a 66-year old woman, Jehovah's Witness, diabetic Type 2 and hypertensive with a history of triple coronary artery bypass graft (CABG) surgery in 2007 was submitted to a redo CABG for failure of all previous grafts. She had a myocardial infarct in April 2013 and had post myocardial infarction angina on exertion (CCS 2). The preoperative ejection fraction was 53%. The preoperative haemoglobin (Hb) was 14.1 g/dL. After freeing the heart from epicardial and pericardial adhesions due to previous surgery, a triple venous CABG was performed on-pump: on left anterior descending (LAD) artery, postero-lateral (PL) artery and posterior descending (PD) artery. At the end of the operation, the Hb value was 10.7 g/dL. The postoperative bleeding at the drain removal was 230 ml. The patient was discharged home on the seventh postoperative day with no complications. The Hb value was 9.5 g/dL. At present, she is alive, well and asymptomatic.
Background and Aim: Access to specialized cardiac surgery is a problem in emerging countries. Here, we reflect on the approach we used to establish a cardiac surgery unit in Trinidad and Tobago. Methods: The program started in 1993 with monthly visits by a team from Bristol Heart Institute. A group of local doctors, nurses, and perfusionists were identified for training, and a senior nurse moved to the island to start a teaching program. The visiting support was gradually reduced, and the local team gained independence in managing the service in 2006. Results: The initial low volume surgery increased to around 380 cases a year with the implementation of comprehensive service in 2006. Most patients required coronary artery bypass graft (CABG). In-hospital mortality declined from 5% in the nascent years to below 2% thereafter. In the last 5 years (2015-2019), 1764 patients underwent surgery (mean age 59.6 ± 10.8 years, 66% male). The majority were East-Indian-Caribbean (79.1%) or Afro-Caribbean (16.7%), half had diabetes, and twothirds hypertension (EuroScore II 1.8 ± 1.9). The majority (1363 patients) underwent CABG (99.5% off-pump; conversion to on-pump 1.5%). The mean number of grafts was 2.5 ± 0.7 with 98.5% and 23.1% receiving one and two or more arterial grafts, respectively. In-hospital mortality was 1.1%, re-exploration for bleeding 2%, stroke 0.1%, mediastinitis 0.2%. The length of the postoperative hospital stay was 5.8 ± 2 days. Conclusion: Frequent outside visits complemented by training in an overseas center, and transfer of knowledge proved to be an effective strategy to develop a cardiac surgery unit in an emerging country with results comparable to accepted international standards.
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