Two Cardiac Centres Are Better Than One Early Outcomes of the First 75 Open Heart Surgeries At Port of Spain General Hospital Randolph Rawlins M.B.B.S., F.R.C.S.(Ed), FRCS (C/TH), Randolph Rawlins M.B.B.S., F.R.C.S.(Ed), FRCS (C/TH), Ronald Henry M.B.,B.S., FACP, FSCAI, CMTT, The Doctors Inn Research Group.

Background: What is the burden of Cardiovascular Disease in Trinidad ?

POSGH 12.2% (2 nd ) 12.6% (2 nd ) SFGH 14.8% (1 st ) 13.9% (1 st ) S/Grande Hosp 15.8% (1 st ) 15.6% (1 st ) Point Fortin 12.6% (4 th ) 22.3% (1 st ) Tobago 10.6% (4 th ) 12.6 th (2 nd ) Hospital Cardiac Admissions % of Admissions for “Diseases of the circulatory system”, Frequency Rank per hospital Annual CSO Report *EWMSC data not in report - not fully public.

Background: What is the current surgical capacity?

Open Heart surgery was first performed in Trinidad & Tobago in 1993 at EWMSC Open Heart surgery was first performed in Trinidad & Tobago in 1993 at EWMSC Collaboration between local and international specialists. Collaboration between local and international specialists. Approximately 200 MOH cases/yr were performed in a single Government institution in Approximately 200 MOH cases/yr were performed in a single Government institution in 2007.

Background: What is the correct surgical target?

NSF. Cardiac Surgery Cases / Million Population Sixth National Adult Cardiac Surgical Database Report

Sixth National Adult Cardiac Surgical Database Report – 2008 CSO, 2008 NSF. Cardiac Surgery Cases / Million Population

Meeting The Underserved Needs: Need to Increase national capacity Increase Institutional Capacity Increase Number of Institutions Five-fold increase needed

Cardiac Surgery Starts at POSGH !! Port of Spain General Hospital was identified as a second public centre. Port of Spain General Hospital was identified as a second public centre. Has always been a major Teaching Centre Has always been a major Teaching Centre EWMSC is not a dedicated Cardiac Centre EWMSC is not a dedicated Cardiac Centre The first coronary artery bypass operation was performed at POSGH in June 2007.

 Initiation of programme by visiting foreign team  Lead Cardiothoracic Surgeon, T&T National locally-based, UK-trained. locally-based, UK-trained. Fully local anaesthesiology team. Fully local anaesthesiology team.  ICU team at POSGH provides post op care.  Cardiology outsourced from local market.  Initial case scheduling 1 day/mth  Now weekly operating list - 2 cases /wk Programme Development….

 Utilization of existing on-site Trans-Oesophageal Echo (TOE) equipment  Introduction of Cell Salvage technology Reduces transfusion requirement Reduces transfusion requirement  Re- introduction of temporary pacing support Programme Development….

Outcomes - General

Outcomes - Mortality

Predictive Mortality Scoring Systems The EuroSCORE Factor Definition Score

Prevalence of Diabetes in Trinidad

IABP – 11% Use

SCTS – 6 th NACSD Report, Post-Infarct VSD & Mortality Risk Two cases of combined VSD & CABG performed 100% Survival !

Endocarditis & Mortality Risk One case of combined Aortic & Mitral Valve Replacement performed 100% Survival !

UK 1 st 75 Cases Atrial Fibrillation 10-65% 20% (n=15) Haemofiltration/Dialysis3.6% 0% (n=0) Re-Exploration4.9% 2.6% (n=2) Surgical Site Infections % 4% (n=3) Post Operative Complications – 1 st 75 Cases

 4 readmissions post discharge (5.3% Readmission Rate)  2 for medication re-adjustment  1 readmitted to medical ward with a CVA.  1 readmitted with MRSA Empyema  died after admission  Creation of a Dedicated Cardiac Space in ICU  MRSA screening of all patients  No further recurrences of MRSA in last 1 yr Re-Admissions:

Isolated Cardiac Unit at ICU - POSGH

Open heart surgeries at POSGH are being performed at low mortality. Open heart surgeries at POSGH are being performed at low mortality. Low complication rates. Low complication rates. Excellent outcomes Excellent outcomes Secondary institutional benefits- e.g. cell saver, TOE, temporary pacemakers and peer-learning opportunities. Secondary institutional benefits- e.g. cell saver, TOE, temporary pacemakers and peer-learning opportunities.CONCLUSION:

Two Cardiac Centres Are Better Than One It is providing a needed service and should be expanded…

Off pump coronary artery bypass surgery

Angelini et al