We have performed 12,868 beating heart coronary surgery procedures with conversion rate of 4% and mortality of 2.7%-Dr.Khalid Hameed


 Cardiac Surgery Session at CARDIO CON 2016

We have performed 12,868 beating heart coronary
surgery procedures with conversion rate of
4% and mortality of 2.7%-Dr.Khalid Hameed

Except Heart Transplant, Pakistani Cardiac Surgeons
now undertake all other surgical procedures-Prof. Anjum Jalal

FAISALABAD: Cardiac Surgeon Prof. M. A. Cheema was the Guest of Honour in the cardiac surgery session organized on the last day of CARDIO CON 2016 here from November 25-27, 2016. This session was chaired by Prof. Anjum Jalal Executive Director of Faisalabad Institute of Cardiology along with Prof. Haider Zaman, Khalid Hameed, Tayyab Pasha and others.

Dr. Azeem Khan from USA was the first speaker who talked about Current status and updates in cardiac surgery with special reference to robotic and Hybrid CABG. He pointed out that at many centers overseas now 10-15% of coronary bypass surgery is being done by robots. LIMA graft is more durable treatment for LAD and offers long term survival benefits. He then discussed hybrid revascularization, failure rate of SVG, PCI with DES in non-LAD vessels. Patients with low risk of re-interventions have the lowest risk of stroke.  He also showed surgical technique with robotic surgery and port placement.  The operator sits inside the consule and the assistants are with the patients who provide the instruments needed. There is no need for ICU and the patients go home next day and the patient’s returns to work soon. During 2012-2015 we did fifty four cases with excellent results. Blood products were used in 26% of cases. Re-admission is being closely monitored and pay is deducted based on re-admissions, he remarked.

Dr. Khalid Hameed then described their sixteen years’ experience of beating heart coronary surgery. We are maintaining the data. OPCAB, he said,  offers advantages in obese patients, female patients, diabetic patients who can be easily managed. He further stated that in 90% of patients we do not use blood at al. POP infection has gone down. For this, a dedicated multidisciplinary team is needed. We have one hundred members in the team and 50% of them are working now for more than fifteen years or so. We have good collaboration between cardiologists, anesthetists. Sequence of graft is also discussed. There is no compromise on quality. He then talked about RCA grafting and Redo surgery on beating heart. We had few problems like less space in chest cavity, right side pleural adhesion and dilated heart.   We reposition the heart for insertion of intra coronary shunts.  If nothing improves, give rest to the heart. Maintaining normothermia, he opined, is extremely important for good outcome. Surgical team uses warm irrigants. Conversion to CPB are matters of safety and should not be viewed as failure, he remarked.

Continuing Dr.Khalid Hameed disclosed that they have performed 12,868 procedures so far from 2000-2016. Our CABG mortality was 2.7% with 4% conversion rate. With experience beating heart surgery has increased and now almost 90% of procedures are being performed on beating heart. During the last 11,866 surgeries, we lost just one hundred thirty nine patients which gives the CABG mortality of 1.17%, he added. We used 3.5 grafts per patient. We try to achieve total revascularization and if need be we do convert for patient safety, Dr. Khalid Hameed remarked.

Dr. Tayyab Pasha from Jinnah Hospital Lahore talked about off pump total or multiple arterial coronary revascularization. While managing these patients, we do not stop Aspirin therapy, he remarked. In fact we give 600mg soluble Aspirin before the start of the procedure. Our patients had 2.6 average grafts. Hospital stay was for seven to eight days and reoperation was needed in 1.23% of cases.  We had zero mortality up to thirty days. His conclusions were that total arterial revascularization with BIMA RA graft in OPCAB is safe and effective in DVD and TVD with low mortality.

Prof. Shahid Malik from University of Lahore discussed surgery of thoracic aorta, its pathogenesis with special emphasis on aneurysm. He quoted Stanley Crawford stating that Simple surgeon would like to keep things simple, clamp and sew. There is 4-20% risk of paraplegia. Now different protective techniques are available to reduce risk of spinal paraplegia. One should reduce the cross clamp time and CSF catheter is not used.  Instead vasodilator infusion is used and straight aortic clamp is used.  Spinal paraplegia, he stated is a reality. All protective measures should be taken. Now endovascular procedures are gaining popularity but re-do incidence is high and mortality is also high. Prof. Riaz Anwar from LRH Peshawar spoke about mitral valve surgery via right mini thoracotomy and the changing demands of cardiac surgery in the present era.

Prof. Haider Zaman from CPE Institute of cardiology Multan made a presentation on Current Status and future challenges in Heart transplant in Pakistan. He pointed out that once they had a boy twenty three years old with Ejection Fraction of just 30%. Sometimes we do operate on high risks patients on humanitarian grounds and they go home but and they do come back with problems and die after three four months. He emphasized the need to have a Registry of cardiac failure.  He then spoke about what modalities they have to initiate cardiac transplant programme and what sort of a setup is needed. Speaking about the history of heart transplant, Dr. Haider Zaman said that with the availability of cyclosporine, the results have become better. Studies show that 1-5 years results are much better. Survival beyond one year is a problem and it is still low. He then referred to ventricular assist device and simple devices for end stage heart failure. After heart transplant, these patients can go for holiday, enjoy their work. Bleeding, thrombosis, infections remain the major problems. Speaking about major post-transplant complications Dr. Haider Zaman mentioned rejection, infection, hypertension, nephrotoxicity and malignancy.  We have approached HOTA to approve our programme. We hope to start doing it soon and we have made all the arrangements. Heart transplant programme is being reviewed at our institution. Final stage is HOTA approval. For this programme we have so far acquired 75% Endowment funds. We need to develop VAD programme and we are in liaison with neurosurgery department for donors.

Dr. Suleiman Hassan from Aga Khan University Hospital talked about valve sparing surgery. He first discussed historical background and pioneering work in saving aortic valve. Right mini thoracotomy was the first case done. Patients with Class III and IV status have poor prognosis. These patients , he opined, do not do better with repair or replacement but we should concentrate on repair.  Replacement is going to double the mortality as compared to repair. He then gave details of an Indian study of one hundred twenty cases of rheumatic mitral valve repair. Some patients had regurgitation and not all required redo surgery. They do much better.

Prof. Anjum Jalal discussed surgical options in heart failure. He started his presentation pointing out that at present three generations of cardiac surgeons were present in the meeting. Short of heart transplant, we can do everything in Pakistan. Now we have to prepare for bigger things and it is our duty to take things forward from here. At FIC till November 2016 we have done over thirteen hundred open heart surgeries. We have large number of patients with heart failure. They stay for few days, are then discharged but they come back again. It is a big burden and it needs lot of resources. We know our shortcomings and majority of these patients are treatable with curative procedure. We have large basket of cardiomyopathy. They do not need open heart surgery but transplants. Heart failure, Prof.  Anjum Jalal further stated is not synonymous with cardiomyopathy. We do not have exact data. Out of 1156 cases, in one hundred thirty six patients we had ejection fraction of less than 30%. Many had advanced valvular heart disease, aortic aneurysm, post MI VSR is neglected.  Some had post MI regurgitation. Young patients will be candidates for cardiac transplant. He also talked about valve surgery in heart failure as well as aortic surgery. If you do not operate, they will be candidates for transplant. We need to train our people to do left ventricular surgery for cardiac failure. Post MI ventricular septal rupture, LV free wall rupture, rupture of papillary muscles are catastrophic situation.  In the days to come Ventricular Assist Devices are going to be easily available.

Prof. Anjum Jalal then discussed the role of ECMO in cardiac surgery in cardiac failure. He showed a video of a young girl who was admitted in ICU.  We replaced aortic valve and repaired mitral valve as well.  Within few days his LV size came to normal. Now she is going to have a normal life. He concluded his presentation by stating that with modern techniques we need to motivate our junior colleagues to do such cases. We are not doing such things routinely but we are capable of changing the scene.  He also announced that the Academic Block at the FIC is being named and dedicated as M. A, Cheema Academic Block.

Responding to questions, Dr. Khalid Hameed said that they have not yet published their results but 30% of our patients had EF less than 30%. Summing up the discussion Prof. M. A. Cheema said that we should not dump everything with cardiologists. We have to go for cardiac transplant. Close mitral valvotomy is no more being done. Mitral Valve repair will not come to an end but one must be committed if you want to do it, otherwise one should replace it. Heart transplant is very dear to my heart and I wish we can have this facility in Lahore. He congratulated Prof. Haider Zaman who has put in lot of effort. I continue to encourage Dr. Khalid Hameed and others. We have to go on using new technology, he added.

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