|LETTER TO THE EDITOR
|Ahead of print publication
Pediatric cardiac surgery in the hills: A curvy road
Anish Gupta1, Anshuman Darbari1, Namrata Gaur1, Ajay Kumar2, Raja Lahiri1, Deepak Kumar Satsangi1, Sandeep Gautam1
1 Department of CTVS and 1Cardiac Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Cardiac Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||17-Feb-2020|
|Date of Decision||21-Apr-2020|
|Date of Acceptance||06-May-2020|
|Date of Web Publication||08-Jun-2020|
Department of CTVS, All India Institute of Medical Sciences, Rishikesh, Flat 4/4, Quarter 2b AIIMS Campus, Veer Bhadra Road, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Gupta A, Darbari A, Gaur N, Kumar A, Lahiri R, Satsangi DK, Gautam S. Pediatric cardiac surgery in the hills: A curvy road. J Pract Cardiovasc Sci [Epub ahead of print] [cited 2020 Aug 4]. Available from: http://www.j-pcs.org/preprintarticle.asp?id=286221
| Introduction|| |
All India Institute of Medical Sciences (AIIMS) Rishikesh is one of the six AIIMS like apex health-care institutes being established by the Ministry of Health and Family Welfare, Government of India, under the Pradhan Mantri Swasthya Suraksha Yojana with the aim of equalizing regional imbalances in health care, especially at the tertiary level. It came into existence as an institute of national importance through an act of parliament as an autonomous body on the lines of existing AIIMS, Delhi. The official inauguration of our institute was done on September 20, 2012, and the first Bachelor of Medicine and Bachelor of Surgery (MBBS) batch comprising 50 students started from September 21, 2012. It made a slow but steady progress since then, making exceptional leaps in primary and secondary health care, slowly acquiring capacity to provide tertiary-level services including robotic surgery to hilly terrains of Uttarakhand as well as surrounding areas of Uttar Pradesh and other neighboring states. The location in the serene, holy environment around river Ganga and as the first accessible tertiary care hospital with a trauma center and world-class architecture are special features of our institute [Figure 1].
|Figure 1: Aerial view of All India Institute of Medical Sciences Rishikesh and river Ganges|
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The institute started outpatient services from May 30, 2013, and inpatient services from January 01, 2014. The institute was providing cardiothoracic and vascular surgery outpatient department (CTVS OPD) services from the beginning itself, and thoracic and vascular surgeries were started from January 2015. The number of patients visiting CTVS OPD has substantially increased over the last 2 years [Table 1]. All varieties of lung and esophageal procedures were being done with excellent results. Peripheral vascular operations including radiofrequency ablation of varicose veins and excision of arteriovenous (AV) malformations were done. Closed-heart operations such as patent ductus arteriosus ligation were started, and the department of CTVS was officially established in May 2017. Simultaneously, we started the procurement procedures for heart–lung machine and other necessary equipment for open-heart surgery. As the department welcomed its first heart–lung machine in January 2017, first mitral valve replacement operation was done which was first in any government hospital of Uttarakhand state.
|Table 1: The number of patients visiting the cardiothoracic and vascular surgery outpatient department in the last 2 years|
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Subsequently, coronary artery bypass surgery was started both off pump and on pump, and around 34 such operations were done in a year itself. With joining of more faculties in the department, a modular cardiac operation theater (OT) was started and daily operative facilities became available and the number of cardiac cases has increased consistently since then [Table 2]. The same thing is reflected in our number of inpatient admissions over the last 2 years [Table 3]. The variety of cardiac cases has also increased as we progressed to start our pediatric cardiac surgery program, and all basic congenital cardiac cases are now being done routinely [Table 4].
|Table 3: A monthly progress of inpatient admissions over the last 2 years|
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|Table 4: Case-wise distribution of cardiac operations in the last 3 years|
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| Air Compressor: an Innovative Adaptation|| |
During initial stages of our cases, the central manifold gas supply system was not functional, so an indigenous technique to get compressed medical air for proper functioning of heart–lung machine was innovated using air compressor used for pneumatic saw of neurosurgeons. A regulator was installed in its circuit by a local mechanic to convert 8-bar to 4-bar pressure which was suitable for our heart–lung machine. A year later, as we shifted to new modular OT, the pendent did not have the port for medical air and changing of pendent was taking time. Another frugal innovation was done, and a compressor of a condemned ventilator was used after modifying the circuit, thus making it compatible with our heart–lung machine [Figure 2]. Finally, medical air manifold became functional, and cardiac surgery has flourished without bounds.
|Figure 2: Modification of condemned ventilator with working air compressor|
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| Ayushman Scheme/rashtriya Bal Swasthya Karyakram|| |
A large number of patients were living with severe rheumatic valvular heart disease modifying their lifestyle and suffering due to lack of surgical facility, financial issues, and long waiting at the nearest government hospital which is AIIMS, Delhi. The patients also had great difficulty to travel to nearby states for the treatment. The financial problem was solved by the excellent health scheme started by our honorable prime minister. Atal Ayushman Scheme was started at AIIMS Rishikesh in 2018.
A memorandum of understanding was signed between AIIMS Rishikesh and Uttarakhand Health and Family Welfare Society, Dehradun, on August 30, 2018, for providing treatment services under Rashtriya Bal Swasthya Karyakram, and the scheme was implemented in our institute from November 26, 2018. The department of CTVS at AIIMS Rishikesh operated its first case under this scheme on a 4-year-old child with ventricular septal defect on August 12, 2019.
| Team Building|| |
A perfusionist is an integral part of any CTVS team, but convincing people to work in hilly areas with difficult climatic conditions and nonavailability of recreational comforts of a busy city life was a difficult task. We convinced people to work with us as we had added advantage of research and teaching activities of an institute. We also had to find people who basically belonged to Uttarakhand region but were forced to work in distant places due to shortage of jobs in our place. Similarly, we did not have a dedicated cardiac radiologist, so one of our colleagues who were interested in cardiac computed tomography (CT) was sent to AIIMS, Delhi, for a short training. Organizing all necessary equipment and support personnel for CT angiography of children with congenital heart disease was also a challenge, but fortunately, we were successful and now we are routinely doing CT angiography with a 128-slice CT scanner and electrocardiography gating with all standard protocols in patients with most complex form of congenital heart disease in all age groups.
We had to organize various training sessions to nurses to make them able to provide postoperative care to cardiac surgical patients, but there were two problems. The postoperative care after pediatric cardiac surgery is more intense and demanding than in adult cardiac surgery. We solved this problem by training nursing personnel who were already working in neonatal intensive care unit (ICU). The other problem was of attrition because they either got a permanent job or a post in their hometown. Hence, we organized our training sessions regularly so that new joining staff can also take benefit and already trained persons become the trainers under their supervision.
| Trouble Shooting|| |
We do weekly meetings with our director on regular basis, regarding the development of our pediatric cardiac surgery program, so that we can find a solution to the hurdles on early basis.
| Exposure from Abroad|| |
Heart and lung transplants have become established treatment modalities for end-stage heart failure and terminally ill patients with pulmonary failure, but there are very few centers with such facilities in North India, especially in government setup. AIIMS Rishikesh is already running a successful cornea transplant program, and kidney transplant unit will be functional in a few months, which will be followed by liver transplant very soon. Keeping in mind, ourselves as future providers of heart and lung transplant facility in Uttarakhand region, we have sent some of our faculty to a famous university in Europe to gain experience in heart and lung transplant anesthesia.
| Heart Team Concept|| |
We organize regular meetings amongst the team of cardiac surgeons, cardiologists, cardiac anesthetists and cardiac radiologists to discuss all complex clinical cases which includes clinical history, echocardiography, CT and MRI findings. The plan of management is decided after discussion among all of us. This is also a great academic feast for all the residents from respective departments.
| Felicitation of Little Hearts – Children Day Celebration|| |
The institute's CTVS department celebrated children day by felicitating all 30 children operated for congenital heart diseases till then, and ceremony was presided by the director of institute, Padamashri Ravikant, who promised people of Uttarakhand to run a dedicated pediatric cardiothoracic surgery theater so that people need not go outside the state of Uttarakhand for operations [Figure 3]. Public awareness lectures were given regarding the need for early detection of congenital heart disease and their treatment options and postoperative care required after congenital heart surgery. All children were given goodie bags, and high tea was arranged for their parents. The media coverage of this program was provided by a local newspaper to create awareness among the general public regarding availability of pediatric cardiac surgery facilities in the institute. The department is planning to organize similar awareness campaign for rheumatic heart disease patients who have undergone valve replacements so that they can understand the importance of checking prothrombin time regularly and problems related to thromboembolic phenomenon can be minimized, especially due to the fact that patients live in difficult hilly terrains of Pithoragarh, Tehri, Garhwal, etc., and it takes almost more than a day to reach tertiary care facility in the plains. We also celebrate all festivals with religious harmony to strengthen mutual understanding and bond with great zeal [Figure 4].
|Figure 3: Felicitating children operated for congenital heart disease on November 14, 2019|
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| Academic Program|| |
Although the department of CTVS at AIIMS Rishikesh has 6 monthly Master of Chirurgie (Mch) seats for training in CTVS, no student has taken admission yet, but regular teaching classes are being organized by our faculty for perfusionists, nursing students, doctorate of medicine cardiac anesthesia students, and MBBS/Master of Surgery students. Our institute will be the first in the country to begin Pediatric Cardiac Surgery Mch course, which will start from the next session. As we have started with full spectrum of CTVS with almost 20–25 open-heart surgeries per month, we look forward to have fully functional cardiothoracic surgery training program very soon, both adult and pediatric. The junior residents from general surgery are being rotated in our department for every 2 months. They attain vascular surgical skills and learn basic surgeries such as embolectomy, AV fistula for hemodialysis, excision of AV malformation, varicose vein surgeries, and basic steps such as sternotomy and thoracotomy. At the same time, they form the backbone of our ward management and emergency calls. We are also planning to start rotation of trauma surgery senior residents in our department.
| Neonatal Surgery|| |
We are able to manage neonatal emergencies with support from neonatal ICU (NICU) till we develop our own CTVS-NICU and extracorporeal membrane oxygenator (ECMO) machine to start elective neonatal cardiac surgeries.
| Pebbles on the Road|| |
Pediatric cardiac surgery is one of the highest levels of super-specialization and needs well-organized setup with availability of fine and special instruments/equipment. There is hardly any difficulty in buying equipment in a tier 1 city, but convincing vendors to supply specific items/instruments/medicines/equipment in a remote area, especially when volume is not high, was a difficult task, but with enthusiastic administration, it was done with utmost priority and pace. However, for surgeons willing to start new setups, we would like to share a list of equipment/medicines/other accessories, whose procurement was difficult:
- Injection phenoxybenzamine
- Peritoneal dialysis fluid and catheter
- Baby cardiotomy sucker
- Hegar dilators
- Pediatric sternal retractors
- Pediatric cardioplegia cannulae
- Pediatric noninvasive ventilator mask
- 16–24-Fr angled chest tube drains
- Ivory coated silk suture
- No. 0 Ethibond
- Small blade of oscillating saw
- Russian forceps
- Polytetrafluoroethylene suture for neochordae.
| The Future Road – the Journey Continues|| |
The process for procurement of second heart–lung machine is almost complete and second modular cardiac OT has been inaugurated recently. With the availability of six dedicated departmental ventilators, setup of dedicated CTVS-ICU including pediatric facility is underway. We have also started the procurement process of nitric oxide generator and ECMO machine which will pave the road to performing complex neonatal cardiac surgeries such as arterial switch operation. M.sc. Perfusion Technology and Mch Pediatric Cardiac Surgery courses have been advertised and will take students from the next session. The standing financial committee has already cleared building up of dedicated cardio-neuro center on lines with AIIMS, Delhi, which will be constructed in the coming few years. We plan to increase our OT strength to 4 in the next few years so that we can perform around 2000 cardiac cases annually with the current strength of five faculties in the department. We have planned an 8-bedded ICU at present, but with four OTs, we will need two such units. We are also planning to develop a homograft valve bank, a project that will cost around 30 lakhs. Our aim is to have a patient-to-nurse ratio of 1:1 in ICU and 2:1 in step-down high-dependency unit. We will also organize awareness campaigns in hilly and remote areas of Uttarakhand state for screening and spreading awareness about congenital heart disease.
| Conclusion|| |
We conclude that new peripheral centers are needed for pediatric cardiac surgery to take care of ever-increasing burden of problem with population explosion and decongest the long waiting lists of central institutes. It is a reality that some children do die due to untreated congenital heart disease because parents do not want to travel to places where facilities are available but, in fact, plan the next pregnancy without any idea of genetic component to problem. We have made satisfactory progress in a year's time with two functional cardiac OTs catering all types of adult and minimally invasive procedures and basic congenital heart surgeries. In a couple of years, we would be doing complex neonatal surgeries, and a dedicated cardio-neuro center will be established in Uttarakhand state.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]