Transcript Muneer Amanullah - Karachi Institute of Heart Diseases
Slide 1
Congenital Cardiac Surgery Program;
The Need of Pakistan
Muneer Amanullah
Congenital Cardiac Surgery
The Aga Khan University Hospital
Karachi - Pakistan
Karachi – 2nd May 2010
Slide 2
Slide 3
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
Slide 4
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 deaths
M Yaqub. Circulation. 2007
Slide 5
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?
Slide 6
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
Slide 7
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
Slide 8
The World Society of Pediatric & Congenital Heart Surgeons
C I Tchervenkov. Montreal. 2008
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.
Slide 9
Rawalpindi; AFIC
Lahore; CHL. IHL
Karachi; NICVD, AKUH
Slide 10
Slide 11
.
Slide 12
Slide 13
Training Years
• Year 1
– Introduction into congenital cardiac surgery
• Year 2
– Consolidate principles of congenital cardiac surgery
• Year 3
– Sabbatical
– Preparation for consultant post
Slide 14
Slide 15
International Aspects of Cardiac Surgery
Recommendations
• 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
Slide 16
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
Slide 17
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
Slide 18
Slide 19
Outcome Monitoring
“Perhaps the most important of all the elements
are the complications occurring after operations.”
Florence Nightingale
Notes on Hospitals (1863)
Slide 20
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
Slide 21
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
Slide 22
Case Distribution over Last Four Years
N=406 (OHS) + 141(CHS) = 547
Year III
Year IV
Slide 23
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%)
10 (hrs)
15 (hrs)
8 (hrs)
Extubation 11 (hrs)
Slide 24
Results of Phase II
Closed 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%)
6 (hrs)
3 (hrs)
3 (hrs)
Extubation 7 (hrs)
Slide 25
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
Slide 26
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
Slide 27
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
Slide 28
Slide 29
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
Slide 30
Collaboration – Change in Practices - AKUH
Understanding 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
Slide 31
Collaboration – Changes in Practices
Different disease patterns
• ToF
• Arterial Switch
– Different coronary pattern
• Atrial Switch
– For double switches
• d-TGA
– In-flow occlusion
Slide 32
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
Slide 33
Slide 34
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
Slide 35
Pediatric Cardiac Surgery in Pakistan
2009
Slide 36
Current Status of Pediatric Cardiac Surgery
Pakistan
• AFIC – International Collaboration
– ICHF
• CHL
– Self taught
– Few International visitors
• NICVD
– Trying to establish International Collaboration
• AKUH
– Freeman Hospital
– CHL
Slide 37
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
Slide 38
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
Slide 39
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
Slide 40
Congenital Cardiac Surgery Program;
The Need of Pakistan
Muneer Amanullah
Congenital Cardiac Surgery
The Aga Khan University Hospital
Karachi - Pakistan
Karachi – 2nd May 2010
Slide 2
Slide 3
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
Slide 4
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 deaths
M Yaqub. Circulation. 2007
Slide 5
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?
Slide 6
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
Slide 7
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
Slide 8
The World Society of Pediatric & Congenital Heart Surgeons
C I Tchervenkov. Montreal. 2008
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.
Slide 9
Rawalpindi; AFIC
Lahore; CHL. IHL
Karachi; NICVD, AKUH
Slide 10
Slide 11
.
Slide 12
Slide 13
Training Years
• Year 1
– Introduction into congenital cardiac surgery
• Year 2
– Consolidate principles of congenital cardiac surgery
• Year 3
– Sabbatical
– Preparation for consultant post
Slide 14
Slide 15
International Aspects of Cardiac Surgery
Recommendations
• 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
Slide 16
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
Slide 17
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
Slide 18
Slide 19
Outcome Monitoring
“Perhaps the most important of all the elements
are the complications occurring after operations.”
Florence Nightingale
Notes on Hospitals (1863)
Slide 20
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
Slide 21
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
Slide 22
Case Distribution over Last Four Years
N=406 (OHS) + 141(CHS) = 547
Year III
Year IV
Slide 23
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%)
10 (hrs)
15 (hrs)
8 (hrs)
Extubation 11 (hrs)
Slide 24
Results of Phase II
Closed 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%)
6 (hrs)
3 (hrs)
3 (hrs)
Extubation 7 (hrs)
Slide 25
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
Slide 26
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
Slide 27
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
Slide 28
Slide 29
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
Slide 30
Collaboration – Change in Practices - AKUH
Understanding 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
Slide 31
Collaboration – Changes in Practices
Different disease patterns
• ToF
• Arterial Switch
– Different coronary pattern
• Atrial Switch
– For double switches
• d-TGA
– In-flow occlusion
Slide 32
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
Slide 33
Slide 34
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
Slide 35
Pediatric Cardiac Surgery in Pakistan
2009
Slide 36
Current Status of Pediatric Cardiac Surgery
Pakistan
• AFIC – International Collaboration
– ICHF
• CHL
– Self taught
– Few International visitors
• NICVD
– Trying to establish International Collaboration
• AKUH
– Freeman Hospital
– CHL
Slide 37
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
Slide 38
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
Slide 39
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
Slide 40