Cardiac Surgical Facilities Research Articles

Outcomes of Treatment for Prosthetic Valve Endocarditis: Experience From a Regional Hospital in Australia Without Cardiac Surgical Facilities

Outcomes of Treatment for Prosthetic Valve Endocarditis: Experience From a Regional Hospital in Australia Without Cardiac Surgical Facilities

Review of sustainable Paediatric Cardiac Surgery Program based on Humanitarian Principles at Govt. Medical College, Goa

Introduction: Paediatric cardiac surgery and paediatric cardiology set-up is an arduous task, in developing countries, like India (4). Access to advanced cardiac care is unavailable in majority of developing countries (5). Due to high fertility rates in India, the annual estimate of CHD is approximately 150,000–200,000 children per year (6, 10). Of these, approximately a third to a quarter (∼50,000) would need early intervention to survive the first year of life (7, 10). Goa is a small state of India situated along the western coast of Indian peninsula. Goa medical college (GMC) is the only tertiary level institute, providing medical facilities in the state. There were no cardiology or cardiac surgical facilities available at GMC, prior to 2014. The cardiac surgical unit at Goa Medical College was started in April 2014. It provides cardiac surgical services absolutely free of cost to all the citizens of the state. Initially only adult cardiac surgical cases were being performed, but from September 2014, we initiated the paediatric cardiac surgical program, for which we availed the facility of a paediatric cardiac surgeon. Materials and Methods: From 26th Sep 2014 to 11th Jan 2020, we operated a total of 90 cases, during 18 visits of the visiting paediatric cardiac surgeon, who operated an average of 5 cases per visit. Mean age of operated children was 3.2 years. We operated 34 cases of VSD’s, 26 cases of TOF, 8 cases of Tricuspid atresia, 9 cases of ASD, 3 cases of MV repair, 1 case of ASD+PS, 5 cases of TAPVC, 3 PA banding & PDA ligation and one permanent pacemaker implantation. Patients were managed initially in a 5 bedded ICU and after extubation were shifted to a step-down ICU for further recovery. Results: The average duration of ventilation was 36hrs and average length of ICU stay was 5 days. Mean CPB time was 92.46 mins and mean aortic cross clamp time was 59.5 mins. Overall mortality was 5.55%. One patient underwent a redo MV repair, as there was moderate residual MR in post operative period. Conclusion: This model of cardiac surgical program has worked well for the state of Goa and has benefitted lot of people from within the state as well as neighbouring states, where easy and affordable access to cardiac surgical facilities are missing. It has produced excellent outcomes for adult cardiac surgery and has encouraged us to extend the facility to paediatric population. Gradually, our local team is getting confident to do these paediatric cases.
 Keywords: Congenital heart disease, India, Goa medical college (GMC), Paediatric cardiac surgical care.

Effects of cardiac surgical support on long-term outcomes of emergent or complex percutaneous coronary intervention cases: a sub-analysis of the SHINANO 5-year registry

Significant improvements in percutaneous coronary intervention (PCI) technology have enabled cardiovascular procedures to be performed without onsite cardiac surgery facilities. However, little is known about the association between onsite cardiac surgical support and long-term outcomes of PCI, particularly among emergent and complex cases. We investigated whether the presence or absence of cardiovascular surgery affects the long-term prognosis after PCI, emergent and complex elective cases. The SHINANO 5-year registry, a prospective, observational, and multicenter cohort study registry in Nagano, Japan, consecutively included 1665 patients who underwent PCI between August 2012 and July 2013. The procedures were performed at 11 hospitals with onsite cardiac surgery facilities [onsite surgery (+) group; n = 1257] and 8 hospitals without onsite cardiac surgery facilities [onsite surgery (−) group; n = 408]. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiac and cerebrovascular events [MACCE: all-cause death, Q-wave myocardial infarction, non-fatal stroke, and target lesion revascularization]. The onsite surgery group (+) had a lower rate of emergent PCI and ST-segment elevation myocardial infarction (40.8% vs. 51.7%, p < 0.01 and 24.9% vs. 39.2%, p < 0.01, respectively), and a higher prevalence of hemodialysis and history of peripheral artery disease (7.6% vs. 2.45%, p < 0.01 and 12.1% vs. 6.9%, p < 0.01, respectively). However, the Kaplan–Meier analysis showed no difference in the 5-year mortality rate (16.4% vs. 15.2%, p = 0.421) and MACCE incidence (31.6% vs. 28.9%, p = 0.354) between the groups. Also, there were no differences in the mortality rate and incidence of MACCE among emergent cases of ST-segment elevation myocardial infarction and complex elective cases who underwent PCI. Long-term outcomes of PCI appear to be comparable between institutions with and without onsite cardiac surgical facilities.

An Overview of First 100 Cardiac Surgery Cases at a Newly Developed Satellite Center in Sukkur, Pakistan.

IntroductionThe aim of this research is to evaluate the in-hospital and early outcomes of the first 100 adult cardiac surgeries performed at a newly developed satellite center in Sukkur, Pakistan.MethodsThis is an audit of the first 100 adult cardiac surgeries performed at a newly developed satellite center of the National Institute of Cardiovascular Diseases (NICVD) at Sukkur, Pakistan, from March 2018 to November 2018 with 12 months of post-operative follow-up. Patients were offered off-pump coronary artery bypass (OPCAB), on-pump coronary artery bypass (ONCAB), mitral valve replacement (MVR), aortic valve replacement (AVR), minimally invasive cardiac surgery (MICS), and congenital adult congenital heart disease (ACHD) procedures by expert faculty of NICVD with a minimum of five years of post-fellowship experience.ResultsThe mean age was 47.11 ± 14.6 years, with a male predominance of 77%. Hypertension and smoking were the most common risk factors that were observed in 32% and 33%, respectively, followed by diabetes and dyslipidemia with a frequency of 20% and 9%, respectively. The mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) II for this patient cohort was 1.165 ± 0.50, with a maximum score of 2.3 in one patient. Out of 100 procedures, 51 were ONCAB, 19 were OPCAB, 16 were MVR, three were AVR, nine were ACHD, and two were MICS. Survival status post-operative as well as after one year was 100%. The frequency of post-operative bleeding was 7%, mean post-operative mechanical ventilation time was 213 ± 273 hours, and in-hospital stay was 5.41 ± 0.165 days. Lost to follow-up at one year was 4% (four). During the follow-up assessment, 39.5% of the patients had complained of mild-to-moderate intensity retrosternal pain and 4.2% had superficial surgical site infection of the sternal wound. A significant improvement in functional class was observed in 38.5% of patients, whereas 4.2% (four) had a significant drop in functional class post-operatively.ConclusionProviding tertiary care and early cardiac surgical facility to the people of Sukkur at their doorstep, in a newly developed satellite center, has resulted in improved outcomes, early quality treatment facility, and avoidance of long travel time.

The Guatemalan echocardiographic network.

Carolinas HealthCare System, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA Unidad de Cirugia Cardiovascular de Guatemala (UNICAR), 9A Avenida 8, Guatemala City, Guatemala 01011, Guatemala The Heineman Foundation of Charlotte, 1001 Blythe Blvd #604, Charlotte, NC 28203, USA *Author for correspondence: francis.robicsek@carolinashealthcare.org Background In the seven countries of the Central-American subcontinent, cardiovascular disease is rampant, especially rheumatic heart valve disease. Cardiac care, especially access to cardiac surgical facilities, is limited to the public. Even today, in most of Central America, with the notable exception of Costa Rica, one may see only a few occasional cases of cardiac procedures performed by fledgling surgical programs or by visiting ‘brigades’ from the USA and Europe. Although they do good, they leave very little behind.

Pericardial Tamponade: A Rare Complication of Sternal Bone Marrow Biopsy

Injury of the heart with concomitant pericardial tamponade as a result of sternal bone marrow biopsy is rare. An 80-year-old man was admitted with dehydration and non-specified abdominal pain to the regional hospital. Sternal aspiration biopsy was performed because of anemia and thrombocytopenia. Later on, because of the back pain, general weakness and blood pressure drop, an echocardiography examination was indicated. Pericardial fluid collection was found. Anticipated ascending aortic dissection was excluded on computed tomography scan, but pericardial fluid collection was confirmed. Transfer to our cardiac surgical facility ensued. Limited heart tamponade was affirmed on echocardiography and surgery was immediately indicated. Blood effusion was found in upper mediastinal fat tissue and 300 mL of blood were evacuated from opened pericardial space. Stab wound by sternal biopsy needle at the upper part of ascending aorta was repaired by pledgeted suture. Postoperative course was uneventful.

Emergency extracorporeal membrane oxygenation in a hospital without on-site cardiac surgical facilities

We report the feasibility and outcomes of emergency extracorporeal membrane oxygenation (ECMO) implantation by a cardiac catheterisation team in patients in severe cardiogenic shock or refractory cardiac arrest in a hospital without cardiac surgical facilities. This prospective cohort study involved 51 consecutive patients who had ECMO implantation (September 2006 - September 2010). Twenty-seven were in severe cardiogenic shock and 24 in refractory cardiac arrest (17 with out-of-hospital cardiac arrest; seven with in-hospital cardiac arrest). Implantations were done via a percutaneous femoral approach by a local interventional cardiologist team, and in collaboration with the nearest cardiac surgical institution. Patients' mean age was 51±15 years; 38 (74.5%) were men. Stable ECMO implantation was achieved in 26/27 (96.3%) patients in severe cardiogenic shock and in 18/24 (75.0%) patients in refractory cardiac arrest. In-hospital complications occurred in 23/27 cardiogenic shock patients; 13/27 were discharged alive. In patients with refractory cardiac arrest, complications occurred in 20/24; 21/24 were disconnected from ECMO because of brain death or multiorgan failure occurring ≤24 hours; one patient was discharged alive. Emergency ECMO implantation by an interventional cardiologist in a hospital without cardiac surgical facilities is feasible, with a failure rate concordant with the literature.

128 Emergency extra-corporeal membrane oxygenation in cardiac shock and cardiac arrest in hospital without on-site cardiac surgical facilities

128 Emergency extra-corporeal membrane oxygenation in cardiac shock and cardiac arrest in hospital without on-site cardiac surgical facilities

Emergency extra-corporeal membrane oxygenation in a hospital without on-site cardiac surgical facility

Emergency extra-corporeal membrane oxygenation in a hospital without on-site cardiac surgical facility

Percutaneous Coronary Interventions without On-Site Cardiac Surgery: A Remote Australian Experience

The current American College of Cardiology (ACC) guidelines recommend that elective percutaneous coronary interventions (PCI) should not be performed in institutions without on-site cardiac surgery. We sought to determine the safety of PCI without cardiac surgical support on-site and specifically the safety of complex elective procedures. The results of the first 1000 procedures performed at our institution, which is a rural centre 80 km from the nearest cardiac surgical facility, are reported. Between September 2002 and April 2006 a total of 1000 procedures were performed in 893 patients at our institution. Patients included both high and low risk cohorts. Clinical and procedural outcomes were recorded and analysed. Of the 921 elective and 79 emergency primary PCI procedures performed, 1138 vessels were treated and 1429 stents deployed. A 95% procedural success rate was recorded. Complex PCI was performed with multi-vessel PCI in 13%, bifurcation PCI in 8%, chronic total occlusions (CTO) in 5%, saphenous vein graft interventions in 5%, unprotected left main interventions in 0.8% and rotational atherectomy in 0.8% of all procedures performed. Of the cohort, 75.3% of the lesions treated were either American College of Cardiology (ACC)/American Heart Association (AHA) type B or C lesions. In the primary PCI group, three deaths and three sub-acute stent occlusions occurred. In the elective group, the following major complications occurred: one death, three sub-acute stent occlusions, one case of contrast nephropathy requiring short-term dialysis, two cases of cardiac tamponade, two significant femoral pseudo-aneurysms and one misplaced stent. Acute myocardial infarction occurred in 21 patients. There were no urgent transfers for CABG surgery to salvage a complication of PCI. PCI including high risk elective procedures can safely be performed without on-site cardiac surgery by experienced high volume operators.

Primary Percutaneous Coronary Interventions Without On-site Cardiac Surgery: Two Years’ Observational Experience and Follow-up

Primary Percutaneous Coronary Interventions Without On-site Cardiac Surgery: Two Years’ Observational Experience and Follow-up

Use what you have: biological assistance for the treatment of heart failure in the Caribbean

Cardiovascular disease represents the main cause of death among adults in the Caribbean. Primary and secondary care facilities are efficiently managed. Cardiac surgical and interventional facilities, however, exist only in a small number of territories and are mainly privately funded and are only accessible to few patients. Patients with end-stage heart failure (ESHF) are given few options apart from palliative care or to seek treatment outside of the region. Transplantation remains the 'gold standard' therapy for ESHF. Establishing a Caribbean cardiac transplantation programme would require legislative and infrastructure changes. Tissue rejection poses a problem and expensive immunosuppressants are needed. Mechanical assist devices are costly and associated with complications such as haemorrhage, thrombosis and infections. Both forms of therapy require significant technical and financial investment and do not appear to be economically viable for the Caribbean. The use of the patient's own skeletal muscle to perform biological cardiac assistance is potentially the ideal alternative. The skeletal muscle is conditioned by electrical stimulation to become fatigue resistant. It is then transposed and harnessed as an auxilliary circulatory pump. The required muscle stimulators are relatively inexpensive and the surgical techniques and postoperative care are not overly demanding. We discuss the financial and research implications of treating patients from the Caribbean who have end-stage heart failure.

Transport and centralization of acute coronary syndrome care.

Primary percutaneous coronary intervention (PCI) is the optimal treatment for patients presenting with ST-elevation myocardial infarction (STEMI). But PCI facilities are not widely available, and the majority of patients who receive reperfusion therapy are treated with thrombolytic therapy. However, with significant improvements in the procedural success of PCI, there has been a concomitant reduction in the need for emergency bypass surgery and there is evidence to support primary PCI without on-site cardiac surgical facilities. Others have proposed immediate transfer to a suitable hospital for immediate primary PCI. An alternative treatment strategy is facilitated PCI, which might combine the early benefits of thrombolysis with the higher patency rates and superior clinical outcomes of primary PCI, although this remains unproven. Finally, rescue PCI remains a reasonable treatment option for patients with failed thrombolysis, but there is insufficient evidence to support this option as a preferred treatment strategy for patients with STEMI.

Percutaneous coronary interventions: Without on-site cardiac surgical facilities

Percutaneous coronary interventions: Without on-site cardiac surgical facilities

The effect of hospital vascular operation capability on outcomes of lower extremity arterial bypass graft procedures

Background. The purpose of this study was to determine whether hospitals with a high capability for vascular operations have lower rates of inpatient mortality, major complication, and major amputation with lower extremity arterial bypass (LEAB) procedures than do less well-equipped hospitals after controlling for hospital procedure volume and patient characteristics. Methods. Admissions of 16,422 northern Illinois residents to Illinois hospitals for aortoiliac (AI) or distal bypass operations during 1993 to 1999 were analyzed. Hospitals were considered to have a high capability for vascular operations if they had cardiac surgical facilities and either an accredited blood flow laboratory, general surgical residency, or fellowship training in vascular surgery. Logistic regression was used to model the effect of hospital capability on mortality after controlling for hospital LEAB procedure volume, operation level, severity of illness, age, sex, and emergent admission. Results. Sixteen of 98 Illinois hospitals with 34.4% of the sample patients, including 8 of 18 hospitals with more than 40 admissions for LEAB procedures annually, were classified as having high surgical capability. Hospitals classified as having high versus low capability had lower mortality (2.8% vs 3.7%; P =.003) and amputation rates (4.6% vs 4.9% [not significant]) but higher major complication rates (9.8% vs 8.5%; P =.006). Conclusions. Mortality outcomes for LEAB procedures were superior at high capability hospitals, even after controlling for patient characteristics, disease severity, and LEAB volume. Hospital complication rates were not correlated with mortality rates and may not be a meaningful measure of quality of care. (Surgery 2001;130:561-9.)

Management of acute coronary syndromes in the community hospital without cardiac surgical capability: how can access to interventional therapy be improved?

Early coronary artery intervention is emerging as the treatment of choice for patients with high risk acute coronary syndromes (ACS). However, most patients with ACS are admitted to hospitals which do not have ready access to interventional therapy. Extending the benefits of early intervention to this population is problematic at such community hospitals, since this approach would require either emergency transfer to a tertiary center or the performance of angioplasty on-site at hospitals without cardiac surgical capability. A third solution, pre-hospital ambulance triage to interventional centers, is not currently practised in most countries. A growing body of evidence indicates that hospitals without cardiac surgical capability can establish safe and effective primary angioplasty programs. Patients with acute myocardial infarction (AMI) who are randomized to transfer for primary angioplasty without fibrinolytic treatment have fewer major adverse cardiac events than those treated with fibrinolytics alone or fibrinolytics and transfer. In patients with unstable angina (UA) or non-ST-elevation AMI, an early aggressive approach led to a significant reduction in the composite end-point of death, AMI, or rehospitalization for recurrent UA at 6 months with no increase in cost, compared with conservative management. Ongoing trials in Europe indicate that pre-hospital ambulance triage of patients with large AMI to interventional centers can be remarkably rapid, safe, and effective. In order to improve the access of such patients to early intervention, 3 interdependent solutions are proposed:The development of more interventional programs at those hospitals without cardiac surgical facilities that can meet rigorous standards. The development of protocols to insure the early and more frequent transfer of patients with high-risk ACS to interventional centers for coronary angiography and revascularization. The pre-hospital triage of patients with AMI to established heart attack centers with 24-hour, 365-day emergency interventional capability for immediate primary angioplasty (after the model of trauma centers). Universal triage/transfer of all such patients to interventional centers could, however, quickly flood the capability of all tertiary surgical hospitals. With the aging of the 'baby boomers' in the near future, the need for interventional facilities will increase even further. Thus the second and third solutions above will ultimately depend on the first solution. Improving the delivery of interventional therapy to patients with ACS can provide a substantial healthcare benefit to society.

A new cardiothoracic centre: 'how to do it?'.

All cardiac surgical patients, emergency and routine, from the South West peninsula of England had to travel long distances until 19 months ago, a stressful if not dangerous situation. This paper describes the planning, commissioning and start-up of a brand new cardiac surgical facility. The lessons learnt may help similar projects as provision of specialist health care decentralizes.

Impact of Race and Age on the Effects of Regionalization of Cardiac Procedures in the Department of Veterans Affairs Health Care System

Previous studies have demonstrated that regionalization of resources for cardiac catheterization, percutaneous coronary artery angioplasty (PTCA), and coronary artery bypass graft surgery (CABG) reduces the rate of procedure use. It was hypothesized that the impact of regionalization would be greater for the elderly and for African-Americans than for other populations. Discharge medical records of 30,901 patients admitted to a Veterans Affairs (VA) medical center between October 1, 1993, and September 30, 1994, with a diagnosis of coronary artery disease were analyzed. The presence of a cardiac catheterization laboratory in the patients’ local VA facility significantly increased the likelihood of undergoing catheterization, PTCA, and CABG, as determined by odds ratios and associated confidence limits estimated by logistic regression techniques. The presence of a cardiac surgical facility also significantly increased the likelihood of having the procedures. The odds ratios estimating the effects of resource availability were significantly greater for the subgroup of patients aged ≥70 years than for the younger subgroup for catheterization, PTCA, and CABG and for African-Americans than for white patients for PTCA and CABG. Thus, within the VA health care system, regionalization of cardiac procedures has a significant impact on utilization rates of tertiary cardiac procedures. These differences are significantly greater for the elderly and for African-Americans than for the general population.

Management of acute coronary occlusion during percutaneous transluminal coronary angioplasty: experience of complications in a hospital without on site facilities for cardiac surgery.

To determine whether percutaneous transluminal coronary angioplasty may be safely performed in cardiology centres in the United Kingdom without immediate on site cardiac surgical cover for complications arising at angioplasty. Retrospective review of coronary angioplasties and complications in a hospital without on site cardiac surgical cover. All angioplasties were performed in the catheterisation laboratory of the Belfast City Hospital. Revascularisation surgery for complicated coronary angioplasty was performed in the cardiac surgical unit of the Royal Victoria Hospital, 2.4 km away from the catheterisation laboratory. 540 Coronary angioplasties were performed on 512 patients between late 1982 and November 1988. Indications included stable angina, unstable rest angina, and suitable coronary disease at coronary arteriography after myocardial infarction. In hospital mortality after complicated coronary angioplasty and delay to surgical revascularisation after acute coronary occlusion at angioplasty. Coronary angioplasty was successful in 444 cases (82%). Acute coronary occlusion occurred in 35 cases (6.5%). Twelve patients required urgent revascularisation surgery and were transferred safely to the surgical unit; none of these patients died. A mean delay of 268 minutes (range 180-390 minutes) occurred before revascularisation compared with 273 minutes (range 108-420 minutes) in the Royal Victoria Hospital, where on site surgical cover was available. The principal cause of delay was the wait for a cardiac operating theatre to become available and not the transfer time between hospitals. Five deaths occurred after coronary angioplasty, a mortality of 0.9%. Three deaths were related to acute coronary occlusion. The absence of immediate surgical help did not influence the outcome in any patient. With careful selection of patients coronary angioplasty may be safely performed in a hospital without on site cardiac surgical facilities, provided that these are available at a nearby centre.

Pulmonary embolectomy: A 25 year experience

For the past 25 years an emergency pulmonary embolectomy service has been offered to the hospitals serving a conurbation of 1.5 million. Fifty-five of these procedures have been performed during a short period of normothermic circulatory standstill produced by clamping the superior and inferior venae cavae. Of 36 patients who underwent pulmonary embolectomy without an episode of asystole or ventricular fibrillation, 35 survived the operation (97.2%). However, there were seven deaths during the postoperative period, three related to pulmonary embolism and four to other causes (mortality 20%). Conversely, in a group of 19 patients who had an episode of cardiac arrest, 14 died during or after the operation of pulmonary embolism and two of unrelated causes (mortality 73.7%). In properly selected patients this technique achieves a satisfactory measure of success. It can be used in hospitals that do not have cardiac surgical facilities and, because of its simplicity, it can be performed during the early period after pulmonary embolism when the risk of death is greatest