Developing a cardiac surgery unit in the Caribbean: A reflection

Background and Aim
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.

Methods
The program started in 1993 with monthly visits by a team from Bristol Heart Institute. A group of local doctors, nurses, and perfusionists were identified for training, and a senior nurse moved to the island to start a teaching program. The visiting support was gradually reduced, and the local team gained independence in managing the service in 2006.

Results
The initial low volume surgery increased to around 380 cases a year with the implementation of comprehensive service in 2006. Most patients required coronary artery bypass graft (CABG). In‐hospital mortality declined from 5% in the nascent years to below 2% thereafter. In the last 5 years (2015‐2019), 1764 patients underwent surgery (mean age 59.6 ± 10.8 years, 66% male). The majority were East‐Indian‐Caribbean (79.1%) or Afro‐Caribbean (16.7%), half had diabetes, and two‐thirds hypertension (EuroScore II 1.8 ± 1.9). The majority (1363 patients) underwent CABG (99.5% off‐pump; conversion to on‐pump 1.5%). The mean number of grafts was 2.5 ± 0.7 with 98.5% and 23.1% receiving one and two or more arterial grafts, respectively. In‐hospital mortality was 1.1%, re‐exploration for bleeding 2%, stroke 0.1%, mediastinitis 0.2%. The length of the postoperative hospital stay was 5.8 ± 2 days.

Conclusion
Frequent outside visits complemented by training in an overseas center, and transfer of knowledge proved to be an effective strategy to develop a cardiac surgery unit in an emerging country with results comparable to accepted international standards.