Download Department of Cardiothoracic Surgery

Department of
Cardiothoracic Surgery
Clinical Activity report 2007 - 2012
CONTENTS
2 Chairman Letter
4 Clinical Profile
6 General Outcomes
10 Clinical Activity
26 Staff Training
28 Innovation
30 Science & Publications
32 Staff
T
he Department of Cardiothoracic Surgery at Hospital Santa Marta built a solid
tradition in the surgical treatment of heart and lung diseases, that it has pioneered since 1959. The unit was the birth place for the speciality in the country and the
site of continuous innovation, also being the training nest for the great majority of
practicing surgeons among us.
This tradition is honoured by undisturbed quality and meets modernity, innovation
and sustainability in the unit’s everyday commitment to patient care and professional development, in the path of our predecessors.
We invite You to follow us down these lines, to meet the People and the Unit, to
know who we are, what we do and what we aim for, through the scope of Quality
assessment.
Caring
Competence
Technology
Prof. José Fragata
Chairman and Professor
Tradition, Innovation and Ambition, all set
the horizons for the future of the Cardiothoracic Department in Santa Marta.
Our mission is diverse and well perceived by
each and every member of the Team:
INNOVATION
EXCELLENCE IN PATIENT CARE
KNOWLEDGE DISSEMINATION
SOCIAL COMPASSIONATE CONCERN
These all focused on Chest Medicine and centred on the Patient’s superior interests.
We wish to share with you the whole of the
Quality Report regarding our activity from
2007 until 2012, focusing on benchmarked
patient care outcomes, performance, scientific production, resident training and satisfaction.
Our vision is to hold a strong Leading position in Cardiothoracic Surgery in Portugal,
and reading through this report makes one
understand why we, as a team, feel so proud
to follow this vision over the years and in the
future ahead.
2
Dr. Teresa Sustelo
Chairman Board Administration, CHLC
As Thomas Jefferson said “I like the dreams
of the future better than the history of the
past”. We, at Santa Marta, foresee a brilliant
future for our department at Lisbon’s Oriental Hospital, the newest academical medical
center in Portugal.
Our Patients, our fellow Colleagues and the
Society at large can count on us for competence, dedication and passion for sustainable development in the field of Cardiothoracic Surgery.
Thank You
Professor Doutor José Fragata, MD, PhD,FETCS, FESC
Chairman Cardiothoracic Surgery
Full Professor of Surgery
Enf. Clara Vital
Chief Nurse
THE
Dr. Vanessa Rodrigues
Department Manager
TEAM
3
STRUCTURE AND CLINICAL PROFILE
The Cardiothoracic Department at Santa
Marta became a part of a huge Medical Center – Centro Hospitalar de Lisboa Central,
EPE, with 1500 beds, in downtown Lisbon.
The Department is fully affiliated with Universidade Nova’s Faculty of Medical Sciences
and its Director is full professor of Surgery.
The Cardiothoracic Department is a supra-regional unit, serving a target population of
Lisbon city and the South, also getting broad
long distance referrals, as far as the Azores
or African countries, due to combined reputation, results and technical specialisation.
The Unit is based at “Edifício do Coração”
in Santa Marta, door to door with the Adult
and Pediatric Cardiology Units and the Cath
Lab, also very close to Vascular Surgery, forming a true medico surgical cardiothoracic
and vascular compound.
4
Cardiothoracic Unit comprises a total of 27
ward beds, 9 adult ICU beds, 3 isolation cubicles, 5 ICU paediatric beds and 5 high dependency care beds. Three devoted operating
theatres and 2 consultation rooms, make up
for a well centralized and functional clinical
facility.
The Department is very sophisticated and its case complexity is
among the highest in the country, with an average case mix of
4,8, almost five times the average national complexity
STRUCTURE AND CLINICAL PROFILE
The unit employs 14 surgeons, 5 residents, 5 paramedics, 86 nurses, 4 secretaries and 25
clerks. Altogether we are 129 staff, adds up to 5000 working hours a week. A part time Administrator, 14 Anaesthetists and several other auxiliary staff work daily in the Department.
A case load of over 1200 cases a year, comprising adult cardiac surgery, neonatal and children cardiothoracic operations, grown up congenital hearts, thoracic surgery, mechanical
heart devices, cardiac transplantation (from infancy to senior ages), lung transplantation and
ECMO make up for the treatment options portfolio.
The unit is unique in the country, as it provides all types of interventions in the speciality and
is the National centre for lung transplantation.
The Department and the whole Hospital holds a CHKS certification since 2004 and the Paediatric Unit passed an official audit by the EACTS congenital Database Centre in 2009.
The Unit is public and funded by taxpayer money, spends an average of 15 millions euro each
year!
5
OUTCOMES
For the whole period (2007-2012), 7000 patients were operated, another 30 000 were
seen at the outpatient clinics and an estimated number of 10 000 people visited the Department each month. Over the last five years and every year, a rather stable case load
of 1200 patients were operated in the Department, covering all fields of the Speciality.
Cardiac cases represent the great majority - 75 % -, and the case distribution is displayed
below. The Thoracic area represents 25 % of all cases and it is expanding in both numbers
and complexity. Case complexity profile, mortality and complication rates are regulary
reported, for registry and benchmarking purposes, to both the Dendrite System and the
European Congenital Database of the EACTS.
Cardiothoracic Surgery
2007/2012
Nr. patients intervencioned
(2007/2012)
1400
1200
1000
1244
1224
1175
1173
1192
274
991
800
24,68%
Thoracic
600
400
75,32%
Cardiac
200
0
2007
2008
2009
2010
2011
2012
2012 - 991 patients untill September; 1260 patients estimated
N= 6999
Cardiac Surgery
nr. patients per procedure
(2007/2012)
Case profile, mortality and
complication rates are regularly reported, for registry
and benchmarking purposes,
to both the Dendrite System
and the European Congenital
Database of the EACTS.
30,70% CABG isolated
26,75% Valve
13,91% Other cardiac
13,47% Congenital
5,71% CABG + valve
4,93% Multiple valve
3,40% Aorta
0,68% Heart transplant
0,46% VAD
N= 5257
6
OUTCOMES
Periodic reports display performance indicators, as “observed / expected ” (O/E) ratios,
mortality and complications being adjusted to complexity. Also, patient satisfaction surveys are systematically conducted. Every three months the Department publicizes its performance, safety and satisfaction rates, for transparency and accountability.
Global hospital mortality for the whole set of age groups and specialities and for the all
period was 3.5%. Adjusted (O/E) mortality for Adult Cardiac Surgery was 0.6, for Paediatric
Heart Surgery was 0.7 and for Thoracic surgery was below 1% (non adjusted). These values
translate superior outcome quality as they stay fairly below expected mortality figures for
the complexity. Put it this way - as we like to put it at Santa Marta - for the all period of report
and looking to the CUSUM chart, displayed chart, where actual and predicted mortality curves
are represented, we have saved over 70 lives!
Patient status at discharge Based on 3144 Cases
200
150
#-Failed
Actual
100
50
0
2008
2009
2010
2011
Years
2012
Expected
Together with the Hospital Group, the Department periodically supplies data to the IASIST®
benchmarking system, and compares favourably to other Iberian levelled institutions. Typical
analysed outcomes are: mortality, complications (that we score according to their impact),
patient safety - adverse events (infection rates). Our performance matches very favourably
with the hospital group namely on risk adjusted mortality and readmission rates (70%).
IASIST
PERFORMANCE DATA
Santa Marta
Benchmark
17,20 16,94
5,11
3,84
Case-Mix Complexity INDEX
3,60
3,73
Risk Adjusted Mortality (%)
Risk Adjusted Complexity (%)
7
OUTCOMES
Nowadays costs are also “production outcomes”, among other efficiency indicators
as number of patients treated per bed, and
length of stay. However, all these need to
be related to complexity. In order to access
Complexity, the Unit uses the “DRG’s” generated “case-mix” index, the EUROScore®
(logistic) for Adult Cardiac Surgery and the
Aristotle Complexity score® for Paediatric
Cardiac Surgery.
We register complications of surgery on a
very strict way; a blood transfusion or an
unconsequential episode of Atrial Fibrillation is recorded as a grade I complication.
Unsurprisingly, and also due to the higher
case-mix and patient age, 1/3 of patients get
at least one complication, most without any
relevant clinical impact. For IASIST our cru-
de complication rate scores 17%, in line with
the benchmark. Regarding severe complications, for instance infection rate (sepsis
or mediastinitis) the score is 4%, which is
nearly half of national average, making of
Santa Marta’s Cardiothoracic Department a
“clean” place.
Patient satisfaction has constantly been improving, and constitutes a major quality indicator. Satisfaction enquires are regularly
conducted by our nursing staff at the follow
up monitoring activity, and show a remarkable 98% patient satisfaction rate, with well
over 90% of patients willing to recommend
the Unit to a relative, a friend or fellow.
Complications
Stroke
2,5%
Acute renal
failure
2,1%
Atrial fibrillation
18,1%
Acute cardiac
failure
3,0%
No
complications
66,9%
IABP
5,1%
Mediastinitis
0,2%
Reop_Bleeding
2,2%
8
OUTCOMES
Patient satisfaction has always been improving, and constitutes a major
quality indicator Satisfaction enquires are regularly conducted by our
nursing staff at the follow up monitoring activity, and show a remarkable 98% patient satisfaction rate, with well over 90% of patients willing
to recommend the Unit to a relative, a friend or fellow.
9
VALVE DISEASES
Valve surgery represents 27% of our cardiac
case load. The prevalence of valve disease among us has increased, due to the fact
that our population is getting older and degenerative aortic pathology is getting more
prevalent, as squeals of rheumatic fever are
becoming more rare. At present, aortic valve
replacement in the senior population represents a significant share of all valve procedures, typically using stent pericardial valves.
Aortic valve repair is not widely practiced in
the unit, except for some congenital cases
and in the setting of aortic aneurysms. Ross
surgery was used in no more than 25 patients,
during this period, typically infants or adolescent girls, with a very high success rate and
no hospital mortality.
Mitral valve repair was possible for over 46%
of our mitral regurgitation cases. Mitral repair techniques are now mastered in the unit
by using a large portfolio of tools: leaflet direct repair, artificial cordae replacement and
other complex reconstructions. Also, atrial fi-
brillation ablation surgery, by pulmonary vein
isolation techniques, was introduced earlier
and practiced whenever indicated. Till now
35 cases were done with a sinus rythm success rate of 73% at one year.
Results with valve surgery are specially good:
Risk adjusted mortality for isolated mitral
and aortic valve surgery is respectively 1%
and 3%. Mortality for aortic valve replacement in the octogenarian scored bellow 5%.
Despite these remarkable results, treatment
for aortic stenosis in the very high risk patient is now also provided by the Heart Team
(surgeon and invasive cardiologist) using the
TAVI option. This type of catheter valve interventions is being performed in partnership
with Cardiology, having done, so far 25 cases.
The activity, mainly performed by transfemural root as being led by our cardiologists and
will soon be expanded, when our hybrid operating room facility will become available.
Mitral Valve
repair and replacement procedures
Mitral Valve
replacement
54,0%
10
Mitral Valve
repair
46,0%
VALVE DISEASES
11
CORONARY HEART SURGERY
The numbers for CABG surgery cases globally
decreased by 25% due to the advent of PCI.
The percentage of isolated CABG patients
among us is not more than 31%. At present,
age, co-morbidities and more complex forms
of disease all account for added surgical risk;
however crude mortality for isolated CABG
has been low in the department, around 2%.
This level of results is due to improvement in
techniques and the progressive adoption of
off pump CABG. This has made the difference,
specially for the older age and sicker group.
Our overall percentage for off pump surgery is
23% for us, with a clear trend to increase.
The quality sustainability for CABG surgery
specially relies on the widespread use of, at
least, one mammary artery. This has occurred
in 98% of our CABG cases. Patients below 60
years of age tend to get two mammary arteries, as this proved to be superior and that
percentage was for us, and for patients younger than 60 years, of 37% also with a tendency
to increase. More, regarding quality standards, 88% of our CABG patients are discharged
on anti platelet therapy, 84% under statins and
75% on Beta - blockers.
CABG Distribution
other CABG
15,67%
CABG isolated
84,33%
CABG Mortality
CABG mortality (O/E)
4,5%
4,0%
3,5%
3,0%
0,51
2,5%
3,9%
2,0%
1,5%
1,0%
2,0%
0,5%
0,0%
CABG mortality (Observed)
12
CABG mortality (Expected)
ARRHYTHMIA SURGERY
Surgery for Atrial Fibrillation has been used for very selected groups of patients: permanent,
non lone and for atrium sizes < 60 mm. So far, 35 pulmonary vein isolation procedures, by
ultrasound ablation (EPICOR), were applied over the period, with a yearly AF recurrence freedom of 73%. Presently there is a clear decrease of AF surgery, as interventional cardiology is
progressing more and more in this area.
13
HEART FAILURE
With the increment in population survival Heart Failure became a real health care issue.
However, the progress in this area has been
outstanding: new drug regimes and mechanical assist devices are predominantly responsible for that progress and, again, this is an area
for common effort initiatives from the “Heart
Team”. Besides conventional surgery: myocardial revascularization, valve replacement,
ventricular restoration therapies (addressing
the coronaries, mitral valve and ventricular
geometry), the Department has been focusing on para-corporeal ventricular assist devices: the Thoratec pneumatic pump for adults
and the Berlin heart for children. Altogether,
27 patients were mechanically supported: 20
adults and 5 children were bridged to transplantation and 2 of those patients were bridged to recovery. On 14 occasions the support
was univentricular and on 11 it was bi-ventricular; mean time under assistance was 41 days
and the percentage of transplanted patients
was 57%. Global survival after transplantation
was 85%. The Department is well equipped
with one Thoratec Console, two ECMO systems and a Levitronix system, and easily accesses the Berlin Heart for heart support in
kids. Heart transplantation still represents
the most valid long time option for managing
heart failure. The Department has a long and
pioneering 25 year old long tradition in heart
transplantation, and a total caseload of 113 cases. Over the last 5 years we have transplanted 37 patients and the global survival rate
is 65 % at 5 years and 45 % at 10 years, similar
to the IHLTS – International Heat and Lung
Transplantation Society.
14
Diagnosis for heart transplantation
Valvular Heart Other
3,7%
Disease
Congenital Heart 5,5%
Disease
1,8%
Ischemic
Cardiomyopathy
38,5%
Noc-Ischemic
Cardiomyopathy
50,5%
Kaplan Meier Survival curve (1987-2011)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
1
2
3 4 5 6 7
8 9 10 11 12 13 14 15 16 17 18 19 20
Years
HEART FAILURE
Heart transplant kids are marathon athletes
15
AORTA
Treatment for aortic aneurysms and aortic dissections has improved dramatically over the last
five years. Cerebral protection strategies that we now use routinely in the Department, such
as selective antegrade cerebral perfusion, spinal fluid drainage and NIR “Invos” spectrometry
monitorization have all contributed to that. The concept of global – segmental aortic approach, oriented by sophisticated aorta scan reconstructions was decisive, as was the approach
through well balanced combinations of multistage surgical strategies and the use of aortic
stenting. It is now possible to address all segments of aortic pathology with minimal intervention risks. Over the last five years 200 aortic cases have been dealt with the Department with
a global neurological damage rate of 2%. For elective aortic aneurysm surgery, involving the
aortic arch, mortality of 3.3%, reaching almost 30% for emergency dissection surgery. During
that period 35 TEVAR cases were performed, 50% with preparing hybrid procedures, namely
debranching of arch vessels, with a global mortality of 5%.
Patology
Aorta Ascending Aneurysm
Aorta Dissection Type A
Pseudoaneurysm
TEVAR
Debranching
Other
8%
3%
19%
51%
6%
13%
One area of innovation and encouraging results is endo aortic surgery. This technique was initially designed to cover descending aorta dissections and / or aneurysms, but we have extended
it to treat aortic arch aneurysms, using a double stage approach: initial surgical debranching of
the head vessels, to create a safe landing area for the prothesis and stenting the aneurysm a
few days later, completing total thoracic aorta replacement. For simple cases, stents may even
be inserted in the awaked patient by endo-aortic surgery. This approach has been a great pretext for the action of the “Cardiovascular Team”: cardiac and vascular surgeons, supported by
anaesthetists in theatre and backed by vascular radiologists and top image technologies. This
is an area of great innovation and disruptive market changes!
16
AORTA
17
PAEDIATRIC HEART SURGERY
Traditional paediatric heart surgery became,
indeed “congenital heart defects surgery”, to
comprise all its spectrum, from neonates to
adults – the “GUCH” population. Our Department has a strong tradition at treating congenital heart lesions, dating back to the sixties,
and continuing until today and into the future.
We will consider, for analysis, neonatal, infant
and children surgery, on one side, and grown
up congenital hearts (GUCH) on the other.
Over the last five years more than 800 congenital heart patients, less than 18 years old,
were treated with a success rate of 3% (European benchmark of 4.5% and complexity matching mean European Aristotle complexity.
Complication rate for children was 21%).
Particularly encouraging are results for neonatal surgery – mortality of 8.2% comparing favourably to European (10.3 %), mostly because
all types of malformations were treated, some
with undeniable innovation, as the hybrid treatment for hypoplastic left heart syndrome,
managed at first stage by the PEDIATRIC HEART TEAM (pediatric cardiologists, surgeons
and anesthesiologists, on the medical side,
backed by all other staff).
Globally, the experience with Glenn and Fontan strategies for all forms of single ventricle
lesions has been gratifying, with over 150 cases, one of the largest in the country, and a
near 0% mortality.
Treatment of heart failure in children, again
a good example of medico surgical interdisciplinary action is, also, an area of rewarding
satisfaction: 5 patients were mechanically supported with Berlin Heart for a median of 90
days , as a bridge to transplantation or recovery (one case by ECMO). During that period,
ECMO was used as needed for post cardiotomy recovery bridge.
18
7 patients were transplanted, with a survival
of 100 % a year, the smaller child being two
months old, the older being 12 years old.
Paediatric heart surgery was also the scenery
for modest humanitarian contributions, as 4
children from Palestine were brought over
and operated in the Unit, by kind grant from
Hospital Administration, and this was particularly rewarding and an opportunity for admirable social encounters.
Due to great improvement on children outcomes, most of them thrive to active adult life
and generate a population of GUCH, an area
for which the Hospital and the department
are specially prepared. Adult cardiology, paediatric cardiology and surgeons, all provide
devoted outpatient clinics and surgical services. GUCH treatment needs a full experienced team and the Department is proud to be
a member.
The hospital is one of national centres for
Pulmonary Hypertension. Besides the congenital heart population, requiring corrective
surgery, a growing number of patients with
either primary or thromboembolic PHT are
being referred and thromboendarterectomy
surgery became recently available, though
still with limited numbers, but with very promising results.
Post OP TGA baby
PAEDIATRIC HEART SURGERY
Hybrid Suite for NORWOOD
Quality graph - pediatric heart surgery
Mortality Vs Complexity - Santa Marta (red dot)
Vasco, 105 days Berlin Heart followed by heart
transplant, with Bugs Bunny
19
CONGENITAL HEART SURGERY - Adults
The great improvement in results with the correction of congenital heart defects in infancy
has contributed to a growing population of GUCH patients (grown up congenital hearts). Our
centre built a solid experience dealing with these patients, the program being run by a devoted GUCH team: adult and paediatric cardiologists together with cardiac surgeons.This is,
truly, an integrated care model, involving all needed specialities, from image diagnosis, to the
cat lab, the electrophysiology lab, interventional cardiology and surgery.
For the last five years an average of 1400 patients were seen at GUCH outpatients clinics,
Department of Cardiology, covering all types of diagnosis. Surgery was needed in 57 % of patients, 40% of those in advanced adulthood (median age at operation 37 years). Also, a very
significant and expanding number are being dealt by interventional cardiology, namely pos
operative Fallots and primary ASD by device closure. Most of our surgical cases are septal defects, followed by left ventricle obstructive lesions, namely discrete sub aortic obstructions.
Recently the number of pulmonary valve implantations after correction of Fallot’s tetralogy,
either at surgery or by interventional catheterization has been expanding.The option for heart
or heart and lung transplantation is always in the horizon and this is yet another reason why
our set up in Santa Marta is so well adapted to look after this difficult, though emerging, group
of patients.
The treatment of GUCH is an area of great development. The population is increasing, the hospital care component is challenging – interventional cardiology and surgery – but also medical
follow up and society integration. A very special group of these patients are young women
willing to become pregnant, and whose pregnancies are of an higher risk, needing special support to both mother and fetus. Our GUCH team at Santa Marta centralizes the interdisciplinary
care of these women, from counselling to pregnancy follow-up and delivery, achieving a most
remarkable success rate.
6%
2% 2% 1%
GUCH Distribution
6%
ASD (27%)
27%
7%
VSD (20%)
PS (11%)
LVOTO (10%)
TOF (8%)
CoAO (7%)
AVSD (6%)
8%
PDA (6%)
10%
20%
11%
20
TGA (2%)
Ebstein (2%)
UVH (1%)
ECMO - Extra Corporeal Membrane Oxygenation
Our Department runs an ECMO program, mainly directed to support cardiac patients, as a bridge to heart transplantation. On some occasions
ECMO was used as a bridge for decision, or for
post cardiotomy rescuing. Also to treat transient lung dysfunction after transplantation,
although we do not run an elective respiratory
ECMO program.
During this period a total of 20 ECMO cases
were performed for different indications, 9 in
children, with a median age of 13 month, and 11
in adult, with a median age of 37 years. The majority of cases were veno – arterial, supporting
cardiac and pulmonary functions, with only two
cases of exclusive lung support. Mean run time
was 6,7 days, with a maximum of 19 days. Cases
related to bridging to transplantation and respiratory were, generally, much better succeeded
than post-cardiotomy rescuing cases.
ECMO is run by a dedicated team, covering 24
hours a day seven days a week.
ECMO Diagnosis
Respiratory
20%
Cardiogenic
Shock
20%
Post
Cardiotomy
40%
Myocarditis
20%
21
CHEST SURGERY &
LUNG TRANSPLANTATION
Over the entire period, 1700 patients with chest and lung problems were operated by our dedicated team. In the mean time, 9000 chest outpatient clinics were attended. The activity is
led by a Consultant Chest Surgeon, two staff surgeons and one resident. Case load comprises
all types of surgeries, from tracheal surgery in adults and children, to lung surgery, from neonate into adultwood, as well as lung transplantation.
Minimal invasive chest surgery and videothorascopy are regularly practiced and represent
30% of the activity. This is also an area of innovation, 23 totally VATS lobectomies were safely
performed. Also, the minimally invasive Nuss technique for pectus escavatum correction has
achieved remarkable results, when compared with traditional open methods.
Lung transplantation program was re-established in 2007 and is truly a success story. From
2008 until this the moment 55 lung transplants were performed, 50% bilateral, with a 1 year
survival rate of 82% and 67% at 3 years, values that compare favourably with those from the
International Registry. This became possible by the revival of a true medico-surgical team and
outstanding inputs from Pneumology, Anaesthesiology, Pathology, Nurses and Technicians all
working as a team. Our centre is the only lung transplantation unit in the country, and works
hard to fulfill national needs.
Lung transplant surgeon and lung transplant patients
winning their race at Lisbon marathon
22
CHEST SURGERY &
LUNG TRANSPLANTATION
Lung Tranplantation Evolution
18
11
4
4
2007
2008
2009
12
10
2010
2012 Sept
2011
0.00
0.25
0.50
0.75
1.00
Survival after Lung Transplantation
0
1
2
analysis time (years)
3
4
23
STAFF TRAINING AND
PROFESSIONAL DEVELOPEMENT
It is our vision that the great value of organizations is their staff and that their sustainable
strategy is a life long learning attitude. Over these five years we have fully trained two residents, partially trained an uncountable number of doctors on temporary rotations, saw 15
nurses and doctors becoming Masters in Science and committed 5 of our staff surgeons into
pHD studies, to be finished in due course.
We take training of our staff very seriously, on everyday work on the wards, ICU’s and in Theatre but also on the bench side. We are now launching the first Simulation Lab for Cardiothoracic surgery in the country. Affiliated to St. Jude simulation facilities in Brussels, our simulation
lab will allow our residents and senior specialists to train technical and non technical skills
applied to cardiothoracic surgery. We look very forward to its impact on the way we train and
access residents.
This facility will allow training of surgical non technical team skills, CPB cannulation , CABG,
valve and aorta simulation surgical techniques.
Simulation Aortic Valve Implantation
26
STAFF TRAINING AND
PROFESSIONAL DEVELOPMENT
27
INNOVATION & DEVELOPMENT
The Department of Cardiothoracic Surgery has a strong innovation history, as most cardiothoracic procedures were performed for the first time indoors. This is mainly due to the giant
leaders that preceded us. Innovation nowadays follows a different path and relates to new
processes and technologies. We wish to highlight different areas of recent innovation:
CONEXALL – a communication device
introduced by our centre, that allows
for on line communication between
theatres and ICU, promoting safety and
facilitating management through IT’s
Integration of
Management and
Clinical Governance for every day
running of the Department. It is our
vision that management and clinical
governance should be run together
and integrating both process and outcomes.
28
INNOVATION & DEVELOPMENT
Hybrid Norwood Surgery - maninly applied to
high risk HLHS babies, this procedure consists of
PA’s banding, ductal and PFO stenting, differing
risk for second stage and allowing for safer completion of the Fontan. Ten cases were done so
far, some having reach the last stage, with remarkable results.
Cardiac Surgical Follow Up – all cardiac pa-
tients are followed closely at home and at outpatient clinics by nursing enquiries, allowing
to record post surgical outcomes. Four thousand patients are being followed and are registered on our database, a quite unique initiative.
Endo-aortic
surgery leading to complete
aortic replacement. Debraching of head vessels was followed by extensive aorta stenting
completing total aorta replacement.
29
SCIENCE & PUBLICATIONS
The Unit is fully affiliated with NOVA University, gets pre graduate and postgraduate students and holds several main research lines:
Cost- Benefit relations in cardiac surgery for the elderly patient
Inflammation triggered by cardiopulmonary bypass
Impact of complementary sub aortic resection, during aortic valve replacement – impact on outomes
Mechanisms of Ascending Aorta dilatation
Additional research topics are: Complication Scoring after Cardiac Surgery Patient Safety,
Health Economics in Lung Transplantation, Molecular - Trans Membrane Mechanisms in Cystic Fibrosis Lungs. More and more, interdisciplinary research is taking over pure “basic” or
isolated clinical research.
We are following that path, as all main research lines are well anchored on basic research institutions. Additionally, two books were launched, one with the history of the Department’s
50 years.
Representing “How we do it” in the Department – Procedures in Cardiothoracic Surgery
2009, Lidel, by J Fragata and co-workers, that
has been marketed and is a best seller in the
field.
30
The History of Department
of Cardiothoracic Surgery, 2009
by J Fragata and D Serra Melo
SCIENCE & PUBLICATIONS
Publish or perish someone has written !
Patient Safety and Quality of Care in Intensive Care Medicine.
Over the last 5 years the main list of publications in J D Chiche, R Moreno, C Putensen, A Rhodes (Eds.) – Capítulo Shall we publish our error rates? – J. Fragata. Medizipeer review from the Department is as follows:
Stenosis of the branches of the neopulmonary artery after
the arterial switch operation: Analysis of differential lung
perfusion using cardiac MRI”
accepted in the Annals Pediatric Cardiology, to appear 2013
Control of TMEM16A by INO-4995 and other inositolphosphates. Yuemin Tian, Rainer Schreiber, J Fragata... Karl
Kunzelmann,Br J Pharmacol ():n/a-n/a (2012)
Characterization of non-technical skills in paediatric cardiac
surgery: communication patterns. Raquel R Santos, Luís L
Bakero, ... José Fragata, Eur J Cardiothorac Surg 41(5):100512; discussion 1012 (2012)
Scimitar syndrome: a European Congenital Heart Surgeons
Association (ECHSA) multicentric study. Vladimiro L Vida,
Massimo A Padalino, ... J Fragata, Giovanni Stellin, Circulation 122(12):1159-66 (2010)
Long-term survival with heart transplantation for fibrosarcoma of the heart. Pedro P Coelho, Nuno G Banazol, ... José I
G Fragata, Ann Thorac Surg 90(2):635-6 (2010)
Surgery for complications of trans-catheter closure of atrial
septal defects: a multi-institutional study from the European
Congenital Heart Surgeons Association. George E Sarris, George Kirvassilis, ... J Fragata, Giovanni Stellin, Eur J Cardiothorac Surg 37(6):1285-90 (2010)
Psychometric properties of the portuguese version of the
Kansas City cardiomyopathy questionnaire in dilated cardiomyopathy with congestive heart failure. Elisabete E Nave-Leal, José J Pais-Ribeiro, J Fragata ... Rui R Ferreira, Rev
Port Cardiol 29(3):353-72 (2010)
nisch Wissenshaftliche Verlagsgesellschaft. 2009
Octreotide--additional conservative therapy for postoperative chylothorax in congenital heart disease. Filipa Paramés,
Isabel Freitas, ... J Fragata, Maria Fátima F Pinto, Rev Port
Cardiol 28(7-8):799-807 (2009)
Primary undifferentiated sarcoma of the mitral and aortic valves. Ruben B RB Ramos, Luísa M LM Branco, ... J
Fragata, Rui C RC Ferreira, J Heart Valve Dis 17(3):348-51
(2008) Risk of surgery for congenital heart disease in the adult: a
multicentered European study. Vladimiro L Vida, Hakan
Berggren, ...J Fragata, Giovanni Stellin- Ann Thorac Surg
83(1):161-8 (2007)
Isolated cleft of the anterior mitral valve leaflet. Ana A Timóteo, Ana A Galrinho, ... J Fragata, Jorge J Quininha- Eur J
Echocardiogr 8(1):59-62 (2007)
The arterial switch operation in Europe for transposition of
the great arteries: a multi-institutional study from the European Congenital Heart Surgeons Association. George E GE
Sarris, Andrew C AC Chatzis, J Fragata… - J Thorac Cardiovasc Surg 2006;132:633-639
Results of surgery for Ebstein anomaly: a multicenter study
from the European Congenital Heart Surgeons Association.
George E Sarris, Nikos M Giannopoulos, J Fragata... European Congenital Heart Surgeons Association
-J Thorac Cardiovasc Surg 132(1):50-7 (2006)
Cardiac myxoma: a 13-year experience in echocardiographic
diagnosis. Ricardo R Oliveira, Luisa L Branco, ... J Fragata,
Rui R Ferreira
Rev Port Cardiol 29 (7-8):1087-100 (2010).
Isolated aortic coarctation: experience in 100 consecutive
patients. Ana A Peres, José Diogo Ferreira JD Martins, ... J
Fragata, Fátima Ferreira FF Pinto, Rev Port Cardiol 29(1):2335 (2010)
A new risk factor for infective endocarditis. Alexandra Toste, Lurdes Ferreira, ... J Fragata, Rui Cruz Ferreira, Rev Port
Cardiol 28(10):1167-75 (2009)
Percutaneous coronary intervention versus coronary-artery
bypass grafting for severe coronary artery disease – Serruys
PW. Morice MC, Kapptein AP et all …. SINTAX Investigators, New England J Med 2009, 5;360(10):961-72
31
STAFF
SURGEONS
Mara Sá
Rosa Matos
Jose Fragata
LUNG TRANSPLANT
Margarida Basto
Sinai Cruz
Department Chairman
AFFILIATED PNEUMOLOGISTS
Fátima Caldas
Sónia Morgado
Fernando Martelo
Luisa Semedo
Jesus Falcão
Consultant Chest & Lung Surgery
Alexandra Borba
Maria Manuel Dias
PERFUSIONISTS
Luis Baquero
Nicole Murinello
Mariana Tranquada
Paulo Franco
Álvaro Laranjeira Santos
Ana Alves
Mário Barral
Duarte Furtado
Marisa Jesus
Ines Figueira
Pedro Coelho
RESIDENTS
Martha Machado
Pedro Lucas
Helena Telles Antunes
Andreia Gordo
Miguel Venda
Vanda Claudio
João Alves Mendes
Luis Rodrigues
Mónica Rodrigues
Luís Coutinho Miranda
Manuel Magalhães
Neide Rodrigues
SECRETARIES
Pedro Baptista
João Eurico Reis
Nuno Frango
Filipa Possante
Daniela Afonso
Antonio Tomás
Paulo Pereira
Luís Martins
Raquel Fragata
Marina Parente
Sandra André
Nuno Banazol
Duarte Serra Melo
Ivan Bravio
NURSES
Ricardo Gomes
Valdemar Gomes
Clara Vital - Chief Nurse
Ricardo Inácio
Marilia Feteira
Ricardo Ribeiro
FACULTY SECRETARY
CARDIOTHORACIC AFFILIATED
Alda Catela
Ricardo Freitas
João Brum
ANESTHESIOLOGITS
Ana Barros
Rita Fragoso
Isabel Fragata
Ana Cardoso
Rui Monginho
CLERK ASSISTANT STAFF
Dolores Cachao
Ana Chambel Pereira
Sandra Leopoldo
Alexandre Ferreira
Nuno Duarte Silva
Ana Rodrigues
Sandra Rosário
Ana Margarida Mateus
Ana Ferro
Ana Mansoa
Sara Agostinho
Ana Rita Rodrigues
Cristina Ramos
Ana Gualdino
Sara Antunes
Arminda Basilio
Teresa Maximo
Andrea Marinho
Sara Silva
Carla Neves
Nuno Santos
Andreia Santos
Silvina Moura
Célia Alves
Cecilia Dias
Barbara Pires
Susana Rocha
Cláudia Antunes
Lurdes Castro
Bruno Pires
Susana Valério e Silva
Conceição Grunho
Lidia Lourenço
Bruno Pereira
Susana Reis da Silva
Estela Borges
Eugenia Moreira
Bruno Mestrinho
Suzette Vilares
Filipe Rodrigues
Teresa Costa
Carina Marcelo
Teresa Matias
Gertrudes Franco
Sara Coelho
Carla Santos
Vanessa Correia
Isabel Dias
Carolina Gonçalves
Dina Lopes
Verónica Monteiro
Maria Agripina Fragata
Estela Martinho
Viriato Pataco
Maria Alice Alves
HEART TRANSPLANT
Fatima Freire
Vítor Almeida
Maria Fátima Furtado
AFFILIATED CARDIOLOGISTS
Filomena Simões
Alzira Cabral
Maria Lurdes Martins
(Adult & Pediatric)
Helena Semedo
Ana Afonso
Maria Carmo Ceita
Rui Soares
Hugo Serra
Ana Mendes
Maria Manuela Cascalho
Joana Feliciano
Isabel Curto
Carina Barreiros
Mário Manteiga
Conceicao Trigo Pereira
Joana Silva
Carla Costa
Noélia Neto
João Lopes
Dário Antunes
Paula Canita
GUCH TEAM
José Santos
Hélder Lopes
Ricardo Ramos
AFFILIATED CARDIOLOGISTS
José Oliveira
José Gonçalves
Rute Faleiro
(Adult & Pediatric)
José Conceição
Luis Reis
Sniazhana Laptseva
Fátima Pinto
Liliana Dinis
Conceição Alves
Vanda Ferreira
Ana Agapito
Lisete Lopes
Carmo Gamito
Lidia Sousa
Luis Marques
Isabel Colaço
Magda Guerra
Isabel Neves
32
Hospital de Santa Marta
Cardiothoracic Department
Contact: +351 21 359 43 41
Address: Rua de Santa Marta, 1169-1024 Lisboa
Email: [email protected]
33
AKNOWLEDGMENTS
We wish to thank the contributions of all that worked in the Department over the years, as
well as the strong leadership of our previous directors - Machado Macedo, Rui Bento and Jose
Roquette.
A word of aknowledgment for our gold sponsors that have so generously helped us to keep on
the wavefront of development:
Graphics and illustrations by Filipa Possante
34
Department of Cardiothoracic Surgery
Hospital Santa Marta
Centro Hospitalar Lisboa Central