Cardiac Surgical Services Research Articles

25th anniversary of the Department of Cardiac Surgery at the University Medical Center Maribor: advancing hearts, changing lives : A quarter century of commitment.

In 1996, Slovenia witnessed aprofound transformation in its cardiac care landscape with the establishment of the Department of Cardiac Surgery at the University Medical Centre Maribor. This momentous milestone heralded the birth of the nation's second heart surgery center revolutionizing cardiovascular care accessibility. Today, the Department of Cardiac Surgery stands as aregional hub, delivering specialized cardiac surgical services to Slovenia's northeastern region and beyond. Its unwavering commitment to excellence, patient-centered care, and adherence to international guidelines reflects its dedication to providing top-tier cardiac care. As the department commemorates its 25thanniversary, this article offers areflective overview of its establishment, development, growth and future trajectory for further development in an ever-changing era of cardiovascular medicine. The article also highlights the department's active involvement in international collaborations, scientific research, medical education, and innovations in minimally invasive cardiac surgery.

Remote Surgical Discussion of Multivessel Coronary Artery Disease Patients without Surgery on Site-Retrospective Insights.

The heart team approach is highly advocated for in treatment decision making in patients with multivessel disease (MVD). Nevertheless, many centers lack on-site cardiac surgical services (CSS)/formal heart team. Our local alternative is of remote surgical consultation without a structured image sharing platform. In our understanding, the incidence of anatomical complete revascularization (ACR) under this daily practice, and its clinical impact, has not been discussed before. We analyzed 477 consecutive patients who were surgically revascularized between January 2009 and March 2018 for MVD, after remote surgical consultation. Unstable, late arrival, and ST elevation patients were excluded (n = 163). ACR was considered grafting all anatomic lesions > 50%. Syntax score (SS) calculation and ACR categorization were determined by an independent interventionalist using diagnostic angiograms and available operative reports (n = 267). Patients' outcomes were assessed in relation to multiple clinical variables including troponin result and the revascularization status. Three hundred and fourteen patients were included. Mean age was 64 years, and mean SS-II was 27.3 ± 11. At the 4-year follow-up, the observed mortality (11.8% and 12.9%, with troponin-positive and -negative groups, respectively), myocardial infarction (11.8%), and repeat revascularization (9.8%) were higher than those predicted using a nomogram depicting the predicted 4-year mortality as a function of the SYNTAX II Score (5.3%, 8.8%, and 3.5%, respectively, p = 0.02). ACR was reported in 33% of 267 available patients' reports. After multivariate adjustment ACR was the only variable associated with a significant increase in 4-year mortality (12.3% vs. 6.7%, p < 0.05). Partial revascularization in the absence of on-site CSS and a structured heart team platform is a frequent occurrence. Not surprisingly, this occurrence was associated with a higher risk for mid-term mortality. An upfront, structured, virtual, heart team interface is mandatory to particularly prioritize the completeness of revascularization when considering the optimal revascularization mode.

Wound management across Australian and New Zealand pediatric cardiac services: a cross-sectional survey.

CHD is associated with considerable burden of care. Up to one-third of babies born with CHD require surgery or intervention during the first year of life with an associated increased risk of surgical site infection. Pediatric wound care is informed largely by adult data, with no national or international guidelines available. To examine pediatric cardiac surgical wound care practices reported by healthcare professionals Australia and New Zealand-wide. A bi-national cross-sectional survey exploring pre-, intra- and post-operative wound practices was distributed using Exponential Non-Discriminative Snowball Sampling. Data were subject to descriptive analysis using SPSS Statistics 22.0. Sixty-eight surveys representing all Australian and New Zealand pediatric cardiac surgical services were analyzed. Most respondents were experienced nurses. Pre-operative care varied greatly in practice and pharmaceutical agents used. Little consistency was reported for intra- and post-operative wound care. Nursing and medical staff shared responsibility for wound care. Wound photography was widely used, but only uploaded to electronic medical records by some. These results highlight that wound care management is largely informed at an institutional level. The many practices reported are likely to reflect a range of factors including cardiac condition complexity, surgery, prematurity, and the presence of scar tissue. The importance of a research and training program, which is multimodal, available, and reflective, is highlighted. These findings call for the establishment of a nurse-led program of research and education. The resultant suite of cardiac wound strategies could offer an effective and consistent pathway forward.

Evaluation of Activated Clotting Times With a Heparin Reversal Protocol Designed to Conserve Protamine During Drug Shortages: A Retrospective, Cohort Study

To retrospectively evaluate a protamine conservation approach to heparin reversal implemented during times of critical shortages. This approach was aimed at maintaining access to cardiac surgical services. In-patient hospital setting. Eight hundred-one cardiac surgical patients>18 years old. Patients undergoing cardiac surgery who received >30,000 U of heparin were given a single fixed vial protamine dose of 250 mg or a standard 1 mg of protamine to 100 U of heparin ratio-based dose to reverse heparin. The primary endpoint was differences in post-reversal activated clotting times between the 2 groups. The secondary endpoint was differences in the number of protamine vials used between the 2 reversal strategies. The first activated clotting times values measured after initial protamine administration were not different between the Low Dose and Conventional Dose groups (122.3 s v 120.6 s, 1.47 s, 99% CI -1.47 to 4.94, p=0.16). The total amount of protamine administered in the Low Dose group was less than that in the Conventional Dose group (-100.5 mg, 99% CI -110.0 to -91.0, p < 0.0001), as were the number of 250 mg vials used per case (-0.69, 99% CI -0.75 to -0.63, p < 0.0001). The mean initial protamine doses between groups were 250 mg and 352 mg, p < 0.0001. The mean protamine vials used were 1.33 v 2.02, p < 0.0001. When the calculations were based on 50 mg vials, the number of vials used per case in the Low Dose group was even less (-2.16, 99% CI -2.36 to -1.97, p < 0.0001).) CONCLUSIONS: Conservation measures regarding critical medications and supplies during times of shortages can maintain access to important services within a community.

Four Decades of Cardiac Surgery in Bangladesh: A Noble Journey That Started with the Help of Japan.

The first-ever open-heart operation in Bangladesh was performed on the 18th of September 1981. Although a few cases of finger fracture closed mitral commissurotomies were performed in the country in the 1960s and 1970s, full-fledged cardiac surgical services began only in Bangladesh after the establishment of the Institute of Cardiovascular Diseases at Dhaka in 1978. A Japanese team that includes cardiac surgeons, anesthetists, cardiologists, nurses, and technician came to Bangladesh and played an important role in the initiation of such a Bangladeshi endeavor. Bangladesh is a South Asian country with more than 170 million people living only in an area of 148460 square kilometers. Information was sought from the hospital records, old newspapers, books, and memoirs written by some of the pioneers. Pubmed and Internet search engines were also utilized. The principal author had personal correspondence with the available pioneering team members. The first open-heart operation was performed by visiting Japanese surgeon Dr. Komei Saji along with Bangladeshi surgeon duo Prof. M Nabi Alam Khan and Prof. S R Khan. Since then, cardiac surgery in Bangladesh has made a significant progress although it may not be enough to serve 170 million people. In 2019, twenty-nine centers performed a total of 12926 cases in Bangladesh. Remarkable advancement in cardiac surgery has been made in terms of cost, quality, and excellence in Bangladesh, but the country is lagging behind in the number of operations, affordability, and geographical distribution, which needs to be addressed for a better future.

Outcomes of Surgical Management for Patent Ductus Arteriosus in Infants in Nigeria.

Patent ductus arteriosus is a common cardiac anomaly in infants that, if untreated, is associated with high morbidity and mortality rates. In lower-middle-income countries, such as Nigeria, obtaining cardiovascular surgical care for infants remains difficult. In recent years, especially with the assistance of international voluntary cardiac organizations, efforts have increased to provide cardiac surgical services to this underserved population. In this case series, the authors describe outcomes in 30 infants surgically treated for patent ductus arteriosus between 2013 and 2019 at an emerging cardiac center in Nigeria (9 male [30%] and 21 female [70%]; mean [SD] age, 8.2 [3.01] months; mean [SD] weight, 5.3 [1.52] kg; mean [range] weight deficit, 34.5% [15%-60%]). All the infants presented with patent ductus arteriosus as the main cardiac lesion, and 4 (13%) were syndromic. The mean (SD) patent ductus arteriosus diameter was 4.73 (1.46) mm. Surgical closure was completed in 29 infants; 1 died before surgery. No procedure-related deaths occurred, but 2 cases of trivial residual patent ductus arteriosus were recorded. Overall, surgical outcomes were excellent, with acceptable mortality rates. Perioperative care will continue to improve as the center is built to a self-sustaining capacity. Findings of this research at this emerging cardiac center in a developing country are a testament to the positive contribution made by international voluntary cardiac missions.

Evaluation of a Multilevel Laboratory Stewardship Intervention Targeted to Cardiac and Thoracic Surgical Services at an Academic Medical Center.

Unnecessary laboratory tests are ordered because of factors such as preselected orders on order sets, clinician habits, and trainee concerns. Excessive use of laboratory testing increases patient discomfort via unnecessary phlebotomy, contributes to iatrogenic anemia, increases risk of bloodstream infections, and increases the cost of care. To address these concerns, we implemented a multilevel laboratory stewardship intervention to decrease unnecessary laboratory testing, measured by laboratory tests per day attributed to service, across 2 surgical divisions with high laboratory use. The multilevel intervention included 5 components: stakeholder engagement, provider education, computerized provider order entry modification, performance feedback, and culture change supported by leadership. The primary outcome of the study was laboratory tests ordered per patient-day. Secondary outcomes included the number of blood draws per patient-day, total lab-associated costs, length of stay, discharge to a nursing facility, 30-day readmissions, and deaths. A difference-in-differences analytic approach assessed the outcome measures in the intervention period, with other surgical services as controls. The primary outcome of laboratory tests per patient-day showed a significant decrease across both thoracic and cardiac surgery services, with between 1.5 and 2 fewer tests ordered per patient-day for both services and an estimated 20 000 fewer tests performed during the intervention period. Blood draws per patient-day were also significantly decreased on the thoracic surgery service but not for cardiac surgery. A multilevel laboratory stewardship intervention targeted to 2 surgical services resulted in a significant decrease in laboratory test use without negatively impacting length of stay, readmissions, or mortality.

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 &amp; 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.&#x0D; Keywords: Congenital heart disease, India, Goa medical college (GMC), Paediatric cardiac surgical care.

Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK.

Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation. Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement. A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.

Improving Access to Pediatric Cardiac Care in the Developing World: the South African Perspective.

Purpose of ReviewThe paper outlines the current status of health care and pediatric cardiac services in South Africa and the challenges faced in providing pediatric cardiac care in the country.Recent FindingsAs infant and child mortality rates in South Africa and most of Sub-Saharan Africa continue to decline, establishing and improving the infrastructure to manage congenital heart disease increases in importance.SummarySouth Africa has well-established pediatric cardiac units in most major centers in the country. These have been able to train sufficient numbers of pediatric cardiologists to double the number in the country in just over a decade as well as train fellows from surrounding countries. A significant proportion of funding for this training comes from non-government sources. The number of pediatric cardiologists is however still far less than required with services spread unevenly throughout the country. Pediatric cardiac surgical services remain severely constrained with an urgent need to train more pediatric cardiac surgeons. Further progress depends not only on focussing resources on cardiac disease but also improvements in the health care systems and socioeconomic conditions in general.

Abstract 29: Evaluating The Feasibility Of A Statewide Collaboration To Improve Cardiac Rehabilitation Participation: The Michigan Cardiac Rehabilitation Consortium

Background: Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this descriptive study was to evaluate the feasibility of the Michigan Cardiac Rehab Consortium to improve CR participation Methods and Results: Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities. Univariate analyses described participating hospital characteristics and hospital-level rates of CR enrollment within 1-year. A total of 95 hospitals and 85 CR facilities with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) provided cardiac surgical services. The overall consortium-wide enrollment rate into CR across all conditions was 19.8% (26,398 of 133,641 eligible admissions), which was highest for CABG (58.4%), followed by SAVR (54.8%), PCI (34.6%), TAVR (33.1%), AMI (12.7%), and CHF (3.4%). There was wide variation in CR participation across participating eligible admissions and hospitals (Figure). A 17-member multidisciplinary stakeholder group was assembled representing 12 institutions and diverse roles, including exercise physiologists, cardiologist, program directors, and patients. Three diverse CR facilities participated in virtual site visits, which revealed individual successes in improving CR participation, but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. Conclusions: This study demonstrated the feasibility of a statewide collaboration centered around the goal of equitably improving CR enrollment for all eligible patients that is supported by a multidisciplinary stakeholder group and performance benchmarking. Future work will seek to continuously improve and evaluate the impact of this consortium on CR participation in Michigan.

Outcomes After Stage I Norwood Palliation in a Recently Established Program Can Achieve Results Similar to Longer Established Services

Infants with hypoplastic left heart syndrome (HLHS) or similar single ventricle cardiac lesions require a three-stage surgical approach, the first step being the Stage I Norwood procedure. The Queensland Children's Hospital (QCH) in Australia is a tertiary hospital providing the only cardiac surgical service to children in Queensland and northern New South Wales. To review the centre's outcomes of Norwood procedures performed in the last 6 years. We retrospectively evaluated all infants undergoing the stage I Norwood procedure between January 2015 and August 2021. Mortality, intensive care length of stay, events of cardiac arrest following surgery and duration of mechanical ventilation were calculated and analysed for subgroups depending on type of pulmonary shunt type (right-ventricle-to-pulmonary-artery shunt [RVPAS] vs the modified Blalock-Taussig shunt [MBTS]). Forty-nine (49) patients were included. Overall survival to stage two operation (Glenn) was 90%. Both shunts were used evenly with the RVPA conduit preferred for HLHS and the MBTS largely chosen for hypoplastic left heart variants. In univariable analysis there was no difference in cardiac arrest or mortality rate for the patient with a RVPAS compared to the patient with a MBTS. We show that a recently established Norwood program can achieve results that are comparable to those reported by longer established centres, and the international literature.

The day after tomorrow: cardiac surgery and coronavirus disease-2019.

The impact of the coronavirus disease-2019 (COVID-19) pandemic forced the governments worldwide to deal with an unprecedented health crisis. The aim of this review is to summarize what happened to cardiac surgery worldwide during the first wave of this pandemic. A literature search was performed to extrapolate key concepts regarding guidelines and reorganization of cardiac surgery wards during COVID-19. Supporting literature was also included to discuss the hot topics related to COVID-19 and cardiac surgery. Hence, both official documents from national scientific societies and single- or multiple-center experiences during the pandemics are reviewed and discussed. In Italy, the first western country hit by the pandemic, two different models were proposed to cope with the need for ICU/ward beds and to reallocate cardiac surgical services: Hub-and-Spoke system ('Hubs', dedicated to perform urgent and nondeferrable surgery, and 'Spokes', turned into COVID centers) and/or a progressive reduction in surgical activity. Worldwide, several guidelines/consensus statements were published, suggesting how to deal with the outbreak. Two different approaches for stratifying surgical indications were proposed: dynamic, based on the number of hospitalized COVID-19 patients; static, based only on the severity of the cardiovascular disease. Moreover, the importance of personal protective equipment was stressed. Several measures should have been adopted to deal with an unprecedented need for healthcare resources allocation to care for COVID-19 patients, putting the healthcare systems under serious stress. Cardiac surgery has, as have most surgical activities, been asked to reduce its own activity, giving priority to emergency and nondeferrable cases.

Subsequent open-cardiac surgery after transcatheter aortic valve implantation-indications and outcomes

Abstract Background Transcatheter aortic valve implantation (TAVI) has been historically done in high-risk patients or patients who are deemed unfit for open-heart surgery. Despite high procedural success rates subsequent open surgery remains an issue, immediately after TAVI implantation or during follow-up as bailout strategy. Purpose Aim of this study was to report on indications and clinical outcomes of patients who underwent open-cardiac surgery following TAVI. Methods Between 01/2011 and 12/2020 our centre performed 3131 TAVI procedures. Twenty-seven patients (including patients in whom TAVI was performed in other centres) underwent subsequent open-heart surgery via cardiopulmonary bypass after previous TAVI. Demographic, intraprocedural data and indications for surgery were evaluated. The VARC-2 criteria were applied to report on clinical outcomes. Results Twenty-seven patients (aged 79 [IQR 76–84]; 59.3% male) were operated on for endocarditis (n=11; 40.7%), 3 patients for annular rupture, severe paravalvular leak and severe stenosis, respectively as well as 1 patient each for severe tricuspidal valve regurgitation, valve thrombosis, malpositioning, valve migration, ostial right coronary artery obstruction, left ventricular rupture and type A aortic dissection. The interval between the index TAVI procedure to open surgery was 3 months (IQR 0–26 months). Eight patients underwent emergency subsequent surgery on the same day immediately after TAVI. The surgical data including the procedures are shown in Figure 1. Four patients died intraoperatively due to uncontrolled bleeding. Immediate procedural and procedural mortality was 25.9% and 40.7%, respectively and all-cause mortality was 51.9% (11/12 died for cardiovascular reasons). Figure 2 shows the Kaplan-Meier estimator for survival. Intraoperative, immediate, procedural and all-cause mortality in patients operated on immediately after TAVI was 25.0%, 25.0%, 37.5%, and 50% respectively. No disabling stroke was observed while a non-disabling stroke occurred in 1 patient. New permanent pacemaker implantation was needed in 3 patients (11.1%). One patient required an additional, second operation to remove a left ventricular thrombus as bailout procedure. One patient suffered from a persisting endocarditis and was discharged on permanent antibiotic intake. Conclusions Subsequent open-heart surgery after TAVI is rare, but may urgently become necessary due to TAVI related complications or progressing other cardiac pathologies. Despite a substantial early attrition rate clinical outcome is acceptable and a relevant number of patients can be discharged after surgery for immediate life-threatening TAVI complications. The option of subsequent surgical conversion remains an indispensable tool in the setting of a modern heart team-based approach. These results substantiate recommendations regarding both, having a cardiac surgical service on site and performing TAVI as an interdisciplinary team. Funding Acknowledgement Type of funding sources: None. Surgical detailsKaplan-Meier estimator for survival

The impact of COVID-19 pandemic on aortic valve surgical service: a single centre experience

BackgroundThe coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve surgery activity at a single two-site centre in the United Kingdom.MethodsData were extracted from the local surgical database, including the demographics, clinical characteristics, and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming operative activity and compared with the respective 2019 period. A similar comparison was conducted with the period between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience of centres world-wide was invoked to assess the efficiency of our services.ResultsThere was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was significantly higher [median Euroscore II was 2.7 [1.9–5.2] in 2020 versus 2.1 [0.9–3.7] in 2019 (p = 0.005)] but neither 30-day survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommencement of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era.ConclusionsOur institution managed to offer a considerable volume of aortic valve surgical activity over the first COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial to monitor.

Non-Governmental Organizations Delivering Global Cardiac Surgical Care: A Quantitative Impact Assessment

In low- and middle-income countries (LMICs), 93% of the population lacks safe, timely, and affordable access to cardiac surgical care when needed. As countries slowly build or expand local, independent cardiac centers, non-governmental organizations (NGOs) partially bridge the gap in cardiac surgical care delivery in LMICs. However, little is known about the current scope of cardiac NGOs. Here, we perform an analysis of active NGOs involved with the delivery of cardiac surgical services in LMICs or for patients from LMICs. Cardiac surgery NGOs were identified from medical literature, established NGO databases, and Google Scholar searches. The search was performed between December 2019 and May 2020. NGOs whose websites were not updated or described missions or projects taking place no later than 2015 were considered inactive. Eighty-six NGOs are actively providing cardiac surgery services in LMICs or treating patients from LMICs. Five NGOs performed adult cardiac surgery only, 56 performed pediatric cardiac surgery only, and 25 performed both adult and pediatric cardiac surgery. NGOs originated from 23 different countries and were operational in a total of 111 countries, 96 of them being LMICs. Fifty-three NGOs reported data on annual surgical volume, of which half performed less than 50 operations per year. NGOs effectively address the burden of cardiac surgical disease in LMICs and contribute to local capacity-building. Increased, more detailed, and standardized reporting of the impact and outcomes of NGOs is necessary to better understand annual cardiac surgical volume and to support local centers working towards independent services.

Exploring the impact of the COVID-19 pandemic on cardiac surgical services: A scoping review.

Cardiac surgery was severely affected by the COVID‐19 pandemic. Reallocation of resources, conversion of surgical intensive care units and wards to COVID‐19 facilities, increased risk of nosocomial transmission to cardiac surgery patients, lead to reduced accessibility, quality, and affordability of health care facilities to cardiac surgery patients. Increasing the mortality and morbidity rate among such patients. Cardiac patients are at an increased risk to develop a severe illness if infected by COVID‐19 and are associated with a high mortality rate. Therefore, measures had to be taken to reduce the spread of the virus. Various approaches such as the hubs and the spokes centers, or parallel system were enforced. Elective surgeries were postponed while urgent surgeries were prioritized. Use of personal protective equipments and surgeries performed by only senior surgeons became necessary. Surgical trainees were also affected as limited training opportunities deprived them of the experience required to complete their fellowship. Some of the trainees were reallocated to COVID‐19 wards, while others invested their time in research opportunities. Online platforms were used for teaching, meetings, and workshops across the globe. Although some efforts have been made to reduce the impact of the pandemic, more research and innovation is required.

Treating pediatric and congenital heart disease abroad? Imperatives for local health system development

Over one million children are born with congenital heart defects each year, whereas four million children live with with rheumatic heart disease. Although a majority of these patients will eventually require surgical or interventional care, most live in areas without access to safe, timely, and affordable cardiac surgical care. Countries with limited or no local cardiac surgical care spend up to over 10% of their health budgets on sending patients abroad to receive cardiac care. Similarly, billions of dollars are spent each year on international medical tourism, notably including seeking cardiac surgical care abroad. Some low- and middle-income countries have successfully invested in domestic cardiac surgical services, saving tens of millions of dollars over time whilst strengthening local health systems. In this article, we describe international medical tourism for pediatric and congenital heart disease, and present an analysis on whether expenditure in seeking foreign care for cardiovascular patients is worth the cost in light of a neglect of investments in local cardiac services in countries with growing health systems.

Health System Needs to Establish Cardiac Surgery Centers.

Cardiovascular diseases are the leading cause of mortality worldwide, responsible for nearly 18 million deaths each year. More than 80% of these take place in low- and middle-income countries (LMICs), where access to cardiac surgical services is scarce. Approximately 93% of the LMIC population, or six billion people worldwide, are estimated to lack access to safe, timely, and affordable cardiac surgical care as a result of workforce, infrastructure, financial, and quality barriers. Various models have been proposed and attempted to establish cardiac surgery centers in LMICs; however, only some have been successful in achieving sustainable local services. Here, we describe the workforce, infrastructure, financial, and political needs and considerations from a health systems perspective to establish a cardiac surgery center.

Sternal wound infections during the COVID-19 pandemic: an unexpected benefit

The novel coronavirus, now termed SARS-CoV-2, has had a significant impact on cardiac surgical services globally. Although drastically reduced, our institution has maintained a significant level of cardiac surgical activity during the pandemic. Rigorous COVID-19 guidelines have been instituted to mitigate the risk of viral transmission. We observed a reduction in sternal wound infections since the institution of new perioperative surgical guidelines. We performed a retrospective analysis of all patients who underwent cardiac surgery at our institution since a national lockdown was declared in March 2020. A retrospective analysis of all patients who underwent cardiac surgery in the 12 months preceding the national lockdown, as a baseline cohort group, was also performed. A total of 2600 patients (493 during the COVID-19 pandemic) were included in this study. Urgent/emergency procedures accounted for more than 60% of procedures performed during the lockdown compared to 39% previously. During the COVID-19 pandemic, there were 4 sternal wound infections with an overall incidence of 0.8%. In comparison, the incidence of sternal wound infections was significantly higher at 3.0% in the 12-month period prior to lockdown with 63 sternal wound infections (p = 0.006). This report suggests a significant role of iatrogenic causes in sternal wound infections prior to the pandemic. The strict implementation of guidelines in the perioperative period suggests that sternal wound infections can be prevented. We propose that the now widespread COVID-19 guidelines to reduce transmission risk be adapted to help reduce the incidence of sternal wound infections.