications for surgery are determined by the severity of symptoms, clear evidence of significant valve damage, as well as cavity size and left ventricular function. Surgical repair (valvuloplasty) or replacement (prosthesis) of damaged valves is critical to preserving left ventricular function and preventing severe pulmonary hypertension [6] . The valves most commonly affected are the aortic and mitral valves, while tricuspid surgery is less frequent and pulmonary valve procedures remain anecdotal.

Across sub-Saharan Africa, the number of cardiac surgery centers and the resources available for effective management of RHD remain critically insufficient to meet patient needs [19] .

The Abidjan Declaration of May 10, 2019, drafted by a panel of cardiovascular surgeons, highlighted the alarming fact that RHD is the leading cause of mortality among children under 10 years in sub-Saharan Africa (12.5% - 20% of deaths), while only a minority of affected children have access to cardiac surgery [20] . The declaration called on governments, NGOs, and private actors to invest in education, research, and the development of cardiac surgery across the region [20] .

Cardiac surgery in Cameroon began in 1985 with humanitarian missions conducted by French teams at the University Teaching Hospital of Yaoundé and later at the Yaoundé General Hospital [21] . These activities came to a halt in 1990, resuming briefly in 2008 with a Belgian-led pilot mission that did not evolve into a sustained program [22] .

In the public sector, a new initiative started in 2012 at the Douala General Hospital (1^st Category, 300 beds) in collaboration with CHU Saint-Pierre in Brussels. This partnership has enabled the organization of two humanitarian missions per year [23] . Due to the lack of a permanent extracorporeal circulation activity, an average of only 10 valve replacements are performed each year. Nevertheless, vascular and thoracic surgery and coronary angiography are routinely performed at this centre.

In 2019, an evaluation of the long-term outcomes of these humanitarian missions in public hospitals confirmed that rheumatic valvular disease remained the leading surgical indication. The study also found that the long-term results of these interventions were acceptable [24] .

In the private sector, a milestone was reached in 2009 with the inauguration of the Shisong Cardiac Center in the Northwest region. The center was staffed with a multidisciplinary team—including cardiologists, interventional cardiologists, cardiac surgeons, perfusionists, intensive care and operating room nurses, and administrative staff—trained in Italy. During the first six years, more than 300 patients with rheumatic valvular disease were operated on, with outcomes consistent with international standards [25] - [27] .

Following a period of interruption due to security crises, surgical activities were transferred to Yaoundé, initially at the Clinique du Jourdain and, more recently, at the Yaoundé General Hospital (1^st category level with 300 beds), where they continue to show promising results [28] . In 2024, approximately 50 valve replacements were performed at this centre by an entirely Cameroonian team, with the aim of doubling this number this year.

Despite these achievements, the two flagship programs have yet to achieve full autonomy and routine daily activity.

Despite promising clinical outcomes, the two main cardiac surgery programs in Cameroon have not yet reached full autonomy or regular daily activity. Several challenges must be addressed to ensure their long-term sustainability: