Pediatric Cardiac Surgery at Tahir Heart Institute

Pakistan is the fifth most populated country in the world with an estimated population of 220 million¹.  Currently, the country spends only 1.9% of its GDP on health. The estimated number of children born with congenital heart disease (CHD) in Pakistan is approximately 40,000-50,000 per year based upon assumed birth prevalence and annual birth rate. The burden of heart disease is compounded by the un-operated CHD in adolescents and adult population. Approximately, 6000 surgeries were performed in 2019 that were distributed across 22 hospitals in the public and private sector in the urban areas².

The challenges in the delivery of care include limited number of centers that offer congenital cardiac surgery. There are 21 surgeons who perform congenital cardiac surgery, of whom only 8 are fellowship trained in congenital cardiac surgery. This situation is worse for pediatric-trained nursing, perfusionist and anesthesia resources. The cost of surgery is subsidized in the public sector and ranges from $ 2000 to $ 3500. This still constitutes a significant financial burden for most families. Due to the considerable patient burden and limited capacity in the public sector, the wait times for surgery are significantly long. These limited capacity and financial resources exacerbate the dilemma of offering complex surgeries to univentricular patients and those with multiple congenital anomalies.

Tahir Heart Institute is the only cardiac hospital in Pakistan that is situated in the semi urban/ rural setting. Patients present to the outpatient setting on a walk-in basis with approximately 200 adult and pediatric patients seen daily.  It is an adult cardiac facility that performs approximately 100-125 pediatric cardiac cases per year. The pediatric surgical program has been supported by two US-trained congenital cardiac surgeons (full-time/part-time basis) since its inception.  Pediatric patients are seen by an adult-based cardiology practice with excellent support from pediatric echo sonographers. Complex cases are referred for dedicated pediatric cardiology imaging and evaluation prior intervention.

The ability to piggy-back onto the adult program allowed us to share personnel, equipment, and structural resources. The pediatric program was made a focal point by the administration, rather than an afterthought as witnessed in some pediatric programs in adult hospitals. The cost was subsidized to the rate of public facilities with professional fees waived for all the physicians.  Timely payments and direct negotiation with the vendors allowed disposable cost to be reduced by 30-35%. Further support in terms of disposables was achieved through relationships with US-based institutions (Seattle Children’s Hospital and Children’s Hospital of Philadelphia).

Early collaboration with Frontier Lifeline Foundation (Dr. K.M. Cherian) in India allowed us to start pediatric cardiac surgery at Tahir Heart Institute. Lesion-specific approach rather than weight-based approach was used to select appropriate cases. The most common structural lesions were Tetralogy of Fallot and atrial/ ventricular septal defects. It was recognized earlier that palliative management (shunts) was more difficult, hence an aggressive corrective approach was undertaken. As the program developed comfort with the management of these lesions, chronologic age was reduced, and these procedures are now routinely performed for infants. Complex lesions included single ventricular palliation, Rastelli procedures, and total anomalous pulmonary venous connections. The current mortality for these lesions is less than 3% which is comparable to major centers in Pakistan³.

The most fundamental resource for the success of the program was nursing. We adopted a model where all nurses onboarded for three specific venues/ tasks. All of them rotated as a bedside nurse, scrub nurse, and nurse anesthetist. This allowed us to identify nurses who excelled at these tasks and use them appropriately. It broke down the silos that are typically encountered with dedicated roles and allowed us to staff the intensive care with a group of nurses with a rich skillset. In the case of an emergency in the intensive care unit, they could seamlessly move forward with intubation, establishing arterial and venous access, and scrub and assist with emergency explorations in the intensive care unit. Since it was combined with an adult unit where patients are fast tracked, these lessons translated to the pediatric population with early extubation and mobility.

The fundamental questions will always remain as to whether the adult facilities should/ could offer high quality pediatric cardiac surgery in low income and middle countries. In the present set up, administrative support, cost subsidization, dedicated pediatric cardiac surgeon, case selection and nursing support can help achieve excellent results.

References

1. http://www.pbs.gov.pk/content/provisional-summary-results-6th-population-and-housing-census-2017-0 Pakistan Bureau of Statistics.
2. Sadiq, M. (2022). Establishing a Congenital Cardiac Program-Pakistan Model. In: Kpodonu, J. (eds) Global Cardiac Surgery Capacity Development in Low and Middle Income Countries. Sustainable Development Goals Series.
3. The spectrum of pediatric cardiac procedures and their outcomes: A six-month report from the largest cardiac facility in Sindh, Pakistan. Cureus. 2019 Aug 7;11(8): e5339