In response

We are particularly pleased and thankful that Ma and Vervoort chose to focus their letter on the potential impact which Heart University may play in providing online supplemental education in low- and middle-income countries.^{Reference Ma and Vervoort1} While there are many ongoing developments and future aims as laid out in our review of Heart University,^{Reference Tretter, Windram and Faulkner2} one for which we are most excited is the e-content aimed for providers of congenital and paediatric acquired heart disease in low- and middle-income countries. This section is led by content editor Krishna Kumar in collaboration with Children’s HeartLink, along with participation from the listed authors. Heart University has already begun to expand towards a global audience, with over 4000 users represented currently by 125 countries across six continents. Near two-thirds of represented countries are classified as a low- or middle-income country.

Over 90% of the world’s children with CHD are born in low- and middle-income countries.^{Reference Musa, Hjortdal and Zheleva3} With similar prevalence and increasing survival, there is an increased global population of both children and adults living with unrepaired, repaired, and palliated CHD. This is in addition to the burden of acquired conditions such as rheumatic heart disease. With this increasing global population, the utilisation of resources and interventions becomes necessary to further improve survival and quality of life. As Ma and Vervoort point out, there remains significant inequity in such utilisation in low- and middle-income countries with many identified barriers which lead to increased morbidity and mortality in these settings.⁴ These barriers include lack of knowledge of congenital and paediatric acquired heart disease, limited access to care, poor health care infrastructure, competing health priorities, and a critical shortage of specialists. Part of this includes lack of structured educational training programmes and content-specific resources for practicing in this setting.^{Reference Musa, Hjortdal and Zheleva3}

While many of these trainees continue to seek training abroad in high-income countries as Ma and Vervoort discuss, if they return to their home country to practice, they are often faced with the dilemma of encountering clinical situations in which they have no direct experience managing. Furthermore, to our knowledge, there is no access to freely available, high-quality, and structured e-content covering such medical education. For example, it can be conceived that during their training abroad, they may have never encountered the late-presenting infant with transposition of the great arteries with very little guidance incorporated into contemporary textbooks and e-learning, amongst a myriad of other scenarios commonplace in the low- and middle-income countries setting. Therein lies the rub, for which Heart University has taken an active advance to address.

We are thankful to Ma and Vervoort for outlining the seven components they have identified to enable and scale e-learning platforms in low- and middle-income countries. We agree with these seven components. However, while eventually we would hope to offer material in multiple languages in keeping with our global aims, without spreading ourselves too thin in the ongoing development of Heart University our focus will be first to assure a comprehensive offering in what is currently the lingua franca. Lastly, we would invite Ma and Vervoort to join our efforts and anyone passionate about this mission to provide an open-access platform for structured, high-quality global education of congenital and paediatric acquired heart disease.