Two Cardiac Centres Two Cardiac Centres Are Better Than One Are Better Than One
Early Outcomes of the First 75 Open Early Outcomes of the First 75 Open Heart Surgeries At Port of Spain Heart Surgeries At Port of Spain
General HospitalGeneral Hospital
Randolph Rawlins M.B.B.S., F.R.C.S.(Ed), FRCS Randolph Rawlins M.B.B.S., F.R.C.S.(Ed), FRCS (C/TH), (C/TH),
Ronald Henry M.B.,B.S., FACP, FSCAI, CMTT, Ronald Henry M.B.,B.S., FACP, FSCAI, CMTT, The Doctors Inn Research Group.The Doctors Inn Research Group.
Background: Background:
What is the burden of What is the burden of Cardiovascular Disease in Cardiovascular Disease in Trinidad ?Trinidad ?
Leading Causes of Death in T&T
0
50
100
150
200
250
1994 1995 1996 1997 1998 1999 2000 2001 2002
Dea
tth
Rat
e/10
0,00
0 Heart
Cancer
DM
Stroke
Acc/Inj/Pois
Resp
AIDS/HIV
20042004 20052005
POSGHPOSGH 12.2% 12.2% (2(2ndnd))
12.6% 12.6% (2(2ndnd))
SFGHSFGH 14.8% 14.8% (1(1stst)) 13.9% 13.9% (1(1stst))
S/Grande S/Grande HospHosp
15.8% 15.8% (1(1stst)) 15.6% 15.6% (1(1stst))
Point Point FortinFortin
12.6% 12.6% (4(4thth))
22.3% 22.3% (1(1stst))
TobagoTobago 10.6% 10.6% (4(4thth))
12.612.6thth (2(2ndnd))
Hospital Cardiac Admissions% of Admissions for “Diseases of the circulatory system”, Frequency Rank per hospital
Annual CSO Report 2004-2005 *EWMSC data not in report - not fully public.
Background: Background:
What is the current surgical What is the current surgical capacity?capacity?
Open Heart surgery was first Open Heart surgery was first performed in Trinidad & Tobago in performed in Trinidad & Tobago in 1993 at EWMSC1993 at EWMSC
Collaboration between local and Collaboration between local and international specialists. international specialists.
Approximately 200 MOH cases/yr Approximately 200 MOH cases/yr were performed in a single were performed in a single Government institution in 2007. Government institution in 2007.
NSF . Cardiac Surgery NSF . Cardiac Surgery Cases / Million Population Cases / Million Population
1000
UnitedKingdomTrinidad &Tobago
Sixth National Adult Cardiac Surgical Database Report - 2008
1000
216
UnitedKingdomTrinidad &Tobago
Sixth National Adult Cardiac Surgical Database Report – 2008CSO, 2008
NSF . Cardiac Surgery NSF . Cardiac Surgery Cases / Million Population Cases / Million Population
Meeting The Underserved Meeting The Underserved Needs:Needs:
Need to Need to
Increase national capacityIncrease national capacity
Increase Institutional Capacity
Increase Number of InstitutionsFive-
fold increas
e needed
Cardiac Surgery Starts atPOSGH !!
Port of Spain General Hospital was Port of Spain General Hospital was identified as a second public centre.identified as a second public centre.
Has always been a major Teaching Has always been a major Teaching Centre Centre
EWMSC is not a dedicated Cardiac EWMSC is not a dedicated Cardiac CentreCentreThe first coronary artery The first coronary artery
bypass operation was bypass operation was performed at POSGH in June performed at POSGH in June 2007.2007.
Initiation of programme by visiting Initiation of programme by visiting foreign teamforeign team
Lead Cardiothoracic Surgeon , T&T Lead Cardiothoracic Surgeon , T&T National National locally-based , UK-trained.locally-based , UK-trained. Fully local anaesthesiology team.Fully local anaesthesiology team.ICU team at POSGH provides post op ICU team at POSGH provides post op care.care.Cardiology outsourced from local Cardiology outsourced from local market. market.
Initial case scheduling 1 day/mthInitial case scheduling 1 day/mthNow weekly operating list - 2 Now weekly operating list - 2 cases /wkcases /wk
Programme Development….Programme Development….
Utilization of existing on-site Trans-Utilization of existing on-site Trans-Oesophageal Echo (TOE) equipmentOesophageal Echo (TOE) equipment
Introduction of Cell Salvage technology Introduction of Cell Salvage technology Reduces transfusion requirementReduces transfusion requirement
Re- introduction of temporary pacing Re- introduction of temporary pacing supportsupport
Programme Development….Programme Development….
13
20
42
0
5
10
15
20
25
30
35
40
45
No
. Pa
tien
ts
2007 to 2008 2008 to 2009 2009 to 2010
Case Distribution - The First 75 Cases (June 22nd 2007 to May 14th 2010)
10
23
30
8 10
5
10
15
20
25
30N
o. P
ats.
<50 50 59 60 - 69 70 - 79 80 - 89
Age Range in Years
1st 75 Cases - Age Distribution
1st 75 Cases - Types of Surgery
CABG Only, 68 (91%)
Valve Only, 11
CABG withValve ,4 CABG with
Other ,3
418
40
6
0
5
1015
20
25
30
35
40N
o. P
ats
1 Graft 2 Grafts 3 Grafts 4 Grafts
No. of Grafts
1st 75 Case - Number of Grafts
26 27
106 0 30
5
10
15
20
25
30N
o. P
ats.
0 to 1% 2 to 3% 4 to 5% 6 to 7% 8 to 9% >9%
EuroSCORE (%Mortality)
Mortality - EuroSCORE Categorization
26 27
106 0 30
5
10
15
20
25
30N
o. P
ats.
0 to 1% 2 to 3% 4 to 5% 6 to 7% 8 to 9% >9%
EuroSCORE (%Mortality)
Mortality - EuroSCORE Categorization
53%
77%
50%
9% 11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
% P
ats.
Diabetes Hypertension Impaired LVFunction
Urgent CABG IABP
1st 75 Cases - Operative Risk Factors
SCTS – SCTS – 66thth NACSD Report, 2008. NACSD Report, 2008.
Post-Infarct VSD & Mortality Post-Infarct VSD & Mortality RiskRisk
Two cases of Two cases of combined combined
VSD & CABG VSD & CABG performed performed
100% 100% Survival !Survival !
Endocarditis & Mortality Endocarditis & Mortality RiskRisk
One case of One case of combined combined Aortic & Aortic &
Mitral Valve Mitral Valve Replacement Replacement performed performed
100% 100% Survival !Survival !
UKUK 11stst 75 75 CasesCases
Atrial FibrillationAtrial Fibrillation 10-65%10-65% 20% 20% (n=15) (n=15)
Haemofiltration/Haemofiltration/DialysisDialysis
3.6%3.6% 0% (n=0)0% (n=0)
Re-ExplorationRe-Exploration 4.9%4.9% 2.6% 2.6% (n=2)(n=2)
Surgical Site InfectionsSurgical Site Infections1.3- 1.3- 12%12%
4% 4% (n=3) (n=3)
Post Operative Complications – 1Post Operative Complications – 1stst 75 Cases75 Cases
4 readmissions post discharge 4 readmissions post discharge (5.3% (5.3% Readmission Rate)Readmission Rate)
2 for medication re-adjustment2 for medication re-adjustment 1 readmitted to medical ward with a CVA.1 readmitted to medical ward with a CVA. 1 readmitted with MRSA Empyema 1 readmitted with MRSA Empyema died after died after
admissionadmission Creation of a Dedicated Cardiac Space in ICU Creation of a Dedicated Cardiac Space in ICU MRSA screening of all patientsMRSA screening of all patients No further recurrences of MRSA in last 1 yrNo further recurrences of MRSA in last 1 yr
Re-Admissions:Re-Admissions:
Open heart surgeries at POSGH are Open heart surgeries at POSGH are being performed at low mortality.being performed at low mortality.
Low complication rates.Low complication rates.
Excellent outcomes Excellent outcomes
Secondary institutional benefits- e.g. Secondary institutional benefits- e.g. cell saver, TOE, temporary pacemakers cell saver, TOE, temporary pacemakers and peer-learning opportunities. and peer-learning opportunities.
CONCLUSION:CONCLUSION:
Two Cardiac Centres Two Cardiac Centres Are Better Than One Are Better Than One
It is providing a needed It is providing a needed service and should be service and should be expanded…expanded…