First/Second Level Master in Innovation in Cardiac Surgery: Advances in Minimally Invasive Therapeutics
2019/20
Project Work/Dissertation Title
Current Status and Future
Prospects for Minimally invasive
Cardiac Surgery in Pakistan
Author
Dr. Attaullah Khan Niazi Scientific Tutor
Prof .Claudio Passino
Current Status & future
Prospects for Minimally
invasive cardiac surgery in
Pakistan
Attaullah Khan Niazi MD MS ,
Pakistan
Introduction :
Living in developing country trying to treat structural heart disease in an endemic area for rheumatic fever is an ever growing challenge , Pakistan is located in South Asia which support at least one quarter of world population and suffered from under nourishment or malnutrition in al most half of its population .
Average age of Pakistani population from its inception in 1947 has almost doubled in the last 70 years but remains significantly behind the developed western world. Main bulk of valvular heart disease still arises from rheumatic heart disease and that to in younger population below 40 years of age and tremendously affect the major work force in the country . The country health system relies on subsidising major teaching hospitals or tertiary care centres, without any comprehensive insurance coverage , so that most patients have to pay for their treatment out of their own pocket . Many large cardiac centres cover bigger volumes of cardiac surgical work load. But at a higher wound infection rate sternal dehiscence and extravagant antibiotic use , Minimal
invasive cardiac surgery brings a major ray of hope for swift recovery , reduced cost , early return to work for the young and pivotal bread earner of the families of the cardiac patients .
Rheumatic heart disease in Pakistan :
Pakistan , like most other developing countries, is today experiencing an increasing incidence of noncommunicable diseases and the unsolved problem of infectious diseases.
In Pakistan Rheumatic heart disease is a common presentation, but only a few patients are recommended for timely surgery, as most of the patients are reluctant to surgery because of expense, lack of education and inconvenience
Recent data from Pakistan has shown a very high prevalence of RHD in both urban and rural population. In a large cross sectional survey, conducted on more than 25000 urban school going children from inner Lahore using echocardiography to confirm the cardiac lesion, has estimated a prevalence of 22/1000. Although this might be an under- estimation as prevalence rate in children who do not attend school may be higher as they tend to be more socio-economically disadvantaged and children with advanced heart disease may be unable to attend school.( Masood S Et Al 2001)
Poor housing conditions and over-crowding remain major contributing factors in facilitating the spread of group A beta-hemolytic streptococci. The younger age of onset is a special feature and most are unaware of the diagnosis, and hence not receiving life- saving secondary prophylaxis (Naveed A Et al 2004)
Finance / socioeconomic circumstance
Pakistan is a densely populated, country in south east Asia. The population is approximately 220 million. The average income is less than Ten sterling pound a day and it is currently ranked as one of the poorest and least developed countries in the world – 40% of the population is under nourished and out of those 30 % are suffering from Rheumatic fever. Indicators of undernutrition among children were high throughout Pakistan. Among adults, there were urban-rural differences and economic gradients in indicators of undernutrition and risk factors for heart disease and cancer. (Ahmed W et al 2014)
Due to unavailability of government medical insurance cover, patients have to arrange funding, Most of them are supported by patient themselves , third-party donors and grant makers. The funding necessary to cover essential medical care services usually exceeds the financial means of most of the patients.
Some Health care services are complemented by nongovernmental organisations that are dependent on fund raising and voluntary donations from a variety of external source.
Also there are some medical support like Sehat Insaaf Card , there is new initiative taken by Pakistan government , through which limited medical funding support and assistance is provided to poor families across the country
Surgical site infection , Sternal dehiscence
Deep sternal wound infection is a serious and expensive complication after cardiac surgical procedures. Study showed in Pakistan In-hospital incidence of Deep Sternal Wound Infection (DSWI)/ Mediastinitis was 7.50% in the group <24h of ABP and 1.25% in the group receiving >24 h of ABP therapy, and the
difference was statistically significant (P=0.042). Similar results were observed in terms of mortality (8.75% Vs 1.25%). (Lok S et al, 2012 )
Hence there is evidence of high infection post operatively and that leads to increased extensive use of iv antibiotics.
Life expectancy in Pakistan
Life expectancy is measure of the average time of people is expected to live based on the year of its birth. Its current age and other demographic factor including gender.
life expectancy at age 65 has increased significantly for both men and women during the past 50 years. Some of the factors explaining the gains in life expectancy at age 65 include advances in medical care combined with greater access to health care, healthier life styles and improved living (Ejaz A et al 2019)
Life expectancy at birth, widely used as an indicator of overall development of a country, has increased over the last ten years in most of the countries of the world. This has a particular indication for the developing world since they are striving earnestly for achieving socio-economic progress through investing significantly on social sectors like health, education, sanitation, environmental management and sustainability, and social safety nets. Improvements in incidence of poverty, nutrition, adult literacy, access to safe drinking water, burden of diseases, and sanitation have also been remarkable over the years that would have impacted positively on life expectancy.
Our experience of Minimal invasive cardiac
surgery in Pakistan
To set up an Minimal invasive cardiac surgical program in the developing world like Pakistan, we has to start with the same principles. . in this article we will discuss about Mini-AVR , In initial stage Main thing is to Link up with a hospital in Pakistan , It has to be a large centre high volume which perform more then 2000 open heart surgery a year . Probably 10 centre which are doing 1500 open heart surges a year , we have to pick the largest centre
ESTABLISHING THE NEED : Minimally invasive aortic valve replacement (Mini- AVR) is now an established procedure. The first parasternal approach for mini- AVR was reported by (Cosgrove and Sabik et al 1996).
Upper mini sternotomy provides a window through which the aortic root is freely accessible. Without additional risk to the patient, the surgeon makes slight modification to already established familiar techniques. This offers the benefit of prompt recovery in appropriately selected patients and enhances patient choice and patient experience. Although suited for iso- lated AVR in patients of all ages, mini- AVR is particularly applicable to the elderly, obese, recent smokers and those with impaired respiratory function.
When compared with a conventional sternotomy, the hemi-sternotomy leaves the sternum more stable. We believe that mini-AVR is particularly suitable for patients who may have a higher risk of sternal dehiscence but otherwise suitable for conventional AVR. There is high prevalence of Chest wound infection & sternum dehiscence in pakistan , so this is advantage in our scenario .
In a propensity score analysis comparing 233 patients with mini-AVR with 233 patients undergoing full sternotomy AVR, (Sharony et al 2014) showed that the length of hospital stay was significantly shorter with mini-AVR. Similar outcomes have been reported by other authors as well (Johanas bonnet et al 2015).
TRAINING : It is also important to establish any training needs, not only for the surgeon, but also for the whole team including anaesthetists, perfusionists and the scrub team. Before the first cases are performed, local departmental teaching should be organised (lectures, evidence, videos etc.) where all disciplines are invited. We used a combination of theoretical information and operative footage in order to familiarise the team with the procedure and its potential pitfalls. Visits to ‘mini-AVR centres’ and attendance at courses targeted at new centres are strongly advised.
COST: Although new additional costs can be involved, mini-AVR can generally be performed without the requirement for any special equipment. The Management should
be reassured that extra funding would not be required for starting a mini-AVR programme.
COMMUNICATE : Before the programme commences, every effort must be made to encourage open discussion in a relaxed environment, to exploit every opportunity to highlight concerns regarding equipment and training and to facilitate team-work and boost morale. This becomes paramount if previous experiences have not been positive. Frequent informal dialogues in corridors and coffee rooms as well as formal discussions at
regular Consultant, Monthly Audit and other Clinical Governance meeting should not be underestimated.
PATIENT SELECTION : In the initial period (first 3cases), patient selection is the key. Avoid very elderly, grossly obese, current smokers and high-risk patients. Once the programme is ‘up and running’, it is these very patients who might benefit from mini- AVR. At the outset, the skin incision can be made slightly longer as it is the mini- sternotomy
SUPPORT FROM COLLEAGUES : Ideally, the proposed procedure should be discussed with all Consultant surgical colleagues formally and their support sought, even if all of them would not be performing the new procedure. The names of the surgeons performing the operation in the ‘setting-up’ phase should be specified.
PROCTOR : It should be considered compulsory to have a named proctor with considerable experience and not the skin incision that provides clinical benefit.
TEAM BRIEFING : Prior to the first case, the whole team must be extensively debriefed (with the proctor present) and ensure that all equipment required is available. It is important that all members of the team are encouraged to ask questions at this point to provide further opportunity to highlight issues and promote team involvement.
FIRST FEW CASES : The first case in our programme was performed by the more experienced surgeon with the proctor as the first assistant and the other surgeon as the second assistant. The second case was again performed by same team whilst the proctor observed the case un scrubbed in theatre. During these cases, there were frequent technical points discussed which helped enormously. Thereafter, another 1 case (un proctored) were performed by the 2 surgeons scrubbed together, On an
average, in our hands, the cross-clamp time is 10 min longer and the whole procedure takes 30 min longer compared with conventional AVR. Hence, the surgical time of mini-AVR is comparable with conventional AVR.
Similarly, we can answer the question ‘Why not do less invasive cardiac surgery? as follows: It is not expensive, It is not as traumatic as classical surgery, It is not difficult, It is not experimental.
Discussion
Conventional heart surgery has undergone extensive changes over the past decade. Specialist surgeons and centres are now equipped to undertake many isolated and combined cardiac valve operation without using sternotomy , through mini thoracotomy. Although evidence from prospective randomised trials is poor .
In this study we discussed different aspect related to initiating minimal invasive programme in Pakistan, most importantly its disease pattern in our south asian population , 90 % of the patients are young male suffering from Rheumatic heart disease , we also elaborate about poor health financing system in Pakistan, as vast majority patients are self paying, in addition we highlighted average age in our inhabitants , which is 15 year younger then European population in comparison . In addition we found high rate of post operative infection which lead to prolong hospital stay and extensive use of IV antibiotics.
When we talk about minimal invasive cardiac surgery in Pakistan , there is very little level of development . It is important to discuss why our population need that require procedure that particular attraction to minimal invasive cardiac surgery approach .I think emerging market is the 1st reason , in my opinion its engine of today’s health care . We all have certain challenges , if we look into Pakistan one has to understand that as very variant population , I understand that our expertise are as good as anyone else . However were not expose to minimal invasive cardiac surgery
Main advantage are less hospital stay, lesser blood loss , and then there are particular benefit in population with south east Asia. These are i.e patient are much younger and in future they may be going for 2nd operation like CABG , redo mitral after
several years or 20 years. if 1st procedure done through minimal invasive approach , later medial sternotomy would be easier, Secondly these guys maybe soul bread earner , so keeping them off from work for 4 weeks in not practical , Thirdly in female the population the younger girls giving the mid line scar , where they is high tendency of forming scar with Keloids . Its practically benefits for them
Establishing Minimal invasive cardiac surgery is multi tier process , key element are to visit , schedule online lesson, share videos , use animal heart stimulator. Very important to have sustained program . Its very easy to initiate but its very difficult to sustain, we have to be financially sound for that . vast majority patients are self paying .
Main Focus remain on team approach , much more collaboration between surgeon , Aneathesia department and perfusion . They have to be tail up and get use to it .
Buying instrument and utilising it on full sternotomy procedure for example using knot pusher in open heart surgeries, practicing on Stimulator with animal heart basically.
Each emergent market has unique challenges, certainly most common factor Is economical ,We are hoping much more Industry support if we want to keep long sustaining program , not onetime launch . There should be clinical and logical support
You to stress upon right centre, pre launch, during launch and post logistical launch. Teams should be completely onboard.
Lastly we have to bear in our mind that its not for marketing purpose, if for patient care and benefit mentioned . There maybe some marketing benefits .but goal is patient care And when all these goals are lined up , then it will be a successful program . Government of Pakistan should Increase and reorganise the public expenditure allocation to health sector in order to provide health facilities and also, adequate management of funds and development of health services should be greatly pursued.
Lastly, government should introduce programs that will give awareness concerning the effect of life expectancy and public health expenditures on individual health and should also advise people and health ministry to appropriate measure to be taken for proper public health policy, to avoid any kind of hazard about health care.
Key Lessons learnt
Although not the subject of this paper, below are some examples of technical difficulties that we experienced in the initial phase of the programme with a brief explanation of how they were solved.
Work together with an experienced surgeon , Proctor is essential, Always have backup, Do not be afraid to convert , It is not as difficult as it sounds .
Disadvantages of Minimally Invasive Surgery : Minimally invasive surgery requires specialised high-end medical equipment. Surgeons need specialised training.The equipment used with MIS is more expensive. There are various procedures, especially the most recent surgeries, that may take longer.
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