Making the transition from Cardiac Missions to Autonomous Heart Surgery at a Nigerian Teaching Hospital; Challenges and Lessons Learned.

Open-Heart Surgery at the Lagos State University Teaching Hospital (LASUTH) commenced in 2004. Early years were based on a Cardiac Mission Model, but since 2017 the focus was on the transition to a Local Team Model with autonomous Open-Heart Surgery. The aim of this study is to describe our progress in making this transition, highlight lessons learned, and detail the outstanding challenges to be overcome. This study is a retrospective analysis of prospectively maintained data from the LASUTH cardiothoracic database and Nigeria Open-Heart Surgery Registry between November 2004 and December 2021. Data extracted included patient demographics, EuroSCORE II, operative procedure, operative category, lead surgeon, complications, and outcomes. Over the study period, 100 operations were done over 2 time periods, 51 operations between 2004 - 2011 (Cardiac Mission Period) and 49 operations between 2017 - 2021 (Transition Period). In the Cardiac Mission Period, 21.6% of the operations were done by the Local Team and in the Transition Period this increased to 85.7% of the operations completed. Overall mortality was 14%, dropping from 17.6% in the Cardiac Mission Period to 10.2% in the Transition Period. The Local Team is now gradually taking on more diverse cases while striving to maintain good outcomes. Our institution has successfully made the transition from Cardiac Missions to Autonomous Open-Heart Surgery without an increase in mortality and a gradual increase in surgical volumes. Lessons learned included a strategy to focus on adult surgery, avoidance of high-risk cases, and moving from free surgery toward an appropriate cost structure for program sustainability. Contributory factors to the successful transition include the active support of the hospital management (provision of appropriate infrastructure and equipment, investment in training of the Local Team), continued humanitarian international collaborations focused on skill transfer, and maintenance of Local Team skills by collaborations with other active cardiac centers in Nigeria. Remaining challenges include financing to bridge equipment gaps, maintenance and replacement of equipment as well as the evolution of a national health insurance schema that would ideally support Open-Heart surgery for Nigerian patients. Until that time, patients & programs must rely on supplemental funding of surgery to increase surgical volumes.