There are one hundred centers in USA with Hybrid Operation Theater Suits and it is increasing 15% annually-Dr.Afsheen Iqbal

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Proceedings of Cardiac Surgery Conference held at AKU
There are one hundred centers in USA with 
Hybrid Operation Theater Suits and it is 
increasing 15% annually-Dr.Afsheen Iqbal
Prof. Anjum Jalal calls for self-policing and accountability
otherwise someone else will start doing it
We need to increase our health budget and establish
a Think Tank for NCDs-Prof.Wasy

Karachi: Prof.M. Wasay consultant neurologist was the first speaker in the first plenary session of the 11th International Biennial Conference of Pakistan Society of Cardiovascular and Thoracic Surgeons held at Aga Khan University from December 6-8, 2019. The theme of the conference was “Cardiothoracic Surgery 2020 and Beyond”.

Speaking about Non communicable disease burden, risk factors and outcome in Paksitan, Dr. Wasay said that we have 10% young population which is less than forty years of age. About eighty millions of our population suffer from NCDs which include Hypertension, cancer, diabetes mellitus, mental health disorders like depression, stroke, injuries, and chronic respiratory disorders. More than 70% deaths are due to NCDs including stroke. Trauma is a major cause of disability. According to various studies we have 40 million people suffering from hypertension, sixty million from diabetes mellitus and another fifty million from mental health disorders. In Pakistan about one thousand patients suffer from stroke daily. All this leads to mortality. We have about eight hundred deaths due to heart diseases and four hundred deaths due to stroke daily. About one hundred people lose their limbs every day. We have three hundred thousand patients on dialysis and forty thousand patients go on dialysis every year. All this results in increased death and disability. About 17% of people suffer from severe depression. 45% pregnant women suffer from iron deficiency anaemia. 

 Group photograph taken during 11th International Biennial Conference of Pakistan Society
of Cardiovascular and Thoracic Surgeons held at Aga Khan University from December 6-8,
2019 shows from (L to R) Dr. Muhammad Aftab, Prof. Haider Zaman, Prof Hasanat Sharif,
Prof. Ata ur Rehman, Prof. Rehman, Prof. Saeed Ashraf, Prof. Shahid Sami, Prof. Saulat
Fatami, Dr. Khalid Nuri, Dr. Syed Shahabuddin and Dr. Qamar Abid.

Continuing Prof. Wasay said that Air pollution is worse in Asia and money spent on health is very little as it accounts of 2.5% of all government expenditures on health. He suggested that we need to increase our health budget and establish a Think Tank for Non-Communicable Diseases, reduce the risk factors and promote life style changes, stop smoking, promote exercise, reduce use of salt, ensure blood pressure screening and control. About 10-12% of our school children suffer from hypertension for which we need to initiate cost effective measures. We have excellent guidelines for almost every disease management but what we lack is implementation, he remarked.

Maj. Gen. Afsheen Iqbal from AFIC was the next speaker who gave highlights of a Hybrid Operation Theatre and pointed out that the future of cardiac surgery was there. AFIC, he said, was a 400-bed tertiary cardiac care facility with eight Cath Labs, two ICUs, Hybrid Suite, six operation theatres. Here cardiac surgeons do go to the Cath Lab as well and they are very accommodating. Cardiologists these days, he further stated, are becoming aggressive. Currently in United States, there are one hundred centers which have Hybrid Operation Theater Suits and there is a 15% increase annually. Concept is changing and there is going to be minimally invasive surgery which will reduce the size of the incision. Now we are ablating and not excising. Image guided is preferred over visual navigation. Suturing is also being reconsidered.


Speaking about the advantages of Hybrid room, he mentioned low cost, short recovery time, minimum communication related errors. He then talked about the current utilization of their Hybrid suite. Hybrid Cath Lab or operating room is not a simple thing. It has too many stake holders who are involved. The hospital should be good, one should know what procedures are planned, what is the budget. Detailed plan of the room usage should be worked out, who is drawing the function space. It is a very expensive job investment and also has a lifelong recurring cost. At AFIC it is the anesthetist who contacts the cardiac surgeons, cardiologist have the plan. There is no single vendor. Joint venture increases the cost and time. Then there are after sale problems as there is limited expertize of the local engineers. The Hybrid suite has to be close to the Cath Lab or Operating Room. We have it next to the ICU. Training of the staff, he further stated, was very important. One of the participants remarked that we at Children Hospital Lahore have a Hybrid Room where cardiologist and cardiac surgeons are collaborating and it is functioning for the last one year.


Dr. Ghulam Abbas from USA spoke on building high performance teams and conflict resolution in operating room. He discussed at length different aspects of competition vs. collaboration. A serious disagreement or arguments, clash, war, opposing ideas were all highlighted in detail. He was of the view that conflict is good and bad as well. Conflict is costly, disturbs or destroys others. Frame in the brain is negotiator. Go for problem solution, it is based on power linkage. Go through a process to resolve the issues. It is interest based solutions. He also referred to alignment of interests or separate motives. He suggested that one should open constructive conversation with negotiating intent and opt for discussions. Enlightened intents will offer new options on what we eventually agree. Make a small agreement and then build on that. When I survive, you succeed. He concluded his presentation by stating that define the problem and mindset, describe different interests. Note agreements and disagreements and then negotiate a solution, he added.


On left Prof. Hasnat Sharif, Conference convener presenting lifetime achievement award to
Prof. Jawad Sajid and on right Prof. Aziz Jamal Naqvi receiving his life time achievement
award from Prof. Akhtar Hussain Conference Convener during 11th International Biennial
Conference of Pakistan Society of Cardiovascular and Thoracic Surgeons held at Aga
Khan University Karachi, recently.

Dr. Sulaiman Hassan from Tabba Heart Institute was the next speaker who talked about developing an advanced Practice Nursing programme in Pakistan and gave details of the programme that he was involved with which was started at Aga Khan University some years ago. Nurse practitioners, he clarified are not competitors, they help us to make things better. In United States, they have Physicians Assistants and Nurse Practitioners. All the registered nurses have to undergo further training to qualify for becoming Nurse Practitioners. We in Paksitan need more such people. They will help us to adhere to our routine. There are over two thousand Nurse Practitioners, and a large number of Surgical Nurse Clinicians. The clinical track is missing in Paksitan. We started this programme at AKU in 2015. Five critical care nurses were trained with a one year curriculum. Mentors were assigned to them. School of Nursing, Medical College and Operating Theatre room were all involved in their training. They had a competency based assessment. It will help in quality improvement. It will also open a new scope for nurses. They prepare all the documents and it was because of them that there was almost 50% reduction in re-admission. Surgical site infections also reduced. India has started a Nurse Residency programme. We started this MSc N programme and so far two batches have graduated. They are working in education, and management. These are issues regarding their recognition, supervision and acceptance. Till licensing is done, what they are doing is countersigned. AKU can only give degree but one has to convince the Pakistan Nursing Council to get them recognition.

Tributes to late 
Col. M.A. Cheema

Dr. Asjad in his presentation paid rich tributes to the late Col. Prof. M.Aslam Cheema a noted cardiac surgeon who passed away a few months ago. He left AFIC and then started work at Mayo Hospital where another Dr.Aslam Cheema had left after getting frustrated at the attitude of the bureaucracy and went back to United States. Col. Cheema apart from starting cardiac surgery at Mayo Hospital, also started cardiac surgery at Punjab Institute of Cardiology and then helped establish twenty cardiac surgery centers all over Punjab. NICVD helped him and his team to start cardiac surgery which he always gratefully acknowledged. He was a polite well-mannered person. He never learnt how to shout and gave credit to many. Participating in the discussion Mr.Shaukat Ali Jawaid Chief Editor of Pulse International remarked that he has documented and published the struggle of his life in his book “Dil Rawan Dawaan” in Urdu which also provided lot of useful information on cardiac surgery in Punjab, Pakistan and the world over.


This was followed by yet another brilliant presentation by Prof. Anjum Jalal cardiac surgeon and Chief Executive of Faisalabad Institute of Cardiology. He shared the data of twenty thousand patients and highlighted some of its salient features. This he said, will be extremely useful or research, audit and governance. He advised his colleagues to save data and project it and publish it.


We started documentation and storage of data in 2007 after developing a software. We wanted to have this as a Registry for the society but not many were interested to share their data. They had certain concerns, they were scared about it. We had planned in such a way that the software is user friendly and to address the concerns of some members, the outcome of the cases can be omitted. At present eight centers he said are entering their data including AKU, AFIC, AIMC, Multan Institute of Cardiology, KPK. It has data of 25,859 patients related to 25,815 cases. He laid emphasis that quality of the data being entered should be ensured. No junk should be there. Executive Committee should validate it. External validation can be done every six months.


Sharing the characteristics of the patients Prof. Anjum Jalal said that 27% were diabetic, 15% had family history of CAD, 27% were smokers, 30% had hypercholesteraemia, and 49% of the patients between the ages of 41-60 years, 20% were over the age of sixty years while 18% of the patients were between the ages of 21-40 years. Nineteen thousand two hundred twenty one patients were operated which included six thousand six hundred thirty eight female patients. It also showed that men get better treatment while women patients are ignored. CABG cases accounted for 16,736 cases. About 48% of patients had a hospital stay of twenty four hours while 26% had a hospital stay between 25-48 hours.

During the discussion an important point which was made related to self-policing and accountability otherwise someone else will start doing it. Surprisingly no one wanted to share the data when we started this Registry but we have maintained transparency. Prof. Anjum Jalal also disclosed that some of us may not be knowing but some agencies have already started monitoring and collecting data which is being reported back to the government. This data is being compiled by silent observers. Let us all be careful, open and forthcoming.


This was followed by a presentation from overseas (Seattle) through video link. The Keynote speaker was Mike McMullan who talked about future of cardiac surgery with special reference to optimizing global ECMO Care. He discussed in detail adult cardiac ECMO, types of ECMO support. At present, he pointed out, almost 30% of health spending are wasted. ECMO specialists opt for concern based decision making. ECMO costs, one needs circulatory support team. He also referred to ECMO groups, ECMO costs, and circulatory support team. ECMO volume and surgery volume balances it. Adult ECMO survival is by diagnosis which balances the survival rate.

Continuing Dr. McMullan said that as the number of procedures are increasing, survival rate is decreasing. There are guidelines for ECMO centers by ELSO which were discussed in detail. We at our center, he said, do forty seven patients every year. Our team includes seventeen surgeons, twenty seven internists and fifteen cardiologists. Causes of events is communication gap. Crew resources management skills, training on simulation also matters and it reduced complications. We can reduce the cost. ECLS offers lot of opportunities. Studies have showed that patients did better when they were managed at ECMO centers. One can plan a one large ‘ECMO Center in the region. As regards neonatal respiratory ECMO its survival rate may go down in future but let us hope it remains stable. We need to balance innovation, cost and safety of ECMO.


During the discussion the expanding role of ECMO was discussed at length. Now cardiothoracic surgeons are also doing cases of lung cancer. The issue of ECMO bank was also discussed but it was pointed out that it is very expensive. China, it was stated, has developed a technology which is affordable. We can take Chinese technology rather than looking towards the industry. Cost is still a problem and in certain areas it is waste of money, hence ECMO should not be considered in some cases. ECMO helps patients with respiratory issues more. Surgeon Sulaiman Hassan opined that it should be given to general interventionists rather than cardiac interventionists. Cost and expertize are to major problems in Pakistan. If we can collaborate with some other centers in USA, it will reduce the cost but disposable cost will remain a problem. We should concentrate on developing technology which is not very expensive. ECMO should be started as a support service. One of the participant from AFIC remarked that ECMO as a service is not feasible as we are doing it for some time.

Debate on MICS vs.
Open Heart Surgery

Debate on the usefulness of MICS and Open Heart Surgery was quite informative and interesting. Dr. Sulaiman Hassan spoke for Minimally Invasive Cardiac Surgery. It was pointed out that there is good visualization during intraoperative TEE. One can do valve repair. Robotic access was also discussed and it was stated that one needs an experienced trained team and continuity of doing these procedures was also important. He also talked about mitral valve exposure, resected leaflets and repaired mitral valve. One can do ASD and also take out tumours besides aortic valve replacement.

Speaking about limitations of MICS Dr. Sulaiman Hassan mentioned multivessel CAD, mitral valve calcification, there are potential additional complications like lung injury, aortic dissection, and bypass time will be longer. He was of the view that inadequate operation was the worst thing to do. Re-operation with prior sternal wound may be safe. There is faster recovery after operation and early return to work. There is less blood usage, reduced chances of infection, superior mitral valve exposure and durable results which are comparable to surgery.


Dr. Azam Jan from Peshawar pleaded the case of conventional open heart surgery. Strenotomy, he stated, has the potential advantage over MIS which has limited exposure dealing with complications. There may be incisional complications and there is increased risk of stroke. Talking about MIVAR vs. Strenotomy he said it requires longer pump and cross clamp. There have been more strokes with MIS. He then talked about OHS, MIDCAB and off pump CABG. A meta-analysis of fourteen studies have showed that there is increased in all-cause mortality. We at our institution have done every surgery and we can do it. It is possible. Off Pump CABG is here to stay. One may do open heart surgery or MIS but make sure that you do not harm the patient. We are responsible for the patient as well as the family. Patients should be able to live. We harm the patient by opening the sternum. We must look at what we are doing and how we can do it better. We have to compete with cardiologists, we taught them CABG. Now they do not want us in the operation theatre. Best treatment and safety of the patient is important. Off Pump CABG is becoming popular but now since there are more complications, on pump CABG is preferred. We have to wait for the results after MIS. He further stated that MIS should be done with Off Pump surgery.

Prof. Sulaiman Hassan remarked that let us look at good results and see what is best for us. We need to learn new techniques. We have to protect our patients with proper means through trained surgeons. We also need to keep cost in mind and do what is best in your hand.

Debate on SAVR vs. TAVR

Dr. Saulat Fatimi moderated the next debate on SAVR or TAVR and are they the same? Prof.Tariq discussed as to what is the future and Death from any cause, whether it is similar. SAVR has less than 1% mortality. Future surgeons, he stated, are being trained in TAVI. It is costly procedure and we have very few surgeons trained to TAVI procedures. Cost is an issue. TAVR should be part of the training, he added.

Prof. Aftab also supported TAVR. It is not the future in fact it is already there. I like TAVR and we have done one thousand procedures during the last four years. We have done SVR which was gold standard. In aortic stenosis, calcified degenerative AV disease, TAVR is recommended. We do it together with cardiac surgeons and do not do it alone. There are certain exclusion criteria’s but TAVR is better than surgery. It is being done in a particular group of patients. Pakistani patients, he said, are younger people as compared to patients in Europe and America. He cautioned that we should be careful about the results of industry funded trials. Do not increase indications for TAVI. Cost is yet another problem. Valves will be very expensive hence we need to keep in mind cost, age of the patient and the complications.

Dr. Saulat Fatimi remarked that TAVI is going to stay. There is an evolution. Surgical AVR indications are there. One should chose valve which is easily available which can be replaced. Cost is an issue with TAVI. We have done forty two cases so far during the last two years. There are people who can afford it and eventually cost will also come down. Hence we should learn TAVI. Look at the plan of the studies and who have funded it. In certain studies investigators were funded by the industry. One cannot get raw data and patient selection was also not discussed in detail in those studies.

One of the participants from UK pointed that we in Pakistan need to set our priorities right. While we are asking for help from Bill Gates for control of Polio, TB and were still fighting to eliminate Malaria, what was the justification to spend public funds on costly procedures like TAV?

In the afternoon there was a session on Women in Surgery which was scheduled to be moderated by Mahim Malik. Dr. Saulat Fatimi moderated the session on Ault Heart Surgery. Mahim Malik was the moderator for the session on Congenital Heart Surgery wile Waris Ahmed moderated session on Thoracic Surgery.

The organizes had also organized pre-conference workshops on Aortic annular enlargement, Cardiac Surgery advanced life support, Aortic annular enlargement and Catheter skills for cardiac surgeons.

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