Evaluation of a project of cardiac surgery in an emerging country
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Evaluation of a project of cardiac surgery in an emerging country

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Evaluation of a project of cardiac surgery in an emerging country Evaluation of a project of cardiac surgery in an emerging country Presentation Transcript

  • Evaluation of a project of cardiac surgery in an emerging countryVladimir Velebit, Michel Montessuit, Marek Bednarkiewicz, Gregory Khatchatourian, Peter Neidhart Denton A Cooley Cardiovascular Surgical Society 15th International Symposium Houston, October 27, 2007 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Education and training in cardiovascular surgery in emerging countries Dr Thomas Pezzella. Luncheon meeting today: Reaching out to Third World Countries Dr James Cox. Presidential adress AATS, San Diego 2001 Dr Richard Jonas. Presidential adress AATS, Philadelphia 2006 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Practice of cardiac surgery in the world No. cardiac operations /million inhab./year United States 1222 Australia 786 Western Europe 569 Latin America 147 Russia 37 Asia 25 Africa 18 J. Cox Presidential Adress AATS San Diego 2001 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Density of Cardiac Surgery centers Center/no. inh. United States 120’000 Europe 1’000’000 Asia 16’000’000 Africa 33’000’000 J. Cox Presidential Adress AATS San Diego 2001 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • European Association for Cardio- thoracic surgery International committee President’s report 2007 Government assistance too expensive Training in surgery in advanced centres in the West: expensive and inefficient Professional charitable organisations inefficient Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • International committee EACTS 2007 President’s report…professional charitable organisations……send a complete team …. to the underdeveloped nations to perform a series of operations in local hospitals. A small group of patients profits from this activity, but the general development of the specialty in the visited country is not necessarily facilitated…..…good results, which the visiting surgeons accomplish, are due to their large experience and to …. their highly experienced team. After the visiting team has departed….visitors good results are difficult to match …. by the local team. Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • European Association for Cardio- thoracic surgery International committee actions Scholarships for the European School of Cardiac surgery in Bergamo Italy Fellowships for training in the West Training courses at the Annual EACTS meeting Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • European Association for Cardio- thoracic surgery International committee actionsNothing is organized or offered for the millions of patients in the emerging countries waiting for surgical treatment Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Ideally Help create efficient centers in emerging nations Teach locally Treat local patients locally and immediately Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Creation of a new center in an emerging country Help organize and plan Help obtain equipment Assure foreign support for a prolonged period Teach professional skills Teach team-work Teach management of local diseases Teach Western ethics - fight corruption Ensure that the trainees work in and for their countries and for their local patients Strive for sustainability Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Our experience Period No. visits No. operations Sarajevo, Bosnia 1998-2002 39 393 Skopje, Macedonia 2000-2002 10 112 Algiers, Algeria 2002-2004 4 44 Tbilisi, Georgia 2002- 47 627 Baku, Azerbaijan 2007- 3 - June 2007 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Members of the teams Surgeons  Scrub nurses  Dr Jean Maurice †  V. Laurent  Dr M. Montessuit  M. Humbert  Dr M. Bednarkiewicz  E. Blondet  Dr G. Khatchatourian  C. Baudelle  Dr V. Velebit  K. Ištvanić Dr X. Muller   ICU nurses Anesthetists  Marie Humbert  Dr P. Badel  Manuela  Dr F. Pepcak  Warren Muir  Dr J-M Aeberhard  Dr D. Zarić  Gérard Suatton  Dr M. Licker  Catherine Poirier   Dr H. Racz Dr D. Dadić  Ward nurses  Dr B. Korkodelović  Gabriella  Dr P Neidhart  M-L Rivière Dr Ph. Masouye   Dr C. Chevalley  Respiratory therapy Anita Tyriseva Perfusionists   Evelyne R. Krahenbuhl   J. Reuse  Cardiologists  N. Ištvanić  Dr Ph. Urban  G. Suatton  Dr E. de Benedetti  Dr Th. Zerm Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Support Governments (Bosnia, Algeria) Charitable foundations Medaid Foundation (Sarajevo, Skopje) Frederic and Jean Maurice Foundation (Skopje, Tbilisi and Baku) Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • GeorgiaCardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • The Caucasus Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Georgia Surface area: 27’000 sq. miles Population: about 4.6 million Capital and largest city: Tbilisi 2 million Language: Georgian Religion: Orthodox Christian Products: agriculture, mining Mean revenue per household: $2’400/yr Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • TbilisiCardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • TbilisiCardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • TbilisiCardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Eristavi Surgical Institute Tbilisi Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Tbilisi OR 2002 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Tbilisi OR 2002 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Tbilisi ICU 2002 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Tbilisi OR 2004 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Tbilisi ICU 2004 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Our approach since 19971. Repeated, frequent visits to a single center over an adequate span of time2. Sufficient case loads at each visit3. Progressive reduction of our team4. Evaluation of work accomplished Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • 1. Repeated, frequent visits to a single centre Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Repeated visits One working week (usually 7 consecutive days) Visits once a month Usually 10 times a year Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Project in Georgia June 2002-June 2007Year No. of visits No. operations  2002 (2 visits) 33  2003 (9 visits) 86  2004 (10 visits) 113  2005 (10 visits) 110  2006 (10 visits) 187  2007 (7 visits) 116 (+84) Total no 47 627 September 2007 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Activity in Georgia 2002-2007 250 200Operations and visits 150 Operations No. visits 100 50 0 2002 2003 2004 2005 2006 2007 Years September 2007 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Consequences and benefits of repeated visits Confidence for investment in infrastructure and equipment of center Stability of employment Education of staff Reputation of center Improved team-work, better results Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • 2. Sufficient case load at each visit Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • During each visit Formal presentations of new cases (between 30 and 50/week) Post-surgical consults (10 to 15 /week) Informal consults for patients (10-15 /week) Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Operations Tbilisi June 2002-June 2007 627 op.CABG 415 off-pump 106 (26%)Valves 147 redo valves 19 (13%)Combined v+CABG 21Ascending aorta 21Aortic root 10Tumours 7Congenital 6 June 2007 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • 3. Progressive reduction of visiting team Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Complete ‘Swiss’ team Surgeon Anesthetist Perfusionist Scrub nurse ICU nurse/respiratory therapist Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Composition of foreign team Tbilisi 2002-2004 Scrub Nurse ICU nurse Perfusionist Anesthetist Surgeon 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007Mean no. team members 5 3.2 1.8 1.0 1.1 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Surgery in Tbilisi today! VV Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • 4. Evaluation of work accomplished Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Evaluation of project Efficacy of teaching Capacity to work independently (sustainability) Risks and benefits to patients Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Evaluation Retrospective estimation of risk by calculatiing Additive Euroscore for all patients Compared this predicted mortality to results Included an eyeball estimation of ‘difficulty’ Included OPCAB as an operation difficult to teach Recorded morbidity (wound infection and/or prolonged intubation > 24hrs) Recorded lengths of stay in ICU and in hospital Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • ‘Difficult’ operations EF> 30% Redo operations Combined operations (Valve+CABG) Multiple valve operations Aortic root operations Aortic dissection Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Mortality during phases of project Tbilisi Mean Euroscore No Mean no No or predicted ObservedPeriod Years visits Total no. op/wk visitors mortality mortalityA 2002-04 11 121 11.0 5 3.45±2.95% 5.80%B 2004-05 13 145 11.2 3.2 5.47±3.26 4.80%C 2005-06 9 113 13.3 1.8 5.83±3.24% 0.00%Total 2002-06 33 386 11.7 3.4 4.65±3.04% 3.60% Presented in part at the Swiss Society of Cardiovascular Surgery Lugano June 2006 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Morbidity and difficulty during project Tbilisi Difficult Hosp.Period cases Off-pump in d ICU in d MorbidityA 10 (8.3%) 17(19.5%) 11.05±2.9 2.8±0.9 3.30%B 16(11%) 27(29.7%) 12.04±3.5 2.9±1.7 3.40%C 21(18%) 22(25.8%) 11.24±2.1 2.3±0.5 2.40%Global 47(12%) 66(25.1%) 3.10%Presented in part at the Swiss Society of Cardiovascular Surgery Lugano June 2006 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Sustainability Operations by Georgian team in the absence of the Swiss team February 2007-October 2007 84 op CABG 82 off-pump 26 (31%) Valves 1 Aortic dissection 1Mean Euroscore 4.4±2.5Overall mortality 2 pts (2.4%) Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Is progress being made?1. Results remain good with less visitor involvement and with increased difficulty of operations2. Morbidity remains low in local conditions3. Technically difficult operations can be taught Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • At present The Eristavi Institute is the only center in Georgia which is reimbursed by state insurance (June 2007) The center is expected to operate over 300 cases this year (up from 33 in 2002) A program of primary prevention in siblings of operated coronary patients was started in September 2007 Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Further developments A program of pediatric heart surgery is being initiated by the University of Zurich in November 2007 Participating in this program by sending teams:  The Hospital for Sick Children, Great Ormond St, London, GB  The Academic Hospital, Amsterdam, Netherlands  The University Hospital, Utrecht, Netherlands  The Red Cross Hospital, Lisbon, Portugal Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Conclusion A modest project started in Tbilisi in 2002 The case load has increased steadily Surgical results have been satisfactory The patients have not been exposed to excessive risk Sustainability has been achieved Center has gained excellent reputation in Georgia A major international co-operative programme is being initiated in 2007 for pediatric heart surgery Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Proposal Numerous similar projects may easily be achieved A registry of projects should be created and maintained by societies such as the AATS, STS or EACTS These societies should make guidelines for projects and/or suggest approved models The WHO’s regional offices could furnish lists of centres/countries demanding assistance Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Cardiovascular Department Hopital de la Tour Geneva, Switzerland Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • www.fondationmaurice.org Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland
  • Estimated progression at the end of 2007 Tbilisi 350 300 250 No operations and visits 200 Operations No. visits 150 100 50 0 2002 2003 2004 2005 2006 2007 Years Cardiovascular Department, Hôpital de la Tour, Meyrin-Geneva, Switzerland