100% survival: a cardiac surgery centre experience inTrinidad and Tobago

OBJECTIVE: To report the 2012 results of a cardiac surgerycentre in Trinidad and Tobago. METHODS: Data was reviewed on 245 consecutive patients who underwent cardiac surgery in 2012 at Eric Williams MedicalScience Complex (E.W.M.S.C) Mount Hope, Trinidad. RESULTS: Mean patient age was 58.5 ±9.5 years; 147 patients(60%) were male and the mean calculated EUROSCORE IIwas 1.7. Coronary artery bypass surgery was the most commonprocedure, performed on 190 patients, 98% were done on the beating heart and 3.15% (6 patients) were redo-CABG. Thirteen patients (5.3%) underwent CABG plus other procedures, 9patients (3.7%) had aortic valve replacement, 21 patients (8.6%)had mitral valve repair/replacement, 2 patients (0.8%) had double valve replacement and 10 patients (4.1%) a variety ofother procedures including atrial or ventricular septal defect closure, fibro-elastoma removal, type A Aortic dissection.The operative mortality in the study period was 0%, and at 6months follow-up all patients were alive. CONCLUSION: Excellent results similar to the best institutions in the world can be obtained even in a medium volume centre in a developing country.

Outcome of elderly patients undergoing open-heart surgery in a developing country

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8 per cent. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31 per cent) patients were above the age of 65 years. The mortality rate was 2.2 per cent for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6 per cent). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Severe neurological complications of post open heart surgery: the Jamaican experience; January, 1994 - August, 1999

Neurological complications after open-heart surgery (OHS) constitute a broad spectrum of injury, and represents the leading cause of morbidity and mortality. The most serious injury is seen in those who remain comatose or never regain meaningful neurologic function. Stroke is another devastating complication that can leave the patient permanently disabled. The incidence of stroke has been documented as ranging from 0.8 - 5.2 percent. Much less information is available on the incidence of the less fatal complications such as delirium, confusion, encephalopathy, developmental delay or other neuropsychiatric disorders. During the period January, 1994 to August, 1999, a total of 360 paitents (adults and children) underwent OHS, at the University Hospital of the West Indies (UHWI), Mona, Jamaica. The types of surgeries performed were: ASD = 53; VSD = 40; valve replacement = 151 (100 MVR, 34 AVR, 17 DVR); valvuloplasty/annuloplasty = 5; CABG = 44; repair of congenital heart abnormalities = 65; other (atrial myxoma) = 2. About eight (8) patients (2.2 percent) developed severe neurological symptoms post-operatively. These ranged from short period (<24 hours) of seizure activities to severe encephalopathy and death, secondary to massive cerebral infarction. Four (4) of these patients died as a result of the neurologic complication. There is no need for avoidance and/or elimination of the factors that increase the risk of post-operative neurologic complications. Unfortunately not all of these can be eliminated. There is also the need for detailed, structured neurological and neuropsychiatric assessments, both pre- and post-operatively. These will enable the early detection of gross, but more importantly the subtle changes and hence prompt institution of counteractive/corrective measure. Detection of markers which will indicate the possible development of severe neurologic injury would also be useful.(AU)

Open-heart surgery in a developing country - Jamaica - abstract

Open-heart surgery, using the Heart Lung machine, was first performed on May 6, 1953. Fifteen years later, the first open-heart surgery operation was performed at the University of the West Indies. Since then, just under 700 cases have been done. There has been a varying number of cases performed each year, ranging from 53 cases in the best year to one in the worst year. Despite the long tradition, we still continue to get the sort of publicity in daily newspaper articles: "Young beautician needs heart surgery" which appeared during the week of June 14-10, 1993 and the most recent article "Open-heart surgery here soon" appearing in the Gleaner Publication of Sunday, July 11, 1993. Open-heart surgery, in a developing country such as Jamaica, is handicapped by late disease, inadequate investigation, lack of equipment and personnel shortage. At present, valve surgery is the main operation performed on the basis of clinical and echocardiographic findings. Congenital conditions are done, such as atrial septal defects and ventricular septal defects in older children. With the refurbishing of the catheterization laboratory to be completed shortly, the number of cases awaiting surgery will increase. We will be faced with a large patient population requiring surgery, with inadequate resources to meet the demand. Jamaica, like all developing countries, is faced with the dilemna of providing expensive but necessary surgery for its population (AU)

The Caribbean and New York: the heart connection - abstract

An association between North Shore University Hospital, New York and the Caribbean region started in 1982, whereby Caribbean children needing cardiac surgery were operated on at North Shore at no, or nominal, cost to the patient. During the last 6 years, 239 patients were referred for cardiac surgery 107 from Trinidad, 69 from Barbados, 19 from Jamaica, 18 from Saint Vincent, 17 from Saint Lucia, 4 from Dominica, 2 from Antigua and one each from Anguilla, Grenada and Nevis. Fifty of the patients were catheterised in Barbados between 1982 and 1985, and 55 were catheterised at Brookdale Hospital, New York, in 1986 - 1987. The other patients were catheterise at North Shore. Two hundred and sixteen (216) patients have had surgery - 180 open and 36 closed heart. Four had pacemaker implantations, 3 balloon valvuloplasties and 2 balloon atrial septostomies. There were 7 operative deaths (3.2 percent mortality) and 4 late deaths. An analysis of the programme points overwhelmingly to its high degree of success. Over the last 2 years, the programme has expanded to include 4 other major hospitals in New York. The programme is critically dependent on a system of co-operation and co-ordination between the referring and accepting physicians. Well-developed links have also been developed wihtin the wider New York based West Indian community. These links provide crucial logistic support to both patients and their families, thus increasing the economic viability of the programme while decreasing the trauma associated with the physical dislocation of extra-regional surgery. While the success of the programme is noted, it should in no way detract from the need to accelerate plans aimed at the development of an active open-heart surgical programme in the region (AU)

Methodology and cost of cardiopulmonary by-pass for open-heart surgery at the University Hospital of the West Indies: review of a 14-year experience (1968-1982)

A 14-year microcomputer-assisted review of cardiopulmonary by-pass at the University Hospital of the West Indies is presented. A total of 436 cardiopulmonary by-pass operations was used for open-heart surgery in 417 patients. The results indicate that the by-pass methodology used was relatively uneventful and easy to manage. The costs of cardiopulmonary by-pass have been low. This procedure which is a necessary adjunct for open-heart surgery at the University Hospital is relatively cheap and safe and its methodology presents no problems in management (AU)

Pregnancy after open-heart surgery

Thirty-eight pregnancies in 27 patients who had previous open heart surgery resulted in 32 healthy babies, 4 spontaneous abortions and 2 elective abortions. Seven forceps deliveries and 5 Caesarean sections were performed. Detailed information was available for 22 infants all of whom were healthy and were born at term without evidence of haemorrhagic or teratogenic complications (no anticoagulant therapy was used in the mothers). The gratifying outcome of the majority of these pregnancies suggests that a more liberal policy in allowing pregnancy in patients who have had successful open heart surgery shoud be pursued (AU)

Pericardial constriction after open-heart surgery

A case of pericardial constriction developing after open-heart surgery is described. As far as we are aware, this is the first such case to be reported in the West Indian medical literature. Possible aetiological influences are discussed, important differences from the clinical features of idiopathic constrictive pericarditis are stressed, and the great importance of considering this diagnosis in any post-operative cardiac surgical patient who develops apparent heart failure is emphasized (AU)

The peri-operative management of the patient scheduled for open heart surgery

The perioperative management of 286 patients scheduled for open heart surgery has been described. Mortality associated with anaesthesia (0.4 percent), patient monitoring and measurement (0.4 percent) and cardio-pulmonary bypass (1.4 percent) has been low. Morbidity produced by these techniques has been reversed with supportive therapy. It is concluded that the techniques of anaesthesia, patient monitoring and measurement, and cardiopulmonary by-pass as reported herein are acceptable and safe for the patient undergoing open heart surgery. Operative mortality in the majority (114 patients) age group of 10-20 years has been relatively low (18 percent). However, cardiac failure is dominant as a major cause of early (operative) and late mortality. It is the authors' opinion that technical problems of intracardiac repair and cardio-pulmonary bypass in patients below 5 years, and errors in deciding operability have largely contributed to refractory cardiac failure. It is hoped that more critical selection of patients for operation and greater experience in operative techniques, would result in a decrease in operative deaths (AU)

The possible relationship between cardiac glycogen levels, ouabain toxicity and the anti-arrhythmic effect of anacardium occidentale

Using the open chest dog with the heart in situ, the influences upon the cardiac glycogen by fasting, anacardium occidentale, and ouabain were studied. Fasting elevated the cardiac glycogen while intravenous infusion of glucose did not increase the cardiac glycogen. Anacardium occidentale elevated the cardiac glycogen after a slow intravenous infusion. The depletion of cardiac glycogen occurred concurrently with the onset of ectopic beats due to ouabain toxicity, and the toxic dose of ouabain was significantly increased in relation to the high cardiac glycogen. The stress of cardiac surgery significantly depleted the glycogen content of the human heart, and this depletion was not related to trauma or the time the patient was on cardio-pulmonary by-pass. It is concluded that: (a) anacardium occidentale protects against ouabain arrhythmias by elevating the cardiac glycogen, (b) there is a critical cardiac glycogen level below which ouabain readily becomes toxic, and (c) surgery on the heart in the human depletes its glycogen stores (AU)

Cardiothoracic surgical problems in Jamaica - abstract

Statistics of the incidence of cardiothoracic surgical problems in Jamaica are incomplete. An attempt is made to compile currently available data. The potential sources of data are the records of the University Hospital, Kingston Public Hospital, George V Sanatorium, the Registrar General's office and private practitioners. Some published data also exist. Most of the records are incomplete and the information is not available in a way which would highlight the major cardiothoracic surgical problems of Jamaica. Because of this, the author, as the person most engaged to any significant degree in the practice of cardiothoracic surgery in Jamaica, reports in this preliminary communication on his own experience at the University Hospital during the past two years. Thirty-seven major chest injuries were seen and 18 of these required admission to the Intensive Care Unit. Only a small percentage of all chest trauma comes under the author's care. One hundred and twenty diagnostic bronchoscopies were performed. For bronchogenic carcinoma only 6 lung resections were performed from a total of 52 cases. The incidence of this disease in Jamaica rose from 7.2 to 12.8 per 100,000 moles during the two 5-year periods ending in 1969 and it now rivals carcinoma of the oesophagus for a second place as a cause of death from malignant disease in the male. In the case of bronchiectasis, 8 lung resections were done frome amongst 17 cases seen by the author and proved by bronchography. In cardiac surgery, 24 closed and 24 open open-heart operations were performed. In the closed group, 13 patent ductuses were treated by division and suture, there were 2 shunt operations for Tetralogy at Fallot, 2 coarctations were relieved and 7 commissurotomies performed for rheumatic mitral stenosis. In the open-heart group requiring cardiopulmonary bypass, the following congenital cases were corrected without mortality: 4 V.S.D., 6 Tetralogy of Fallot, 3 pulmonary valve stenosis, 1 infundibular stenosis, 2 ostium secundum, 1 ostium primum primum, and 1 double outflow right ventricle. Only a small percentage of the potentially curable congenital cases have had the benefit of surgery. It is estimated that at least 150 of the 400 new cases born annually with congenital heart disease can be cured by surgery. For rheumatic heart disease, the following operations were performed: 3 mitral valve replacements, 1 aortic valve replacement, 1 aortic and mitral valve replacement and 1 mitral valveannulaplasty. Rheumatic heart disease is not uncommon and was present in 7.3 percent of 738 disease hearts examined at autopsy in adults over 17 years of age at U.H.W.I. In a miscellaneous group requiring major surgery, the following opertions were performed; 3 thymectomies for myasthenia gravis, 3 lung resections, 5 decortications, 9 mediastinal tumours were removed, 2 oesophagectomies, 4 colon bypass operations for oesophageal obstruction, and 11 operations on major vessels. In a miscellaneous number of surgical investigations, the following procedures were performed; 9 scalene node clearances, 7 anterior mediastinoscopies, 11 thorascopies and 33 oesophagoscopies. Carcinoma of the oesophagus is regarded as a general surgical problem. Recent rapid strides in the surgery of coronary artery disease suggest that this common condition, which is present in 14.2 percent of adult diseased hearts, will be a major surgical service problem. Only a small percentage of the vast number of cases are seen at the University Hospital. The precise incidence of the various cardiothoracic surgical conditions require urgent investigation (AU)

Thoracic surgical trauma - abstract

The subject of this paper is based on the experiences during a five-year period of treating patients with respiratory distress in a general surgical unit in San Fernando, Trinidad. These patients required to have surgical intervention by one form or other. They were cases of thoracic surgical trauma. Of 120 cases of thoracic surgical trauma, 35 cases required some form of intervention. There were five cases of stove-in chest, two (2) cases of haemopericardium, five (5) cases of haemothorax and nineteen (19) cases of pneumothorax. Most of these were associated with blunt trauma, whilst the rest were associated with pellets, bullets or stabbing weapons. In the cases of pulmonary and/or pleural abnormalities, it is the resulting derangement of physiology which cause severe and urgent symptoms. These are mainly due to collapse of lung, shift of mediastinum, decrease in circulation of oxygenated blood. In the addition, there may be injury and fracture of the bony thoracic cage, which will aggravate such symptoms. When such bony injury occurs in two (2) places and over a large extent of the chest wall, stove in chest ensues. In cases of haemopericardium, the classical symptoms of cardiac tamponade ensue. These include rising venous pressure, falling arterial pressure and a quit heart. The diagnosis of the exact abnormality is most important and urgent as a satisfactory outcome depends on accurate diagnosis and treatment. Considerable use is made of X-rays and good X-rays are most important. As accurate as these may be, however, great reliance is placed upon the results of aspirating the pleural and/or pericardial cavities. The resulting aspirate with the interpretations of X-rays form the basis of accurate diagnosis. The use of indwelling intercostal catheter and open surgery for the primary condition or for its complication are used. Tracheostomy and internal fixation of the bony chest wall with various forms of tractions are utilized for the case of stove-in chest(AU)