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Abstract Introduction: This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean. Methods: Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database. Results: Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiac-related deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%. Conclusion: Despite challenges of maintaining skills in a low-volume centre, mitral valve repair can be performed safely with good early- and long-term results.

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INTRODUCTION: This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean. METHODS: Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database. RESULTS: Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiac-related deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%. CONCLUSION: Despite challenges of maintaining skills in a low-volume centre, mitral valve repair can be performed safely with good early- and long-term results.

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INTRODUCTION: Same-day discharge percutaneous coronary interventions (SDD-PCI) may be quite impactful on healthcare burden for small island developing states (SIDS) such as Trinidad and Tobago. METHODS: From June 2012 to November 2014, 11 patients underwent SDD trans-radial PCI and followed up at one-month and three months. Data was retrospectively reviewed from a prospectively entered unit-maintained cardiology database. Baseline patient characteristics, in-hospital expenditure, and complications were assessed. Descriptive statistical analysis was performed in Microsoft Excel. RESULTS: The mean age at SDD-PCI was 50.90±9.96 and nine were male. Nine patients were of East Indian Caribbean ethnicity. Six were diabetic and five were hypertensive. Procedural success was 100% with no major early complication or three-months complications; patient satisfaction was achieved with a potential in-hospital savings up to $1480 USD per patient. CONCLUSION: This SDD approach for elective trans-radial PCI may be safe and cost-effective in properly selected patients and merits a review of relevant policy issues in Trinidad and Tobago.

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BACKGROUND AND AIM: The coronavirus disease 2019 (COVID-19) pandemic has seen the cancellation of elective cardiac surgeries worldwide. Here we report the experience of a cardiac surgery unit in a developing country in response to the COVID-19 crisis. METHODS: From 6th April to 12th June 2020, 58 patients underwent urgent or emergency cardiac surgery. Data was reviewed from a prospectively entered unit-maintained cardiac surgery database. To ensure safe delivery of care to patients, a series of strict measures were implemented which included: a parallel healthcare system maintaining a COVID-19 cold site, social isolation of patients for one to 2 weeks before surgery, polymerase chain reaction testing for COVID-19, 72 hours before surgery, discrete staff assigned only to cardiac surgical cases socially isolated for 2 weeks as necessary. RESULTS: The mean age at surgery was 59.7 ± 11 years and 41 (70.7%) were male. Fifty-two patients were hypertensive (90%), and 32 were diabetic (55.2%). There were three emergency type A aortic dissections. Forty-seven patients underwent coronary artery bypass graft surgery with all but three performed off-pump. Fourteen cases required blood product transfusion. One patient had postoperative pneumonia associated with chronic obstructive pulmonary disease. The median length of stay was 5.7 ± 1.8 days. All patients were discharged home after rehabilitation. There were no cases of COVID-19 infection among healthcare workers during the study period. CONCLUSION: These strategies allowed us to maintain a service for urgent and emergency procedures and may prove useful for larger countries when there is decrease in COVID-19 cases and planning for the restart of elective cardiac surgery.

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BACKGROUND AND AIM: Access to specialized cardiac surgery is a problem in emerging countries. Here, we reflect on the approach we used to establish a cardiac surgery unit in Trinidad and Tobago. METHODS: The program started in 1993 with monthly visits by a team from Bristol Heart Institute. A group of local doctors, nurses, and perfusionists were identified for training, and a senior nurse moved to the island to start a teaching program. The visiting support was gradually reduced, and the local team gained independence in managing the service in 2006. RESULTS: The initial low volume surgery increased to around 380 cases a year with the implementation of comprehensive service in 2006. Most patients required coronary artery bypass graft (CABG). In-hospital mortality declined from 5% in the nascent years to below 2% thereafter. In the last 5 years (2015-2019), 1764 patients underwent surgery (mean age 59.6 ± 10.8 years, 66% male). The majority were East-Indian-Caribbean (79.1%) or Afro-Caribbean (16.7%), half had diabetes, and two-thirds hypertension (EuroScore II 1.8 ± 1.9). The majority (1363 patients) underwent CABG (99.5% off-pump; conversion to on-pump 1.5%). The mean number of grafts was 2.5 ± 0.7 with 98.5% and 23.1% receiving one and two or more arterial grafts, respectively. In-hospital mortality was 1.1%, re-exploration for bleeding 2%, stroke 0.1%, mediastinitis 0.2%. The length of the postoperative hospital stay was 5.8 ± 2 days. CONCLUSION: Frequent outside visits complemented by training in an overseas center, and transfer of knowledge proved to be an effective strategy to develop a cardiac surgery unit in an emerging country with results comparable to accepted international standards.

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Situs inversus totalis considered a malposition syndrome is a very rare condition, occurring in 1 : 8000 births, usually without associated structural congenital heart disease. The diagnosis is often incidental as in this case, which presented with an acute coronary syndrome as a manifestationof multivessel coronary artery disease. Here, we present the challenges encountered during the diagnosis and management of this entity via percutaneous intervention.

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OBJETIVO: A populacão do Caribe constitui uma sociedade multiétnica, incluindo caucasianos, afro-caribenhos, indianos, asiáticos, hispânicos, europeus e nativos, com uma grande variabilidade de padrões socioeconômicos. A incidência e os tipos de doencas cardíacas também variam significativamente entre essas etnias. Relatamos aqui a experiência (em pacientes adultos e pediátricos) em um servico de cirurgia cardíaca de baixo volume em Trinidad e Tobago, no Caribe. MÉTODO: O programa de cirurgia cardíaca de adultos comecou em novembro de 1993, são reportados os dados de 878 pacientes (629 homens, idade entre 18 e 88 anos, com média de 67 anos). Destes, 39,4 por cento eram diabéticos e 46,5 por cento hipertensos. Os procedimentos incluíram cirurgia de revascularizacão miocárdica (CRM), reparo e substituicão de valvas e cirurgias da aorta. O programa de cirurgia cardíaca pediátrica (idades entre duas semanas e 21 anos) comecou em setembro de 1998, tendo sido realizado um total de 279 operacões. RESULTADOS: Adultos - a mortalidade total foi de 3,8 por cento. A maioria dos procedimentos foi CRM (82,3 por cento) com mortalidade total de 2,8 por cento (0 por cento em 2004). A técnica sem circulacão extracorpórea foi empregada em 43 por cento dos procedimentos de CRM (71,2 por cento em 2004). A cirurgia de valva aórtica foi feita em 49 pacientes, e a substituicão/reparo da valva mitral em 96 doentes. Pediátricos - a maioria dos procedimentos foi correcão de comunicacão interventricular (111), comunicacão interatrial (57), tetralogia de Fallot (23), e 88 outros (com mortalidade de 1,5 por cento). CONCLUSAO: Cirurgia cardíaca em um servico multiétnico de baixo volume pode ser realizada com excelentes resultados, comparáveis com padrões internacionais de qualidade.

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