Developing a cardiac surgery unit in the Caribbean: A reflection

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.


| INTRODUCTION
The English-speaking/Commonwealth Caribbean is a multiethnic society with a population of 6.2 M people. Trinidad and Tobago is a dual-island republic near Venezuela with a population of 1.39 M people. The ethnic makeup is dominated by two groups, roughly equal in size: Afro-Caribbean, descended from enslaved Africans brought in to work on sugar plantations beginning in the late 18th century, and Indo-Trinidadians, or East Indians, whose ancestors were primarily indentured laborers who immigrated from the Indian subcontinent as plantation workers after the abolition of slavery in the mid-19th century. People of mixed ethnicity, migrants from Spain and other European countries, Africa, East, and Southeast Asia, and the Middle East constitute a slightly smaller group of the islands' population. 1 The incidence of cardiovascular diseases among the different races is high at 32.6%, and approximately 20% are diabetic, 21% hypertensive, and 36.9% overweight. 2 A national health system program relies on a network of public clinics and hospitals where treatment is free or low-cost. Concerns about the quality of the care they offer have led to a proliferation of private, fee-paying hospitals and clinics. In the early 1980s, a state-of-the-art hospital, the Eric Williams Medical Science Complex (EWMSC) was opened with the aim of providing specialized services. However, despite this development, a patient requiring heart surgery had to travel to the United States or the United Kingdom.
In November 1993, a complete visiting team from the Bristol Heart Institute (BHI) performed the first open-heart procedure at the EWMSC, and following an agreement between local professionals and the BHI, a plan was implemented to develop a unit capable of dealing with the need of the population of Trinidad and Tobago and the surrounding Caribbean islands. 3 From its inception, the aim was to support the unit with frequent visits from an overseas team and at the same time to train the local personnel. The final goal was a unit run independently, by the local professionals capable of delivering a service of international standards. Here we reflect on our experience and offer some insight which we hope will be of benefit to the surgical community and emerging countries wishing to develop a cardiac surgery program and confronted by a similar set of challenges.

| Local infrastructure, personnel, and finance
An exploratory visit was made in 1992 (GDA) at the request of local professionals interested in developing a private cardiac surgery unit.
Previous attempts had been made by the government, but the project was considered too ambitious and abandoned. A visit to the EWMSC showed excellent theater, intensive care unit (ICU), and ward facilities that were fully equipped but still to be commissioned.
The cardiology service was just in the process of starting to perform coronary angiography and related diagnostic procedures. Except for an anesthetist who had spent a few months at the Hammersmith Hospital in London there was no cardiac surgery expertize whatsoever on the island. A private company was formed, Caribbean Heart Care (CHC), to finance the project. A local management team lead by a medically qualified doctor (KAR) secured rental of the necessary facility from the government at the EWMSC and plans were developed for the start of the surgery the following year by a complete overseas visiting team from the BHI.

| Oversees visiting team and training
The overseas team provided regular monthly visits for the duration of a week during which on average five to eight private operations were performed. The surgical team was initially made up of two surgeons, an anaesthetist, a perfusionist, a scrub nurse, two intensive care nurses, and two ward nurses. One of the main aims of the projects was to progressively reduce the number of visiting team members and allow the local personnel to gain total independence. Two local anesthetists, a thoracic and a vascular surgeon, and a group of nurses (theater, ICU, and ward) were therefore identified for ad- year. In 2008, a senior surgeon from Italy (GT) permanently joined the team. The team was now made of three surgeons (two consultant 3018 | equivalents and a senior resident), four anesthetists, three intensivists, one perfusionist, a group of specialized nurses, and supported by two cardiologists.

| Evaluation of results
The record on the volume of cases performed over the years (November Coronary artery bypass graft (CABG) remains the main surgical procedure performed, followed by mitral and aortic surgery. A small proportion of miscellaneous cases included emergency type A acute aortic dissection, endocarditis, and correction of grown-up congenital heart defects ( Figure 2). The overall mortality per periods is presented in Figure 3.

| Last 5 years (2015-2019) results
During the study period, 1764 patients underwent surgery, mean age 59.6 ± 10.8 years, of which 66% were male. The majority were East-Indian-Caribbean (79.1%) or Afro-Caribbean (16.7%), with the rest Caucasian, Chinese, and mixed race. More than half of the patients had diabetes (12.8% insulin-dependent), two-thirds were hypertensive and 8.7% had renal dysfunction. The mean EuroScore II (%) was 1.8 ± 1.9. Most patients, 1363 underwent CABG, followed by mitral valve surgery (144 pts) with the majority being replacement (rheumatic disease) with about 20% repair. Sixty-four patients underwent AVR and 33, AVR plus CABG (Table 1). AVR or MVR with the combined procedure and miscellaneous cases are reported in Table S1.

| DISCUSSION
In emerging countries with no specialized cardiac surgery units, most patients have no choice but to live with their cardiovascular condition unless they can afford to travel abroad for high-cost treatments.
In an American Association for Thoracic Surgery presidential address in 2001, James Cox called for action to reduce worldwide inequalities in cardiac surgical care. 5 However, finding the best way to establish a personnel. This approach has been questioned by the European Association of Cardiothoracic Surgery and its International Committee, which does not believe that the best solution is achieved by sending teams to the developing world. 7 Vervoort et al point out, that there are 77 non-profit, nongovernmental organizations that have attempted to provide some cardiac surgery care in low-to lowmiddle income groups. They suggested a unified approach that includes these organizations, perhaps with an overarching, more global administrative structure, that could allocate needed resources to specific areas. 6 However, what seems to be missing, as suggested by Ferraris and Pezzella, 7 is an organized approach that understands the needs and is capable of allocating assets to the under-resourced lowincome countries. The World Heart Foundation, which was founded in 1999 to help develop cardiac surgery in the emerging world, suggested teaching via the Internet, complemented with local visits. 8

F I G U R E 2 Number of coronary artery bypass graft (CABG), aortic valve replacement (AVR), mitral valve replacement (MVR), miscellaneous, and total procedures per 5-year period
F I G U R E 3 Overall mortality per 5-year period 3020 | An alternative option would be to train a complete team from a developing country in a foreign specialized unit. However, this is often impractical, complex, and expensive. The ideal solution would be to build a local cardiac surgery unit that will ultimately deliver continuous treatment for patients. However, each developing nation has its unique environment, and starting a new program that requires extensive preparation and financial commitment to a long-term project, can be a problem.
In the early '90s, when we planned to develop a cardiac unit in Trinidad and Tobago, we formulated a medium to long term strategy   Re-exploration for bleeding pump. This reflected the off-pump practice at the BHI which influenced training, but also the desire to minimize postoperative bleeding associated with the technique. 10 This was in part dictated by the limited access to blood products and particularly platelets and fresh frozen plasma on the island and a practical decision to reduce costs. This policy seems to be justified by the low 1.2% rate of reopening for bleeding. The incidence of mediastinitis was also very low at 0.2% considering the high incidence of diabetes in our patient population. The data we present, although not risk-adjusted, compares favorably to those of the training centre (BHI). 10,11 These results from a low-mid volume unit seem to be a little at odds with the consensus in the literature that a certain minimal volume of surgery is needed to be performed, by individual surgeons or institutions, to obtain good quality results. [12][13][14] A limitation of this report is the absence of long-term follow-up data. However, it is challenging to follow patients coming from different islands, and it is the unit's practice to send patients back to the referring cardiologist.

| CONCLUSION
Frequent regular outside visits, identification of a core group to be trained locally, complemented with training in a designated partner overseas center and transfer of knowledge, proved to be the right strategy to develop a cardiac surgery unit in an emerging country with results comparable to accepted international standards. The success of the program was the result of appropriate long-term planning and execution and was made possible by an enthusiastic local management team and a dedicated and motivated medical, nursing, and perfusion group of professionals.

ACKNOWLEDGMENTS
We wish to thank all the overseas personnel who helped to establish the cardiac unit and all the members of the local team, who made this a reality. The British Heart Foundation and the NIHR Bristol Biomedical Research Centre supported this study.