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.

Background: Background:

What is the correct surgical What is the correct surgical target?target?

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….

Outcomes - GeneralOutcomes - General

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)

50

25

0

20

40

60

No.

Pat

s.

Male Female

1st 75 Cases - Gender Distribution

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

Outcomes - MortalityOutcomes - Mortality

Predictive Mortality Scoring Systems The EuroSCORE

Factor Definition Score

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

Prevalence of Diabetes in Trinidad

IABP – IABP – 11% 11% UseUse

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 !

99%

1%

Discharged Alive In-Hospital Mortality

In Hospital Mortality on Index Admission

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:

Isolated Cardiac Unit at ICU - POSGH

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…

Off pump coronary artery Off pump coronary artery bypass surgery bypass surgery

Angelini et alAngelini et al