Open Heart Surgery “The Nigerian Experience”

1. Open Heart Surgery “The Nigerian Experience” Dr Michael Sanusi, FACS FWACS Cardiovascular Surgeon TriStateCardiovascular Institute

2. Introduction • History of open heart surgery in Nigeria • The 80’’s and 90’s • Activity now • The future

3. Open heart surgery in its strictest definition is surgery done within a cavity of the heart e.g intracardiac valve replacement or closure of an intracardiac defect.

4. The definition is however expanded to any surgery in which the great vessels of the heart are cannulated for cardiopulmonary bypass support e.g coronary artery bypass surgery, cavopulmonary shunts or ascending or arch aortic repairs

5. Recently, procedures that have evolved to pump standby only e.g off pump coronary bypass or Glenn anastomosis are also classified as open heart surgery.

6. History of Open Heart Surgery • John Heysham Gibbon (USA) invented the heart lung machine in 1935 and performed open heart surgery using it in 1952. • He however performed the first successful open heart surgery a year later May 6 1953. • Today about 5 million open heart surgeries are performed world wide.

7. Original Gibbon machine

9. Early Heart Surgery in Nigeria • Mr John Weaver a British cardiothoracic surgeon practicing at the UCH Ibadan did first “closed” heart surgeries culminating in the first closed mitral valvotomy in 1960.

10. The first open heart procedure done in Nigeria was at UNTH Enugu in 1974 with a team led by Sir Magdi Yacoub from the UK and by Prof Fabian Udekwu an American trained surgeon employed by UNTH.

11. Enugu • Prof Udekwu had left UCH Ibadan in 1967 at the start of the civil war. • After the war, he concentrated on the establishment of open heart surgery at UNTH. • He developed strong relationships with Dr Magdi Yacoub a very successful UK surgeon of Egyptian origin.

12. Sir Magdi Yacoub Prof Fabian Udekwu

13. Prof Grillo, Dr Adebonojo Dr Adebo and their team performed open heart surgeries in UCH Ibadan between 1978 and 1982 • UCH did total of 5 cases

14. The 80’s and 90’s • Open heart surgery in this era was limited in Nigeria to UNTH Enugu • The main drivers were Prof Martin Aghaji and Dr John Okereke • Total of about 102 cases were done during this time. • The program became dormant in the late 1990’s and Dr Okereke left for greener pastures

15. Cases done at UNTH up to the 90’s Eze J C Ezemba N: Open heart surgery in Nigeria: Indications and challenges. Tex Heart institute Journal 2007; 34(1): 8-10

16. The 21st Century • The rebirth of open heart surgery in Nigeria was in Lagos 2004 when Global Eagle Foundation led by Dr Jonathan Nwiloh from Atlanta visited LASUTH and operated on patients. • The series of surgeries by GEF encouraged Mr Bode Falase a UK based cardiothoracic surgeon to return back home and help LASUTH build and sustain a cardiothoracic program.

17. The LASUTH program was initially promising but never went past its infancy stage. • A critical care unit was set up to facilitate surgeries • I joined LASUTH October 2009. The open heart surgery program has not been active since December 2011.

18. UNTH Enugu recorded 102 cases while the program was active. • LASUTH did 51 cases involving cardiopulmonary bypass between 2004 and 2011.

19. Why did these programs fail? • They were both completely under the care of public institutions • Doctors were salaried and completely subject to whims and visions of their medical and departmental directors. • There was no unit solely committed to cardiology, cardiac anesthesia or cardiac surgery (cardiac was like a hobby).

20. Challenges • Patient ability to pay. • Commitment of Infrastructure e.g sharing icu and operating room equipment. • Commitment of personnel and intellectual resources (hospital distractions) e.g cardiology taking care of rheumatology. • Training and staff development.

21. Other challenges • Political inertia. Status quo • Personality clashes ** • Cardiologist incentive from abroad (medical tourism). • Not many “easy” cases (late pick up/referral) • Ignorance among primary care providers

22. Currently active programs • Tri State Cardiovascular associates/UCH/Babcock University program Prof AdelekeProf DavisProf ObaroDr MajekodunmiDr SalamiDr Sanusi

23. UNTH Enugu • VOOM foundationDr Nzewi • UNTH teamProf Aghaji others

24. Garki Hospital Abuja • Dr Miner • Dr Okereke • Dr Sanusi • Dr Talabi

25. Bickett Hospital Oshogbo • Dr Adenle • Dr Onakpoya

26. ? Gbagada cardiorenal program • Reniscore Group • Rebirth of Lagos State vision

27. Models of activity • Public e.g LASUTH • Public Private Partnerships e.g UCH/Tristate, Garki hospital • Private e.g Bickett medical center

28. Public Private Partnership • Tri State Cardiovascular associates is a private cardiovascular group composed of surgeons, cardiologists with anesthesia and perfusion services • The group has contracted with a public institution( UCH Ibadan) to provide interventional cardiology, structural heart and cardiac surgical services • To date 18 surgeries have been performed with 100% successful hospital discharge.

29. Public Private Partnership • Garki hospital Abuja • Government owned facility contracted management out to a private group • Easier to organize specialized care e.g open heart surgeries and renal transplants • 5 open heart surgeries 100% success and a number of closed heart surgeries.

30. Public Private Partnership • Another example is the planned concession of the Lagos State Cardio renal center to a private group (public private). • This group now will have agreement with professional clinical groups for actual service delivery (private-private)

31. Private • Open heart surgery at Bickett hospital. • Focus on congenital heart disease patients. • Total 12 cases done by 2 teams.

32. Surgical Missions • Surgical missions model still enjoys success in parts of Nigeria in both the public and private sectors • The VOOM foundation/UNTH is an example in the public sector while Bickett hospital Oshogbo works this model in the private sector.

33. Problem with surgical missions • Sustainability • For effective skills transfer there has to be already a minimum basic level of training

34. Mix of cases • Most Adult cases have been valvular specifically rheumatic heart disease. • I am aware of only 4 coronary bypasses but with increase in cardiac catheterizations there will be more cases diagnosed. • Pediatric cases have mostly been ASD, VSD, TOF repairs with 2 Glenn bidirectional shunts done for single ventricles at LASUTH.

36. Growth of cardiology • Cardiac catheterization lab at Reddington hospital Lagos and later at UCH Ibadan has encouraged open heart surgery especially coronary and congenital surgeries. • There is also a mobile catheterization lab in Abuja • Cath lab in Kano AKTH • Better quality echocardiography machines

37. Financing cases • Financing for surgery in Nigeria has been mostly fund raising from friends, families and foundations • Most middle and upper class families would rather pay for surgery abroad • NHIS has promised to pay for 100 OHS this year

38. Some foundations have sponsored and some have asked patients to raise money • There have been attempts to form a central foundation dedicated to help patients to raise funds for OHS. • So far cost for open heart surgery has ranged from 500k to about 2.5M dependent on subsidies.

40. Way forward • On ground fully indigenous team prepared to do surgery as soon as diagnosis is made. • Good results should spur confidence in local teams and increase volume of surgery. • Foundation dedicated to raising funds and sponsoring of the less privileged • Health insurance funding for open heart surgery