Congenital Cardiac Surgery Program; The Need of Pakistan

Muneer Amanullah

Congenital Cardiac Surgery

The Aga Khan University Hospital

Karachi - Pakistan

Karachi – 2nd May 2010

Developing Congenital Cardiac Surgery Program

• 4.5 billion people have no access to cardiac surgery

• Many die before having the chance to present for surgery

R Neirotti . CITY. 2004

•WHO; 2.5 million population – 300 cases/year

•Many countries with population up to 50 million have no

paediatric cardiac centre

M Yaqub. Circulation. 2007

Developing Congenital Cardiac Surgery Program

“The time has come when physicians have to decide whether

they will continue to be a part of the problem or whether they

want to be part of the solution” R Neirotti . CITY. 2004

Lack of facilities for sustainable paediatric cardiac services

in the developing world results in a massive number

of preventable deathsM Yaqub. Circulation. 2007

Health Problems in Developing Countries

Survey Questions

• Availability of comprehensive cardiac care for a child

• What is the population of your country?

• What Resources Exist?

• How many pediatric heart programs exist in your country?

• How are these centers distributed: all clustered in big cities?

Developing Congenital Cardiac Surgery Program

• Population of Pakistan – 170 million

• Conservative estimates

– 65-85,000 children born each year with CHD in Pakistan

– 2,00,000 children with CHD need surgery this year

– There are approximately 1000 d-TGA born each year

– 5 Centres in the country performing 2000 cases/year

Developing Congenital Cardiac Surgery Program

• 85% cannot afford any type of surgery

• Poorly-existent health services

• Lethargic approach of Govt

• 20 years behind developed countries

• 10 years behind India and China

The Vision of the World Society is that every child born

anywhere in the world with a congenital heart defect should

have access to appropriate medical and surgical care. Its

Mission is to promote the highest quality comprehensive care to

all patients with pediatric and congenital heart disease, from the

fetus to the adult, regardless of the patient’s economic means.

The World Society of Pediatric & Congenital Heart Surgeons

C I Tchervenkov. Montreal. 2008

Rawalpindi; AFIC

Lahore; CHL. IHL

Karachi; NICVD, AKUH

.

Training Years

• Year 1

– Introduction into congenital cardiac surgery

• Year 2

– Consolidate principles of congenital cardiac surgery

• Year 3

– Sabbatical

– Preparation for consultant post

International Aspects of Cardiac Surgery

• Identify best role model unit – Freemen Hospital (UK)

• Continuous Funding - AKUH

• Develop on existing cardiac surgery programs - AKUH

• Training/refresher courses of personal - Collaboration

• 5 years sustained commitment - leads to growth & success

Recommendations

Developing Congenital Cardiac Surgery Program

• Sustainability – Charge reasonably with subsidy from HWP

• Expensive imported consumables

– Brazil, India, China – develop industry

• Overall mortality –▼from 20% - 5% over last 10 years.

S Rao. Pediatric Cardiology. 2007

Developing Congenital Cardiac Surgery Program

• Improvement in results when PCICU separated

from CICU with dedicated pediatric staff

• Increasing volumes = decreasing mortality

• Guatemala experience

– Morbidity 28%

– Mortality 10.7%A Castenada. Circulation. 2007

http://groups.msn.com/badbadboys

Outcome Monitoring

“Perhaps the most important of all the elements

are the complications occurring after operations.”

Florence NightingaleNotes on Hospitals (1863)

Minimising the learning curve

• No surgeon should attempt a procedure beyond his competence

• How to learn a new procedure

– Visits & observes established surgeons performing the procedure

– Specifically designed courses

– Invite the established surgeon and his team to assist in surgery

A Hasan. BMJ. 2000

Collaboration - AKUH• Freeman Hospital – UK 2006-09

– Surgeon – Asif Hasan

– Anaesthetist/Intensivist - Kelly Dilworth

– Perfusionist – William Watson

• Fortis/Escort Hospital – India - 2008

– Surgeon – Rajesh Sharma

• Children’s Hospital – Lahore – 2007-10

– Surgeon – Asim Khan

Year III Year IV

Case Distribution over Last Four YearsN=406 (OHS) + 141(CHS) = 547

Results of Phase II

Open Heart Surgery N=406

Year I

N=82

Year II

N=101

Year III

N=113

Year IV

N=110

Morbidity 39 (47%) 46 (45%) 17 (15%) 12 (10%)

Mortality 11 (13%) 8 (8%) 6 (5%) 3 (2.8%)

Extubation 11 (hrs) 10 (hrs) 15 (hrs) 8 (hrs)

Results of Phase IIClosed Heart Surgery N=141

Year I

N=24

Year II

N=36

Year III

N=56

Year IV

N=25

Morbidity 3 (12%) 5 (14%) 5 (9%) 4 (16%)

Mortality 3 (12%) 3 (8%) 3 (5%) 2 (8%)

Extubation 7 (hrs) 6 (hrs) 3 (hrs) 3 (hrs)

Results of Phase II

Open Heart Surgery – ToF (n=99)

Year I

N=26

Year II

N=25

Year III

N=28

Year IV

N=25

Morbidity 14 (53%) 15 (60%) 5 (18%) 5 (20%)

Mortality 4 (15%) 3 (12%) 2 (7%) 0

Results of Phase II

Open Heart Surgery – VSD (n=108)

Year I

N=17

Year II

N=25

Year III

N=35

Year IV

N=31

Morbidity 9 (53%) 15 (60%) 11 (31%) 4 (13%)

Mortality 2 (12%) 0 0 0

Results of Phase II

Open Heart Surgery – TAPVD (n=19)

Year I

N=6

Year II

N=4

Year III

N=5

Year IV

N=4

Morbidity 2 (33%) 2 (50%) 1 (20%) 1 (25%)

Mortality 2 (33%) 1 (25%) 0 0

Collaboration – Visits • Freeman Hospital – UK 2007

– Surgeon

– Anaesthetist/Intensivist

– CICU Nurses/Physiotherapist

• Escorts Hospital – India – 2007/8

– Surgeon

– Cardiologist

• Children’s Hospital – Lahore – 2008/9

– Surgeon

Collaboration – Change in Practices - AKUHUnderstanding different disease patterns

• ToF– Leave small ASD

– Functioning pulmonary valve• Mono-cusp

• Tissue valve

• Arterial Switch– Different coronary patterns

• Atrial Switch– Patient selection

• d-TGA – late presenters– Role of PA banding/shunt

Collaboration – Changes in Practices

Different disease patterns

• ToF

• Arterial Switch

– Different coronary pattern

• Atrial Switch

– For double switches

• d-TGA

– In-flow occlusion

Phase III – Consolidation Phase

• Implementation of end of phase II audit recommendations

– More complex surgeries

• Arterial switch, TAPVD, redo-operations

• Development of service

– International referrals

• Initiation of research based publications

– Steroids, Parent led rounds

Current Status of Pediatric Cardiac Surgery in Pakistan

• Increasing number of corrective open heart surgeries

• Improving results with lower mortality

• Formal training of Congenital Cardiac Surgeons

– CHL and AKUH

• Improving understanding between pediatric Cardiologists and pediatric

Cardiac surgeons

• Development of Congenital Cardiac Surgery Database

– AKUH

Pediatric Cardiac Surgery in Pakistan 2009

• AFIC – International Collaboration

– ICHF

• CHL

– Self taught

– Few International visitors

• NICVD

– Trying to establish International Collaboration

• AKUH

– Freeman Hospital

– CHL

Current Status of Pediatric Cardiac Surgery Pakistan

National Collaboration

• Enough experience in dealing with infants & neonates

• Have learnt how to develop a functioning unit both in public and

private sector

• Continuous help available instead of sporadic or scheduled

short visits

• Self reliance

• Better resource utilization

Current Status of Pediatric Cardiac Surgery Pakistan

Suggestions

• Governmental support for congenital cardiac surgery units

• National Training & Certification of pediatric cardiac surgeons

• Develop national congenital cardiac surgery database

• Intensive National collaboration

• Pediatric Cardiac Surgery society

Current Status of Pediatric Cardiac Surgery Pakistan

Conclusion

• Congenital heart disease is a challenge for Pakistan

• Proper planning & implementation of a phased program

• Results satisfactory but need improvement

• Continue collaboration to improve outcomes