Towards excellence in cardiac surgery: experience from a developing country.

OBJECTIVE: The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark. DESIGN: Cross-sectional (prospectively collected data analysed and compared retrospectively). SETTING: Aga Khan University Hospital, Karachi, Pakistan. PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons' National Cardiac Database (STS-NCD). RESULTS: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%). CONCLUSIONS: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world.

Factors associated with poor outcomes after congenital heart surgery in low-resource setting in Pakistan: insight from the IQIC Registry - a descriptive analysis.

OBJECTIVE: This study aimed to assess the International Quality Improvement Collaborative single-site data from a developing country to identify trends in outcomes and factors associated with poor outcomes. DESIGN: Retrospective descriptive study. SETTING: The National Institute of Cardiovascular Diseases, Karachi, Pakistan. PARTICIPANTS: Patients undergoing surgery for congenital heart disease (CHD). OUTCOME MEASURE: Key factors were examined, including preoperative, procedural and demographic data, as well as surgical complications and outcomes. We identified risk factors for mortality, bacterial sepsis and 30-day mortality using multivariable logistic regression. RESULTS: A total of 3367 CHD surgical cases were evaluated; of these, 59.4% (2001) were male and 82.8% (2787) were between the ages of 1 and 17 years. Only 0.2% (n=6) were infants (≤30 days) and 2.3% (n=77) were adults (≥18 years). The in-hospital mortality rate was 6.7% (n=224), and 4.4% (n=147) and 0.8% (n=27) had bacterial sepsis and surgical site infections, respectively. The 30-day status was known for 90.8% (n=3058) of the patients, of whom 91.6% (n=2800) were alive. On multivariable analysis, the adjusted OR for in-hospital mortality was 0.40 (0.29-0.56) for teenagers compared with infancy/childhood and 1.95 (1.45-2.61) for patients with oxygen saturation <85%. Compared with Risk Adjustment for Congenital Heart Surgery (RACHS-1) risk category 1, the adjusted OR for in-hospital mortality was 1.78 (1.1-2.87) for RACHS-1 risk category 3 and 2.92 (1.03-8.31) for categories 4-6. The adjusted OR for 30-day mortality was 0.40 (0.30-0.55) for teenagers and 1.52 (1.16-1.98) for patients with oxygen saturation <85%. The 30-day mortality rate was significantly higher in RACHS-1 risk category 3 compared with category 1, with an adjusted OR of 1.64 (1.06-2.55). CONCLUSIONS: We observed a high prevalence of postoperative infections and mortality, especially for high-risk procedures, according to RACHS-1 risk category, in infancy/childhood, in children with genetic syndrome or those with low oxygen saturation (<85%).

COVID-19 international experience in paediatric patients with congenital heart disease.

OBJECTIVE: As COVID-19 continues to affect the global population, it is crucial to study the impact of the disease in vulnerable populations. This study of a diverse, international cohort aims to provide timely, experiential data on the course of disease in paediatric patients with congenital heart disease (CHD). METHODS: Data were collected by capitalising on two pre-existing CHD registries, the International Quality Improvement Collaborative for Congenital Heart Disease: Improving Care in Low- and Middle-Income Countries and the Congenital Cardiac Catheterization Project on Outcomes. 35 participating sites reported data for all patients under 18 years of age with diagnosed CHD and known COVID-19 illness during 2020 identified at their institution. Patients were classified as low, moderate or high risk for moderate or severe COVID-19 illness based on patient anatomy, physiology and genetic syndrome using current published guidelines. Association of risk factors with hospitalisation and intensive care unit (ICU) level care were assessed. RESULTS: The study included 339 COVID-19 cases in paediatric patients with CHD from 35 sites worldwide. Of these cases, 84 patients (25%) required hospitalisation, and 40 (12%) required ICU care. Age <1 year, recent cardiac intervention, anatomical complexity, clinical cardiac status and overall risk were all significantly associated with need for hospitalisation and ICU admission. A multivariable model for ICU admission including clinical cardiac status and recent cardiac intervention produced a c-statistic of 0.86. CONCLUSIONS: These observational data suggest risk factors for hospitalisation related to COVID-19 in paediatric CHD include age, lower functional cardiac status and recent cardiac interventions. There is a need for further data to identify factors relevant to the care of patients with CHD who contract COVID-19 illness.

Knowledge, attitude and practice of wearing mask in the population presenting to tertiary hospitals in a developing country.

BACKGROUND: In the era of COVID-19 where there is emphasis on the importance of wearing a mask, wearing it rightly is equally important. Therefore, the purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population of a developing country at three major tertiary care hospital. MATERIALS AND METHODS: Participants of this cross-sectional study were patients and attendants at three major tertiary care hospital of Karachi Pakistan. Selected participants, through non-probability convenient sampling technique, were interviewed regarding knowledge, attitude, and practice of wearing mask using an Urdu translated version of a questionnaire used in an earlier study. Three summary scores (0 to 100) were computed to indicate participants' mask wearing practice, technique of putting it on, and technique of taking if off. Collected data were analyzed with the help of IBM SPSS version 19. RESULTS: A total of 370 selected individuals were interviewed, out of which 51.9% were male and mean age was 37.65±11.94 years. For more than 90% of the participants, wearing a face mask was a routine practicing during the pandemic. The mean practice score was 65.69±25.51, score for technique of putting on a face mask was 67.77±23.03, and score of technique of taking off a face mask was 51.01±29.23. Education level of participant tends to have positive relationship with all three scores, while presence of asthma or chronic obstructive pulmonary disease (COPD) as co-morbid had negative impact on mask wearing practice. CONCLUSION: We have observed suboptimal knowledge, attitude and practice of wearing mask among the selected individuals. There is a continued need to spread awareness and educate general population about the importance of using a face mask, as well as the proper technique of wearing and taking off a face mask.

Clinical profile and outcome of recurrent infective endocarditis.

AIMS: Purpose of this study is to compare the clinical course and outcome of patients with recurrent versus first-episode infective endocarditis (IE). METHODS: Patients with recurrent and first-episode IE enrolled in the EUROpean ENDOcarditis (EURO-ENDO) registry including 156 centres were identified and compared using propensity score matching. Recurrent IE was classified as relapse when IE occurred ≤6 months after a previous episode or reinfection when IE occurred >6 months after the prior episode. RESULTS: 3106 patients were enrolled: 2839 (91.4%) patients with first-episode IE (mean age 59.4 (±18.1); 68.3% male) and 267 (8.6%) patients with recurrent IE (mean age 58.1 (±17.7); 74.9% male). Among patients with recurrent IE, 13.2% were intravenous drug users (IVDUs), 66.4% had a repaired or replaced valve with the tricuspid valve being more frequently involved compared with patients with first-episode IE (20.3% vs 14.1%; p=0.012). In patients with a first episode of IE, the aortic valve was more frequently involved (45.6% vs 39.5%; p=0.061). Recurrent relapse and reinfection were 20.6% and 79.4%, respectively. Staphylococcus aureus was the microorganism most frequently observed in both groups (p=0.207). There were no differences in in-hospital and post-hospitalisation mortality between recurrent and first-episode IE. In patients with recurrent IE, in-hospital mortality was higher in IVDU patients. Independent predictors of poorer in-hospital and 1-year outcome, including the occurrence of cardiogenic and septic shock, valvular disease severity and failure to undertake surgery when indicated, were similar for recurrent and first-episode IE. CONCLUSIONS: In-hospital and 1-year mortality was similar in patients with recurrent and first-episode IE who shared similar predictors of poor outcome.

Socioeconomic variations determine the clinical presentation, aetiology, and outcome of infective endocarditis: a prospective cohort study from the ESC-EORP EURO-ENDO (European Infective Endocarditis) registry.

AIMS: Infective endocarditis (IE) is a life-threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socioeconomic factors might influence its epidemiology, clinical presentation, investigation and management, and outcome, in a large international multicentre registry. METHODS AND RESULTS: The EurObservational Programme (EORP) of the European Society of Cardiology EURO-ENDO (European Infective Endocarditis) registry comprises a prospective cohort of 3113 adult patients admitted for IE in 156 hospitals in 40 countries between January 2016 and March 2018. Patients were separated in three groups, according to World Bank economic stratification [group 1: high income (75.6%); group 2: upper-middle income (15.4%); group 3: lower-middle income (9.1%)]. Group 3 patients were younger [median age (interquartile range, IQR): group 1, 66 (53-75) years; group 2, 57 (41-68) years; group 3, 33 (26-43) years; P < 0.001] with a higher frequency of smokers, intravenous drug use, and human immunodeficiency virus infection (all P < 0.001) and presented later [median (IQR) days since symptom onset: group 1, 12 (3-35); group 2, 19 (6-54); group 3, 31 (12-62); P < 0.001] with a higher likelihood of developing congestive heart failure (13.6%, 11.1%, and 22.6%, respectively; P < 0.001) and persistent fever (9.8%, 14.2%, and 27.9%, respectively; P < 0.001). Among 2157 (69.3%) patients with theoretical indication for cardiac surgery, surgery was performed less frequently in group 3 patients (75.5%, 76.8%, and 51.3%, respectively; P < 0.001), who also demonstrated the highest mortality (15.0%, 23.0%, and 23.7%, respectively; P < 0.001). CONCLUSION: Socioeconomic factors influence the clinical profile of patients presenting with IE across the world. Despite younger age, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and lower use of surgery.

Psychosocial Impact of COVID-19 on Healthcare Workers at a Tertiary Care Cardiac Center of Karachi Pakistan.

OBJECTIVES: Aim of this study was to determine the depression, stress, and anxiety level among healthcare workers working at a tertiary care cardiac center of Karachi Pakistan during COVID-19 pandemic. METHODS: This survey was conducted at the National Institute of Cardiovascular Disease (NICVD), Karachi, Pakistan. Participants of the study were fulltime employees of hospital. Data were collected using an online questionnaire and Depression, Anxiety and Stress - 21 (DASS-21) scale was used. RESULTS: A total of 224 healthcare workers were included, 46 (20.5%) participants were screened for moderate to severe depression, 20.1% (45) for moderate to severe anxiety, and 14.7% (33) for moderate to severe stress. CONCLUSION: A significant levels of depression, anxiety, and stress were noted with the major concerns of workplace exposure, increased risk of infection, and transmission to their families and friends.

Prevalence of Cardiac Risk Factors and Attitude toward Self-Risk Assessment among Cardiac Care Givers.

OBJECTIVE: Aim of this survey was to assess the prevalence of cardiovascular diseases (CVD) risk factors and attitude toward self-risk assessment among cardiac care physicians (who did not have CVD history), at a tertiary care cardiac center in Pakistan. DESIGN: In this survey we included cardiac care givers who had a minimum of 1 year of working experience in a cardiac care center. PARTICIPANTS: Participants with self-reported history of established diagnosis of CVD were excluded. Face-to-face interviews were conducted with the help of a structured questionnaire which consisted of demographic information, data regarding established CVD risk factors, self-awareness, and attitude toward CVD risk assessment. RESULTS: A total of 126 participants were interviewed, out of which 20.6% (26) were females and mean age was 36.1±7.6 years. The most prevalent CVD risk factor was family history of CVD (33.3%) followed by smoking (14.3%) and 23.8% had body mass index of ≥27.5 kg/m2. Around 23% of the participants did not know their cholesterol levels, similarly more than 74% were not aware of their high-density lipoproteins levels. More than 76% had never assessed their CVD risk and more than 37% don't know or don't have any opinion about their own CVD risk. CONCLUSIONS: The present study reveals low prevalence of conventional cardiac risk factors and marginally higher tendency of modifiable risk factors, such as smoking and obesity, among the cardiac physicians. A large proportion of these cardiac physicians have not yet assessed their CVD risk.

Performance of the TIMI risk score in predicting mortality after primary percutaneous coronary intervention in elderly women: Results from a developing country.

BACKGROUND: Despite women undergoing primary percutaneous coronary intervention (PPCI) having a higher rate of adverse outcomes than men, data evaluating prognostic risk scores, especially in elderly women, remains scarce. This study was conducted to validate the predictive value of Thrombolysis in Myocardial Infarction (TIMI) risk score in elderly female patients. MATERIALS AND METHODS: This was a retrospective analysis of elderly (>65 years) female patients who underwent PPCI for ST-elevated myocardial infarction (STEMI) from October 2016 to September 2018. Patients' demographic details and elements of TIMI risk score including age, co-morbidities, Killip classification; weight, anterior MI and total ischemic time were extracted from hospital records. The primary outcome was in-hospital mortality and post-discharge mortality reported on telephonic follow-up. RESULTS: A total of 404 elderly women with a median age of 70 years were included. The mean TIMI score was 5.25±1.45 with 40.3% (163) patients of TIMI score > 5. In-hospital mortality rate was 6.4% (26) and was found to be associated with TIMI score (p<0.001). The in-hospital mortality rate increased from 3.1% at TIMI score of 0-4 to 34.6% at the score of 8. On follow-up (16.43±7.40 months) of 211 (55.8%) patients, the overall mortality rate was 20.3%, and this was also associated with TIMI score (p<0.001). The mortality rate increased from 5.6% at the score of 0-4 to 54.5% at the score of 8. The predictive values (area under the curve) of TIMI risk score for in-hospital and post-discharge mortality were 0.709 (95% CI 0.591-0.827; p <0.001) and 0.689 (95% CI 0.608-0.770; p <0.001), respectively. CONCLUSION: Increased adverse outcomes were observed with higher TIMI risk score for in hospital and post-discharge follow-up. Therefore, the prognostic TIMI risk score is a robust tool in predicting both in-hospital as well as post-discharge mortality in elderly females.

The ESC-EORP EURO-ENDO (European Infective Endocarditis) registry.

AIMS: The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) European Endocarditis (EURO-ENDO) registry aims to study the care and outcomes of patients diagnosed with infective endocarditis (IE) and compare findings with recommendations from the 2015 ESC Clinical Practice Guidelines for the management of IE and data from the 2001 Euro Heart Survey. METHODS AND RESULTS: Patients (n = 3116) aged over 18 years with a diagnosis of IE based on the ESC 2015 IE diagnostic criteria were prospectively identified between 1 January 2016 and 31 March 2018. Individual patient data were collected across 156 centres and 40 countries. The primary endpoint is all-cause mortality in hospital and at 1 year. Secondary endpoints are 1-year morbidity (all-cause hospitalization, any cardiac surgery, and IE relapse), the clinical, epidemiological, microbiological, and therapeutic characteristics of patients, the number and timing of non-invasive imaging techniques, and adherence to recommendations as stated in the 2015 ESC Clinical Practice Guidelines for the management of IE. CONCLUSION: EURO-ENDO is an international registry of care and outcomes of patients hospitalized with IE which will provide insights into the contemporary profile and management of patients with this challenging disease.

Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan.

BACKGROUND: Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease. METHODS: Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed. RESULTS: Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (≥2 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively. CONCLUSION: Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.

Body mass index--predictor of outcome after coronary artery bypass grafting.

OBJECTIVE: Increased body mass index has been associated with increased postoperative morbidity. We studied the effect of body mass index in our population, using a modified scale suggested by the World Health Organization. METHODS: From January 2006 to December 2008, 1019 patients undergoing first-time isolated elective coronary artery bypass grafting were selected from our cardiac surgery database. Data were analyzed by univariate and multivariate analyses. RESULTS: Of the 1019 elective coronary artery bypass patients, 168 (15.8%) had a normal body mass index (18.5-22.9 kg·m(-2)) and 894 (84.2%) had a high body mass index (≥23.0 kg·m(-2)). There were 921 (86.7%) patients with 3-vessel disease, and 1012 (95.3%) had internal mammary artery grafts. The 30-day mortality was 0.8%. Multivariate analysis revealed age, hospital stay, perfusion time, and renal failure were significantly associated with hospital complications. High body mass index was not significantly associated with morbidity or mortality. The model had an adequate fit at p = 0.708 by the Hosmer and Lemeshow test. CONCLUSION: Increased body mass index alone is not a predictor of increased mortality and morbidity. In fact, these outcomes were associated with advanced age, hospital stay, perfusion time, and renal failure.

Trends in coronary artery bypass surgery: impact on early outcomes.

BACKGROUND: improvements in nonsurgical revascularization have left a group of higher-risk patients presenting for operation in a later stage of coronary artery disease. We undertook this study to analyze temporal changes in demographic and clinical profiles and outcomes of cardiac surgical patients. METHODS: we identified and retrieved preoperative, intraoperative, and postoperative variables for 3064 consecutive patients who underwent myocardial revascularization at the Aga Khan University Hospital between 2006 and 2011. Mortality and morbidity outcomes were compared using univariate and multivariate analyses. RESULTS: mean age, prevalence of left ventricular systolic dysfunction, unstable angina, mean number of occluded vessels, and arrhythmias at presentation increased steadily over time. The prevalence of diabetes, chronic lung disease, peripheral vascular disease, prior stroke, prior myocardial infarction, and left main disease declined. Operative mortality did not change significantly (3.5% vs. 3.8%, p = 0.512). Determinants of operative mortality included older age, female sex, renal insufficiency, left ventricular systolic dysfunction, and longer bypass and crossclamp times. CONCLUSION: coronary operations are increasingly performed in higher-risk patients with greater comorbidities. Despite this, operative mortality has not increased.

Coronary artery bypass grafting after percutaneous coronary intervention.

Following percutaneous intervention (PCI), restenosis, progression of disease and multi-vessel involvement may require further intervention in the form of surgical revascularization. Patients with coronary artery bypass grafting (CABG) done after PCI were evaluated to find out the reason for the need of surgical revascularization. Over a period of 12 months, 610 patients underwent CABG. Out of them, 34 patients had previous PCI/stenting. Coronary risk factors including hypertension in 85%, diabetes mellitus in 60%, dyslipidemia in 60%, tobacco use in 50% and a positive family history was present in 53% of the patients. All patients were symptomatic. Multi-vessel disease was present in 67% and single vessel in 4.7%. The extent of disease and stenosis of stents were responsible for reintervention. Careful selection of patients is required in presence of multiple risk factors for coronary artery disease to provide maximum benefit by either PCI or CABG.

Risk stratification analysis of operative mortality in isolated coronary artery bypass graft patients in Pakistan: comparison between additive and logistic EuroSCORE models.

We compared the performances of the additive and logistic EuroSCORE in predicting mortality in patients undergoing isolated coronary artery bypass grafting at a single institution in Pakistan. Both models were applied to 2004 patients, operated upon at the Aga Khan University Hospital from January 2006 to July 2010. The actual mortality (3.8%) was significantly different from the additive (4.35%) and the logistic (6.41%) estimates. On the basis of degree of risk, actual mortality was 0.6% in the low-risk (additive EuroSCORE 0-4), 4.2% in the medium-risk (EuroSCORE 5-9) and 19.1% in the high-risk (EuroSCORE 10-19) group. With the low risks, both systems slightly overestimated mortality, with the logistic EuroSCORE being more accurate. At a EuroSCORE of between 10 and 19, the additive EuroSCORE underestimated and logistic EuroSCORE overestimated mortality. Both models satisfactorily discriminated outcomes (receiver operating characteristics areas of 0.866 and 0.859 for the additive and the logistic model, respectively). The Hosmer-Lemeshow test showed that calibration was good for the additive model (P=0.424) but turned out to be inadequate for the logistic model (P<0.001). We conclude that the additive EuroSCORE is a more accurate model for risk assessment compared to the logistics model in the Pakistani population.