INCONTRO CON LA CARDIOCHIRURGIA PEDIATRICA DI PADOVA: STORIE DA RACCONTARE E DA CONOSCERE. Prof. Giovanni Stellin

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1 INCONTRO CON LA CARDIOCHIRURGIA PEDIATRICA DI PADOVA: STORIE DA RACCONTARE E DA CONOSCERE Le missioni umanitarie: «Progetto Elias» Prof. Giovanni Stellin UOC Cardiochirurgia Pediatrica e Cardiopatie Congenite Università degli Studi di Padova

2 Eritrea Italian colonization British administration Struggle for liberation Independency millions inhabitants

3 Capital: ASMARA Inhabitants Altitude: m Old Colonial City

4 Why Eritrea? One of the poorest countries of the world Past 30 years war region ( ) No human and economic resources No medical school until 2004 No pediatric, no cardiac surgery

5 Demographics Er USA I GER Population (mio) 6, ,3 81,3 Total fertility rate 4,4 2,06 1,40 1,41 Birth rate (per 1000 pop.) 32 13,7 9,06 8,33 Population growth rate (%) 2,4 0,96 0,38-0,2 Median age of pop. (years) 18,7 36,9 43,5 44,9 (Urban, )

6 Health Workforce Er USA F Physicians 1, Nurses Midwifes per population 2 in all: 12 pediatricians and 7 surgeons

7 Maternal and Child Health Indicators Er USA F Births (%) attended Maternal mortality Neonatal mortality Infant mortality ,1 3,3 Child < 5 years mortality by skilled personnel 2 per births 3 per life births

8 Incidence of CHD in Eritrea Life births per year Neonates with congenital anomalies Newborns with CHD (Urban, )

9 Hammer Forum is a German group of physicians who care for children in war and precarious regions of Europe In 1996 Hammer Forum started an humanitarian project in Eritrea THE GOAL To build an equipe at the International Operation Center for Children in Asmara (IOCCA) To commence surgical treatment for children in Asmara on a multidisciplinary basis including open heart surgery

10 The Model Project Central organization by ArcheMed (NGO) Infrastructure & equipment from all CT-teams Individual team funding by respective NGO Conjoint CT-team strategy & quality control

11 Participating NGOs ArcheMed e.v. Un Cuore Un Mondo Un Cuore Un Mondo Kinderherzen.ch Möhnesee, Germany Massa Carrara, Italy Padova, Italy Zurich, Switzerland

12 Participants teams Andreas Urban, M.D. Former Director of Pediatric Cardiac Surgery, Saint Agostin Hospital - Germany (Teams Coordinator) Bruno Murzi, M.D. Massa Carrara Hospital, Italy Pascal Berdat, M.D. Heart Care Medical AG Zurich, Switzerland Giovanni Stellin, M.D. Director of Pediatric Cardiac Surgery, Padova, Italy

13 Mission Eritrea Local coordinator University of Padua Team (Italy) (project Elias) Since 2004 Mr. Alem Demoz

14 Padova Cardiac Team composition Paediatric cardiologist 2/1 Anaesthesiologists 2 Pediatric cardiac surgeon 2 OR nurses 2/1 Perfusionist 2/1 Intensivist 2 PICU nurse 6/4 Total 13/18

15 Objectives of the Mission Correct CHDs Training of local people

16 The International Operation Center for Children in Asmara/Eritrea (IOCCA) (Former Ospedale Regina Elena )

17 The hospital

18 The Operating Room

19 Postoperative ICU 4 equiped beds (sometimes more )

20 Subintensive ICU 5 beds sometimes more..

21 Italian Equipement Supply Echocardiographers 4 Heart-lung machine 1 Heat exchange blanket 2 Portable x-ray machine 1 Electrocardiographer 1 Pediatric ventilator 1 Portable monitors 4 Infusion pumps 4 External Pacemakers 4

22 Hospital renovation and supply (ArchMed, Germany) Medical gases Modular oxygen producer Electricity Photovoltaic unit at the roof Uninterrupted power supply (UPS) Hygiene Floor, windows, doors enlarged Water At the moment supplied by tank trucks; process of creating independent water supply

23 Hospital renovation and supply (ArchMed, Germany) Operating room Anaesthesia room Cardiac surgical I.C.U. Cardiac surgical intermediate care Cath lab?

24 Patients management A forward team of pediatric cardiologists will screen patients with local cardiologists and select candidates for surgery Selected pts are further discussed among surgeons, cardiologists, anesthetists before surgery

25 Pediatric cardiologists (Prof. Ornella Milanesi + 1 younger pediatric cardiologist, rotating) Screening: clinical assessment + 2D-echo

26 Anesthesia team TEE Echo

27 CRITERIA for Patients selection (I) Single ventricle malformations are not usually treated Down syndrome patients are accepted, upon patients request No selection is made in according to age, body weight and/or CHD complexity

28 CRITERIA for Patients, selection (II) CHDs with associated severe pulmonary hypertension (i.e. large VSDs, CAVC) are selected for palliation (PA banding) and corrected 12 months later Arterial switches for TGA are performed when a large VSD is present and the LV is not deconditioned

29 Surgical activity Needs to be adapted to the local availability for Prosthetic material ICU efficiency and quality of care Drugs availability ICU beds

30 Pre operative patients status Nearly all of them have: Hypoalbuminemia Anemia Recurrent pulmonary infections Malnutrition Long-standing cardiac diseases (cyanosis, left-to-right shunt with CHF and PAH)

31 The OR team

32 Results (CT-Operations all teams) Number of cases NO CPB CPB 20 0 Year

33 Procedures Op s without CPB Op s with CPB others valves complex ASD coarct. PDA VSD

34 Results ( all teams) Cardiac-Procedures n = 1076 With CPB n = 716 No CPB n = 360 Early + late mortality (2%)

35 Cost-Effectiveness For the expense of one neonatal heart operation in Europe i.e ,- A team of 16 people including doctors, nurses and technicians can travel to, diagnose, operate and treat 20 children with CHD in Eritrea

36 Results at last follow-up All patients have been followed by Dr. Tsagareda (local pediatric cardiologist) Late death 1 pt 14 year-old patient after mitral valve plasty

37 MAIN GOAL: Training the local people Dr. Yoseph Tewolde Ghidei

38 Continuing education Multi-disciplinary teaching sessions included: In-job training Clinical lectures For doctors in-training, medical student and personnel, at different levels

39 Funding Donations Government support Industrial sponsorship Charitable foundations

40 Summary The goal of developing a Pediatric Cardiac Surgical program in Eritrea has been achieved by a European multi-institutional cooperation of 4 different surgical teams Early and long term results can be compared with those of the best cardiac surgical units in Europe and US

41 Future goals Catheterization Laboratory (nearly operating) Continue medical and surgical education Develop a totally indipendent Eritrean team

42 Conclusions A conjoint international multi-institutional cardio-thoracic team approach is feasible It could serve as a model for providing a sustained humantiarian Paediatric Cardiac- Service in a poor no-resource countries

43 We are very grateful to the Eritrean people for the great value in humanitarian experience which helps us in our daily work The Eritreans are very thankful to us for saving their children s lives