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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