Two Cardiac Centres Are Better Than One: Early Outcomes Of The First
75 Open Heart Surgeries At Port Of Spain General Hospital.
Mr Randolph Rawlins M.B.B.S., F.R.C.S.(Ed), FRCS (C/TH), Consultant Cardiothoracic
Surgeon, Ronald Henry M.B.,B.S., FACP, FSCAI, CMTT, Interventional Cardiologist,
Peter Seignoret M.B.,B.S., D.A., FRCA, CCST, Consultant Anaesthetist, Anthony Parkinson
B.SC., M.B.,B.S, D.M. (Anaestheisa), Consultant Anaesthetist, Roberto Casula…..
Consultant Cardiothoracic Surgeon, The Doctors Inn Research Group.
Advanced Cardiovascular Institute Surgical Therapies, Clinical Surgical Services Eric
Medical Sciences Complex, Department of Anaesthesia and Intensive Care Port of Spain
General Hospital, St Mary’s Hospital, England, UK.
INTRODUCTION:
Open Heart surgery was first performed in Trinidad & Tobago in 1993 as a private sector
initiative with collaboration between teams of local and international specialists. It was
extended to the local population and surgery was performed at a single Government
institution until 2007. To expand the existing cardiac surgery service to meet the needs of the
population, Port of Spain General Hospital (POSGH) was identified a second public centre.
The first coronary artery bypass operation was performed at POSGH in June 2007. The
programme at POSGH has progressed from a monthly operating schedule to a weekly
operating list with the appointment of a UK trained local Cardiothoracic Surgeon as lead
surgeon.
We report outcomes of the first seventy five (75) open heart surgeries performed at this
Hospital.
METHODOLOGY:
Multiple parameters were prospectively entered into a computerized database for each patient
operated on at this centre from June 2007 to April 2010 which allowed for the data analysis
now presented.
RESULTS:
There were 75 open heart surgeries performed at this centre over the period June 2007 to
April 2010. Distribution by age and sex revealed there were 49 males and 26 females figure
1. with age range from 28 to 82 with median age X Figure 2
years with the mean age being
59 years.
X % ( No) were Diabetic and Y% (no) were hypertensives
Coronary artery bypass grafting was the commonest operation performed accounting for
91 % of all surgeries. There were 16 patients who underwent Heart valve surgery. Figure3
Patients undergoing coronary bypass surgery had from 1 to 4 grafts done with 3 grafts being
the most common (50 %) fig 4. 42 % of patients had impaired left ventricular function
preoperatively and x patients required use of the Intra aortic balloon pump to support cardiac
function due to cardiogenic shock or poor LV Figure 5.
Timing of surgery showed 94% of cases (70 patients) underwent elective surgery and 5
patients ( 6%) presented as urgent inpatients or emergency surgery. Figure 6
One (1) patient was accepted from the general intensive care unit in a critical pre –operative
state, intubated and ventilated on high doses of inotropes. He underwent Aortic & Mitral
Valve surgery for bacterial endocarditis. Figure 7. ( risk vs surgical timing).
Risk assessment models utilised EuroScore [1] and Parsonnet scoring systems [2]. Expected
mortality for this population of patients ranged from 1% to 11% with a mean of 2%. Figure 8.
There are 3 survivors with preoperative risks of the order of 20% not reflected by the
EuroScore.
Impaired LV function, urgency of operation and the use of cardiac assist devices such as the
Intra aortic balloon pump are associated with higher risks of mortality and morbidity. In this
group of high risk patients there was a 100% success rate.
Post operative atrial fibrillation was the most common complication and occurred in 17% of
patients. This compares favourably with a rate of 30% in most cardiac units worldwide. Two
patients required re-exploration post surgery. 74(98.6%) of patients were discharged home.
There was 1. cardiac related death and one non cardiac death(a sternal wound infection at
Post mortem) after readmission giving an overall mortality rate of 2.75%. One patient
sustained a stroke after discharge and 1 patient developed. Renal replacement therapy was not
required in this group of patients.
infection, stroke.
.
(complication slide vs %.. alive, mortality, sternal
DISCUSSION
Cardiovascular disease is the number one cause of mortality in Trinidad & Tobago.
The high incidence of diabetes and hypertension in the population are documented risk
factors for ischemic heart disease (IHD).1,2 A significant number of patients with Ischemic
heart disease are likely to benefit from coronary artery bypass surgery.
Cardiac surgery in Trinidad & Tobago developed as a Joint venture between teams of local
specialists and visiting international cardiac surgical teams. The model embraced
relationships between public sector and private sector. Those involved should be commended
for initiating and supporting this essential service to the region.
For initiatives based on similar models to expand and succeed over the long term, it is
essential that skills and knowledge be acquired and transferred to the local team.3 Good
governance and continuing medical education is paramount.
Approximately 1200 open heart surgeries per million population (pmp) were performed in
North America in 1999 and approximately 800/million/yr in Australia. These numbers are
increasing in line with government policy to meet local needs for revascularization.
Prior to 2007 approximately two hundred heart operation per year (200/yr) were performed in
Trinidad &Tobago in a single government centre. There is a great underserved need.
In the
United Kingdom there are forty one (41) National Health Service cardiac centres and two
hundred (200) cardiac surgeons. National service framework (NSF) guidelines for
management of coronary artery disease developed in 2000 form the basis of modern
management of ischemic heart disease in the population. All patients meeting the NSF criteria
for angiography and revascularisation are identified and treated to the standards set out in this NSF 4.
It was estimated that this will equate to a national rate equivalent to at least 750 operations per million
population annually for coronary artery bypass surgery. In 2008 twenty three thousand (23,000)
cardiac operations were performed in the UK 5.
The high incidence of diabetes and hypertension in Trinidad & Tobago compared to the
developed world suggests this may increase further the number of individuals at risk for IHD
and need for revascularisation.
More than one centre for Trinidad & Tobago is likely to improve patient care and allows for
patient choice.
-It Increases the number of operations which may be performed simultaneously
-Allows for collaboration between cardiologist and cardiac surgeons on best practice for
difficult cases.
-Allows sharing of information through contributing to a single National or regional r
database where data may be accessed by care givers and service providers.
- Facilitates Audit and submissions of publications and presentations for peer review locally
and internationally
-Allows multidisciplinary approaches with more than one surgeon and cardiologist
CONCLUSION:
The first 75 open heart surgeries at POSGH have been performed on a variety of
patients including high risk patients. The outcomes have been excellent and the early
data indicates that open heart surgery is being performed at below expected mortality with
low complication rates. It is providing a needed service and should be expanded.
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In 1999, Professor Felix Unger from Salzburg, Austria published the results of a remarkable worldwide survey that clearly defined the magnitude of
the differences that exist in cardiac care in developed versus underdeveloped countries (see Figure 1).
Figure 1. Discrepancies by Region in Cardiac Surgery Cases
REFERENCES