Open Heart Surgery “The Nigerian Experience”

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Open Heart Surgery “The
Nigerian Experience”
Dr Michael Sanusi, FACS FWACS
Cardiovascular Surgeon
TriState Cardiovascular Institute
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Introduction
History of open heart surgery in Nigeria
The 80’’s and 90’s
Activity now
The future
• Open heart surgery in
its strictest definition is
surgery done within a
cavity of the heart e.g
intracardiac valve
replacement or closure
of an intracardiac
defect.
• The definition is
however expanded to
any surgery in which
the great vessels of the
heart are cannulated for
cardiopulmonary
bypass support e.g
coronary artery bypass
surgery, cavopulmonary
shunts or ascending or
arch aortic repairs
• Recently, procedures
that have evolved to
pump standby only e.g
off pump coronary
bypass or Glenn
anastomosis are also
classified as open heart
surgery.
History of Open Heart Surgery
• John Heysham Gibbon
(USA) invented the heart
lung machine in 1935 and
performed open heart
surgery using it in 1952.
• He however performed
the first successful open
heart surgery a year later
May 6 1953.
• Today about 5 million
open heart surgeries are
performed world wide.
Original Gibbon machine
Early Heart Surgery in Nigeria
• Mr John Weaver a British cardiothoracic
surgeon practicing at the UCH Ibadan did first
“closed” heart surgeries culminating in the
first closed mitral valvotomy in 1960.
• The first open heart procedure done in Nigeria
was at UNTH Enugu in 1974 with a team led
by Sir Magdi Yacoub from the UK and by Prof
Fabian Udekwu an American trained surgeon
employed by UNTH.
Enugu
• Prof Udekwu had left UCH Ibadan in 1967 at
the start of the civil war.
• After the war, he concentrated on the
establishment of open heart surgery at UNTH.
• He developed strong relationships with Dr
Magdi Yacoub a very successful UK surgeon of
Egyptian origin.
Sir Magdi Yacoub
Prof Fabian Udekwu
• Prof Grillo, Dr Adebonojo Dr Adebo and their
team performed open heart surgeries in UCH
Ibadan between 1978 and 1982
• UCH did total of 5 cases
The 80’s and 90’s
• Open heart surgery in this era was limited in
Nigeria to UNTH Enugu
• The main drivers were Prof Martin Aghaji and
Dr John Okereke
• Total of about 102 cases were done during this
time.
• The program became dormant in the late
1990’s and Dr Okereke left for greener
pastures
Mitral Valve surgery
40
Ventricular septal defect
16
Tetralogy of Fallot
13
Atrial Septal Defect
12
Aortic Aneurysms
7
Others
15
Total
102
Cases done at UNTH up to the 90’s
Eze J C Ezemba N: Open heart surgery in Nigeria: Indications and
challenges. Tex Heart institute Journal 2007; 34(1): 8-10
The 21st Century
• The rebirth of open heart surgery in Nigeria was
in Lagos 2004 when Global Eagle Foundation led
by Dr Jonathan Nwiloh from Atlanta visited
LASUTH and operated on patients.
• The series of surgeries by GEF encouraged Mr
Bode Falase a UK based cardiothoracic surgeon to
return back home and help LASUTH build and
sustain a cardiothoracic program.
• The LASUTH program was initially promising
but never went past its infancy stage.
• A critical care unit was set up to facilitate
surgeries
• I joined LASUTH October 2009. The open
heart surgery program has not been active
since December 2011.
• UNTH Enugu recorded 102 cases while the
program was active.
• LASUTH did 51 cases involving
cardiopulmonary bypass between 2004 and
2011.
Why did these programs fail?
• They were both completely under the care of
public institutions
• Doctors were salaried and completely subject
to whims and visions of their medical and
departmental directors.
• There was no unit solely committed to
cardiology, cardiac anesthesia or cardiac
surgery (cardiac was like a hobby).
Challenges
• Patient ability to pay.
• Commitment of Infrastructure e.g sharing icu
and operating room equipment.
• Commitment of personnel and intellectual
resources (hospital distractions) e.g cardiology
taking care of rheumatology.
• Training and staff development.
Other challenges
• Political inertia. Status quo
• Personality clashes **
• Cardiologist incentive from abroad (medical
tourism).
• Not many “easy” cases (late pick up/referral)
• Ignorance among primary care providers
Currently active programs
• Tri State Cardiovascular
associates/UCH/Babcock University program
Prof Adeleke
Prof Davis
Prof Obaro
Dr Majekodunmi
Dr Salami
Dr Sanusi
UNTH Enugu
• VOOM foundation
Dr Nzewi
• UNTH team
Prof Aghaji others
Garki Hospital Abuja
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Dr Miner
Dr Okereke
Dr Sanusi
Dr Talabi
Bickett Hospital Oshogbo
• Dr Adenle
• Dr Onakpoya
? Gbagada cardiorenal program
• Reniscore Group
• Rebirth of Lagos State vision
Models of activity
• Public e.g LASUTH
• Public Private Partnerships e.g UCH/Tristate,
Garki hospital
• Private e.g Bickett medical center
Public Private Partnership
• Tri State Cardiovascular
associates is a private
cardiovascular group
composed of surgeons,
cardiologists with anesthesia
and perfusion services
• The group has contracted with
a public institution( UCH
Ibadan) to provide
interventional cardiology,
structural heart and cardiac
surgical services
• To date 18 surgeries have been
performed with 100%
successful hospital discharge.
Public Private Partnership
• Garki hospital Abuja
• Government owned facility contracted
management out to a private group
• Easier to organize specialized care e.g open
heart surgeries and renal transplants
• 5 open heart surgeries 100% success and a
number of closed heart surgeries.
Public Private Partnership
• Another example is the planned concession of
the Lagos State Cardio renal center to a
private group (public private).
• This group now will have agreement with
professional clinical groups for actual service
delivery (private-private)
Private
• Open heart surgery at
Bickett hospital.
• Focus on congenital
heart disease patients.
• Total 12 cases done by 2
teams.
Surgical Missions
• Surgical missions model still enjoys success in
parts of Nigeria in both the public and private
sectors
• The VOOM foundation/UNTH is an example in
the public sector while Bickett hospital
Oshogbo works this model in the private
sector.
Problem with surgical missions
• Sustainability
• For effective skills transfer there has to be
already a minimum basic level of training
Mix of cases
• Most Adult cases have been valvular
specifically rheumatic heart disease.
• I am aware of only 4 coronary bypasses but
with increase in cardiac catheterizations there
will be more cases diagnosed.
• Pediatric cases have mostly been ASD, VSD,
TOF repairs with 2 Glenn bidirectional shunts
done for single ventricles at LASUTH.
Institution
Valve
Coronary
Replacemen Bypass
t/repair
Congenital
repair
Others e.g
myxoma
resection
Total
LASUTH
Lagos
2004-2011
21
26
2
51
2
UNTH Enugu
2013-2014
52
UCH Ibadan
2013-2014
9
2
7
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18
Garki Abuja
2013-2014
3
-
2
-
5
NHA/ABU
Abuja/Zaria
2006-2008
11
-
4
-
15
Bickett
Oshogbo
2013-2014
-
-
12
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12
OAU Ife
2010
-
-
1
-
1
Total
154
Growth of cardiology
• Cardiac catheterization lab at Reddington
hospital Lagos and later at UCH Ibadan has
encouraged open heart surgery especially
coronary and congenital surgeries.
• There is also a mobile catheterization lab in
Abuja
• Cath lab in Kano AKTH
• Better quality echocardiography machines
Financing cases
• Financing for surgery in Nigeria has been
mostly fund raising from friends, families and
foundations
• Most middle and upper class families would
rather pay for surgery abroad
• NHIS has promised to pay for 100 OHS this
year
• Some foundations have sponsored and some
have asked patients to raise money
• There have been attempts to form a central
foundation dedicated to help patients to raise
funds for OHS.
• So far cost for open heart surgery has ranged
from 500k to about 2.5M dependent on
subsidies.
Way forward
• On ground fully indigenous team prepared to
do surgery as soon as diagnosis is made.
• Good results should spur confidence in local
teams and increase volume of surgery.
• Foundation dedicated to raising funds and
sponsoring of the less privileged
• Health insurance funding for open heart
surgery
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