A decade of cardiothoracic surgery at a tertiary care hospital in Karachi, Pakistan.
ABSTRACT The medical records at Aga Khan University were reviewed to analyze the trends, mortality and patients characteristics of cardiothoracic surgeries in the last decade.
The medical records of all adult cardiac, thoracic and combined cardiothoracic operations performed during January 1995 to December 2004 at the Aga Khan University Hospital were reviewed. Data were retrieved and analyzed for trends, patient characteristics, and procedure mortality.
From January 1995 - December 2004, 4553 cases were eligible for the study, of which 73% were males and 9.4% were children. Male to female ratio changed from 1.3:1 to 3:1 from childhood to adulthood. Number of patients requiring cardiothoracic intervention increased continuously throughout the period, cardiac operations outnumbering thoracic or combined procedures. Ten-year average annual mortality remained 4.8% with slight variation per annum. Age distribution of cardiac surgery patients remained the same, however, constantly increasing number of over-70-year olds was observed. Mortality for isolated CABG, isolated valve and CABG with valve remained 1.9%, 4.3% and 18.3% respectively.
Trends of cardiothoracic procedures appear similar to those in the developed countries, so are the mortality figures.
- SourceAvailable from: aacn.orgCritical Care Nurse 05/2003; 23(2):72-91. · 1.07 Impact Factor
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ABSTRACT: To estimate the prevalence of diabetes and the number of people with diabetes who are > or =20 years of age in all countries of the world for three points in time, i.e., the years 1995, 2000, and 2025, and to calculate additional parameters, such as sex ratio, urban-rural ratio, and the age structure of the diabetic population. Age-specific diabetes prevalence estimates were applied to United Nations population estimates and projections for the number of adults aged > or =20 years in all countries of the world. For developing countries, urban and rural populations were considered separately Prevalence of diabetes in adults worldwide was estimated to be 4.0% in 1995 and to rise to 5.4% by the year 2025. It is higher in developed than in developing countries. The number of adults with diabetes in the world will rise from 135 million in 1995 to 300 million in the year 2025. The major part of this numerical increase will occur in developing countries. There will be a 42% increase, from 51 to 72 million, in the developed countries and a 170% increase, from 84 to 228 million, in the developing countries. Thus, by the year 2025, >75% of people with diabetes will reside in developing countries, as compared with 62% in 1995. The countries with the largest number of people with diabetes are, and will be in the year 2025, India, China, and the U.S. In developing countries, the majority of people with diabetes are in the age range of 45-64 years. In the developed countries, the majority of people with diabetes are aged > or =65 years. This pattern will be accentuated by the year 2025. There are more women than men with diabetes, especially in developed countries. In the future, diabetes will be increasingly concentrated in urban areas. This report supports earlier predictions of the epidemic nature of diabetes in the world during the first quarter of the 21st century. It also provides a provisional picture of the characteristics of the epidemic. Worldwide surveillance of diabetes is a necessary first step toward its prevention and control, which is now recognized as an urgent priority.Diabetes Care 09/1998; 21(9):1414-31. · 8.57 Impact Factor
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ABSTRACT: Reliable information on causes of death is essential to the development of national and international health policies for prevention and control of disease and injury. Medically certified information is available for less than 30% of the estimated 50.5 million deaths that occur each year worldwide. However, other data sources can be used to develop cause-of-death estimates for populations. To be useful, estimates must be internally consistent, plausible, and reflect epidemiological characteristics suggested by community-level data. The Global Burden of Disease Study (GBD) used various data sources and made corrections for miscoding of important diseases (eg, ischaemic heart disease) to estimate worldwide and regional cause-of-death.patterns in 1990 for 14 age-sex groups in eight regions, for 107 causes. Preliminary estimates were developed with available vital-registration data, sample-registration data for India and China, and small-scale population-study data sources. Registration data were corrected for miscoding, and Lorenz-curve analysis was used to estimate cause-of-death patterns in areas without registration. Preliminary estimates were modified to reflect the epidemiology of selected diseases and injuries. Final estimates were checked to ensure that numbers of deaths in specific age-sex groups did not exceed estimates suggested by independent demographic methods. 98% of all deaths in children younger than 15 years are in the developing world. 83% and 59% of deaths at 15-59 and 70 years, respectively, are in the developing world. The probability of death between birth and 15 years ranges from 22.0% in sub-Saharan Africa to 1.1% in the established market economies. Probabilities of death between 15 and 60 years range from 7.2% for women in established market economies to 39.1% for men in sub-Saharan Africa. The probability of a man or woman dying from a non-communicable disease is higher in sub-Saharan Africa and other developing regions than in established market economies. Worldwide in 1990, communicable, maternal, perinatal, and nutritional disorders accounted for 17.2 million deaths, non-communicable diseases for 28.1 million deaths and injuries for 5.1 million deaths. The leading causes of death in 1990 were ischaemic heart disease (6.3 million deaths), cerebrovascular accidents (4.4 million deaths), lower respiratory infections (4.3 million), diarrhoeal diseases (2.9 million), perinatal disorders (2.4 million), chronic obstructive pulmonary disease (2.2 million), tuberculosis (2.0 million), measles (1.1 million), road-traffic accidents (1.0 million), and lung cancer (0.9 million). Five of the ten leading killers are communicable, perinatal, and nutritional disorders largely affecting children. Non-communicable diseases are, however, already major public health challenges in all regions. Injuries, which account for 10% of global mortality, are often ignored as a major cause of death and may require innovative strategies to reduce their toll. The estimates by cause have wide Cls, but provide a foundation for a more informed debate on public-health priorities.The Lancet 06/1997; 349(9061):1269-76. · 39.21 Impact Factor
Adecade of cardiothoracic surgery at a tertiary care hospital in Karachi, Pakistan
Fahad Javaid Siddiqui, Shahid Ahmed Sami
Department of Surgery, Aga Khan University, Karachi, Pakistan.
Objective: The medical records at Aga Khan University were reviewed to analyze the trends, mortality and
patients characteristics of cardiothoracic surgeries in the last decade.
Method: The medical records of all adult cardiac, thoracic and combined cardiothoracic operations performed
during January 1995 to December 2004 at the Aga Khan University Hospital were reviewed. Data were retrieved
and analyzed for trends, patient characteristics, and procedure mortality.
Results: From January 1995 - December 2004, 4553 cases were eligible for the study, of which 73% were males
and 9.4% were children. Male to female ratio changed from 1.3:1 to 3:1 from childhood to adulthood. Number of
patients requiring cardiothoracic intervention increased continuously throughout the period, cardiac operations
outnumbering thoracic or combined procedures. Ten-year average annual mortality remained 4.8% with slight
variation per annum. Age distribution of cardiac surgery patients remained the same, however, constantly
increasing number of over-70-year olds was observed. Mortality for isolated CABG, isolated valve and CABG
with valve remained 1.9%, 4.3% and 18.3% respectively.
Conclusion: Trends of cardiothoracic procedures appear similar to those in the developed countries, so are the
mortality figures (JPMA 57:532:2007).
With the increase in chronic non-communicable and
man-made disorders, incidence of cardiac and thoracic
diseases has increased throughout the world with
concomitant rise in interventions required to treat these
diseases.1,2This increase is also due to the greater
acceptability of the treatment modalities as quantum leaps
in the progress of technology have made interventions
easier and safer.3-8This control over the situation is gained
because hospitals providing such services in the
industrialized world have developed a mechanism to share
their experience, and disseminate the knowledge to the
scientific community and medical industry across the
globe.9,10 This mechanism has allowed continuous
monitoring of effects of different procedures, techniques
and implants on the outcomes, thus providing a useful
feedback for making appropriate adjustments and
refinements in all aspects of cardiothoracic surgery.
In this background of ever increasing success rate, it
is not surprising that cardiac and thoracic surgeries are now
a commonplace in medical practice. Number of Coronary
Artery Bypass Grafting (CABG) alone exceeds 800,000 per
year globally.11Thoracic as well as the congenital cardiac
operations are also being performed with increasing
frequency and improved results.
Sharp increase in the chronic non-communicable
diseases such as coronary heart diseases (CHD) in
developing countries has also compelled the healthcare
sector to provide advanced surgical services in this part of
the world, but the concomitant development of data
collection and sharing mechanism is largely lacking,
especially in Southeast Asian region.1Consequently there is
paucity of scientifically collected data to show the need,
benefits and effects of interventions for CHD. A major
deterrent to maintain a data collection and processing
system (database) is its considerable cost, however, its
benefits outweigh the cost.12
At the Aga Khan University, a private tertiary care
hospital, with state of the art facilities for cardiothoracic
support, we had the opportunity to retrieve the data of last
10 years. The objective of this medical record review was to
look at the trends of cardiac, thoracic and combined
surgeries, patient characteristics and their outcomes over
the last decade.
A medical record review of all patients admitted to
AKUH for cardiothoracic surgery during last 10 years was
conducted. For administrative purposes some variables are
recorded in our hospital's database routinely, hence we
could obtain secondary data for the analysis. From the
AKUH information system department database we
retrieved data with selection criteria of 'all the surgeries,
done by classified cardiothoracic surgeons from January
1995 to December 2004'. All operating room (OR) re-visits,
e.g. for re-opening due to complications were excluded.
532 J Pak Med Assoc
Age was noted as the completed years at the time of
surgery. Any patient who had not crossed his/her 14th
birthday on the day of surgery was considered as a child.
Surgical procedures were coded using ICD 9.0
(International Classification of Diseases 9.0 Clinical
Modification). Any procedure having a code from 35.00 to
39.99 was considered as 'cardiac procedure', whereas all
procedures given codes from 30.00 to 34.99 were
considered as 'thoracic procedure'. All procedure codes
outside this range were for adjuvant procedures hence did
not affect the original classification of a case. However, if a
patient underwent procedures from both the cardiac and
thoracic code ranges, it was considered as 'cardiothoracic
procedure'. Multiple procedures done in one OR visit were
represented once. Isolated CABG operation was defined as
CABG with no simultaneous procedure involving valves,
aneurysms, septa, pericardium or any procedure for
congenital malformation. Isolated valve cases were also
defined in the same way. Any death before discharge of the
patient was counted towards mortality due to the surgery. As
cardiac procedures were the most common type of
procedures, it was analyzed in greater detail.
Data was retrieved from AKUH electronic database
and imported into SPSS® version 12.0 (SPSS Inc., Illinois,
USA). All reopen procedures were deleted from the dataset.
Appropriate variables were created using ICD (9.0 CM)
procedure codes. Frequencies and cross tabs were run to get
statistics. Charts were made by exporting tables to MS
Excel® (Microsoft Corp. Redmond, WA, USA).
From January 1995 to December 2004, we found
cases of cardiothoracic
inclusion/exclusion criteria. Out of these 3321 (72.9%)
were males. Adults were 4217 (90.6%). Among adults, male
to female ratio was 3:1 whereas among children it was
1.3:1. Majority of the procedures were cardiac (75%),
cardiothoracic procedures were 5% and rest were thoracic
(20%). Trend over time showed ever increasing number of
cardiac operations, whereas number of other procedures
displayed relatively little change (Table 1). Cardiac
procedures were more commonly done on very young,
middle and old age people whereas thoracic procedures
were mostly done on people between 15 to 30 years of age
(Figure 1). As the age increased, the percentage of females
undergoing cardiac or thoracic surgery decreased from
nearly 46% to 20% stabilizing there after (Figure 2).
4553 surgery fulfilling
Overall ten year in-hospital mortality of the cardiac
surgery unit remained 4.8%, 8 (0.2%) patients either left
against medical advice or were transferred to another
facility for various reasons and the rest (95.0%) were
discharged home. Combined mortality trend over the
decade showed that there was a little variation, ranging from
2% to 10%. Category wise ten year mortality of cardiac,
thoracic and combined procedures was 3.4%, 5.4% and
Table1. Cardiothoracic procedures and proportionate composition of
work load at cardiothoracic surgery department, the Aga Khan
University, Karachi, Pakistan (1995 - 2004).
Type of operations
Cardiac (%)Thoracic (%) Cardiothoracic (%)
1 09 (16.5)
Figures 1. Age distribution of cardiothoracic surgical procedures done at the Aga Khan
University Hospital, Karachi, Pakistan (1994 - 2004).
Figures 2. Gender distribution of cardiothoracic procedures done at the Aga Khan University,
Karachi, Pakistan (1995 - 2004).
Vol. 57, No. 11, November 2007533
23.1% respectively whereas mean (SD) of these mortalities
were 4.4 (1.3), 6.1(2.0) and 22.2 (22.2) respectively. There
was also no significant difference of average mortality of
these categories between first half of the decade and the
second (p-values: 0.63, 0.73 & 0.98).
Age distribution of patients undergoing cardiac
surgical procedures did not show any change although we
received larger number of patients from each group in
successive years. Patients undergoing cardiac surgery in
their 70s increased constantly and in 2004 we also operated
upon 3 patients who were in their 8th decade of life.
Isolated CABG was the most commonly done
operation among the cardiac procedures (2674; 79%)
followed by isolated valve operations (255; 7%). Other
major cardiac procedures (213; 6%) included surgery of
aneurysms, septal repairs, pericardiectomy, correction of
Tetralogy of Fallot, and systemic to pulmonary shunts.
CABG with valve or other procedures were relatively less
frequently done (67; 2%). Remaining were miscellaneous
procedures like redo CABG, redo valves, redo CABG with
valve and cardiac myxomas (208; 6%).
Ten year mortality of isolated CABG and isolated
valve was 1.9% and 4.3% respectively. CABG when
combined with valve or any other procedure carried higher
mortality (18.3% and 14.3%). Other major and
miscellaneous cardiac procedures (as described above) had
8.5 and 10.6% mortality.
Isolated CABG mortality is now considered as the
indicator of quality of care of any cardiac surgery unit. Our
experience showed that initially mortality increased as the
patient load increased until 2001 but thereafter it constantly
decreased to reach a lowest level of 1.1% in 2004.
We also looked at the isolated valve mortality. At our
unit total of 255 isolated valve procedures were done from
1995 to 2004. Out of these less than one fourth (59) were
carried out in first half. Total deaths were 11 making over all
mortality of 4.3%. Mean (SD) of mortality per year was
4.5% (4.1). There was no association between year of
surgery and mortality (p<0.18). Average mortality rate
during the first half was also compared with the second half
using t-test. No significant difference was found again
(p<0.96). Mortality nevertheless ranged from 0 - 12%.
Despite being fortunate to have the facilities of a
well established information technology department which
keeps electronic records of all the procedures being done at
the hospital, only a very small number of variables were
being recorded. It is because this data was not collected for
medical outcome research purposes, but rather for
administrative purposes. Therefore, we had secondary data
with its inherent problems, including missing information
and unclear definitions. Data were also not entered twice to
enable detection of key punching errors. However, during
our analysis we found only couple of key punching errors
which was rather unusual for any secondary data. Further,
as for the coding of surgical procedures ICD codes were
used, ambiguity in definitions was also avoided. So we had
relatively much valid data to analyze.
Population is aging world over and so is in our
region. Demographic and epidemiologic transitions are
behind this phenomenon.1In Europe life expectancy was
raised from 71 years to 83 years in the last four decades and
life expectancy at age 65 ranged from 16 to 19 years.13In
US it increased to around 2 years since 1989, the smaller
increment may be due to already high life expectancy of
75.5 years.14A much sharper 5-6 year increase has been
observed in Southeast Asia in the last 7 to 8 years.15On the
one hand, it is a sign of protection from diseases and
hazards in early years of life but paradoxically, it also serves
as an indicator of higher prevalence of degenerative
diseases in later age.16Increasing incidence of condition
like coronary artery disease with increasing age has been
reported in the absence of any other risk factor.17,18This
provides sufficient evidence to support our observation that
more and more people are requiring intervention for
cardiovascular illnesses. Furthermore, diabetes mellitus, an
established risk factor for coronary heart disease (CHD) is
on the rise worldwide, while obesity, smoking,
dyslipidemias and hypertension are highly prevalent
indicating that CHD will rise further.19-21Moreover, despite
addition of other cardiothoracic surgery centers in the city
AKUH received increasing number of patients. This gives
further support to our premise that number of people
requiring cardiovascular interventions is rising.
We found that as the age increased, males made the
larger proportion of the cardiothoracic surgery patients. In
the early years of life, the male to female ratio was almost
equal. This is because gender does not significantly
influence the occurrence of congenital malformation,
therefore both sexes were represented equally. However, we
know that as age increases, certain factors act differently on
each gender for example females are protected by their
hormones against cardiovascular diseases.9However, this
change in proportion might not be only due to physiological
reasons. Factors like health care behaviour may also be
acting, at least in our part of the world, e.g. preference is
given to the bread earner of the family in case of health care
need. This preference often persists even after the bread-
earner has grown old and has retired.22
Isolated CABG mortality world wide is decreasing.
The European Association of Cardio-thoracic Surgery
534J Pak Med Assoc
database report of 2005 shows the same trend and so does
the Spring report of Society of Thoracic Surgeons, USA.10
Furthermore, isolated CABG is now considered to be the
indicator for quality of care of any unit as the procedure is
now standardized and statistical models have been
developed to calculate the preoperative mortality of each
patient undergoing isolated CABG.
Valve surgery is although being done more
frequently, but not only is the mortality still high, around 4
- 6%, but also no clear decreasing trend is seen.10Our
experience, too, was not much different from the other
centers across the globe. It ranged from 0% to 12% over the
decade in our center with a decline in later years.
Despite having good quality data, we felt restricted
due to the paucity of variables available to us. This is
because there is no mechanism for collecting and
computerizing cardiothoracic surgery patient data routinely.
Variables to look at the preoperative mortality of patients
were insufficient to adjust mortality rate. The high mortality
of cardiac surgery can be due to selection of high risk cases
for surgery and may not always indicate poor quality of
care. The evaluation of such patients with risk stratification
systems like EuroSCORE, Parsonet score etc have helped in
calculating risk adjusted mortality which is gradually
becoming a prime indicator of performance.
Since we are presenting data of a single center only,
it is not representative of the population. Therefore, there is
a dire need to develop and maintain data collection and
processing systems for cardiothoracic surgeries at all the
centers providing such services. This can help formulate
national policies for the future.23
Cardiac and thoracic operations are being done more
frequently in which cardiac procedures dominate. Less than
10-year-olds and adults over 40 undergo cardiac surgery
more frequently. Thoracic surgery is more commonly done
in age group of 10 - 40 years. Percentage of females among
cardiothoracic surgery patients decreases as the age
increases which may not only due to physiological reasons.
The cardiac surgery trends show increasing number of
elderly being offered surgery. Most common procedure is
isolated CABG with a crude mortality not different from
western centers. Other isolated and combined procedures
carry higher mortality risk.
Trends of cardiothoracic surgery seem comparable
with the west but extensive and more representative data
must be obtained from centers across the country to identify
national trends in cardiothoracic surgery ultimately leading
to development of firmly based action plan.
We hereby acknowledge the support of Health
Information Management Systems, The Aga Khan
University, especially the help of Ms. Amna Safdar, who
provided us the required data for analysis. There is no
conflict of interest to declare.
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