Congenital Cardiac Surgery Program; The Need of Pakistan

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

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

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

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?

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

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

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.

9. Rawalpindi; AFIC Lahore; CHL. IHL Karachi; NICVD, AKUH

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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

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

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

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

19. Outcome Monitoring “Perhaps the most important of all the elements are the complications occurring after operations.” Florence Nightingale Notes on Hospitals (1863)

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

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

22. Case Distribution over Last Four Years N=406 (OHS) + 141(CHS) = 547 Year III Year IV

23. Results of Phase II Open Heart Surgery N=406

24. Results of Phase II Closed Heart Surgery N=141

25. Results of Phase II Open Heart Surgery – ToF (n=99)

26. Results of Phase II Open Heart Surgery – VSD (n=108)

27. Results of Phase II Open Heart Surgery – TAPVD (n=19)

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

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

31. Collaboration – Changes in Practices Different disease patterns • ToF • Arterial Switch • Different coronary pattern • Atrial Switch • For double switches • d-TGA • In-flow occlusion

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

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

35. Pediatric Cardiac Surgery in Pakistan 2009

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

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

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

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