Cardiovascular Journal of Africa: Vol 27 No 3 (May/June 2016)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016

AFRICA

175

a stroke as a third major complication. None of these 17 (1.0%)

patients died. Their median BMI was 29.4 kg/m

and those with

intact sternums had a BMI of 28.4 kg/m

The presence of COPD was found in 29% of patients with

sternal dehiscence compared with 12% among those with a

sternum in one piece. In a large Finnish study, 70% of patients

with deep sternal sepsis were taken to theatre. This represents a

prevalence of 0.8%.

Patients are under the impression that the

chest bone does not heal. A South African study investigated the

general picture of post-CABG patients after six weeks and found

six patients of 179 with no healing of the chest bone. Two of them

had already had a second attempt in hospital to approximate the

sternum.

At least three others had risk factors such as prolonged

mechanical ventilation and heart failure with pneumonia.

Most patients in our series were not from Bloemfontein,

where the operation was done. They had to be well enough to

travel back to whence they came, where health facilities are often

limited. In general, patients are discharged only when the risk

of re-admission is low. According to the STS registry, 51.2%

of patients had an LOS of less than six days and 5.6% were

hospitalised for more than two weeks.

As far as isolated CABG

is concerned, the hospital LOS compared well with the STS.

Limitations

Larger numbers have more statistical power, but smaller numbers

are the reality of a typical South African cardiac unit. In the

private sector one finds units with a single surgeon and many

with only a few surgeons per unit. Although the surgeon used

transparent definitions, there was still a personal interpretation.

The additive EuroSCORE was used but this probably

underestimated the real mortality risk. The logistic EuroSCORE

was perhaps more accurate for the higher-risk patient, especially

in a low-volume practice.

It has been stated before that 26.3%

of patients fell into a higher-risk category. Low-risk patients did

very well, with an O/E of

0.61 and even less.

To determine a unit’s care of patients withmajor complications

is a good way of assessing performance. The fewer the number of

patients that die with a major complication, the better the unit

performs. Those are the patients who failed to be rescued (FTR).

A Canadian unit reported on 5 000 various open cardiac surgical

cases over five years,

where the mortality rate was 3.6%. Ten

important complications were associated with 92% of the deaths.

Their calculated FTR was 19.8%. In other words, in spite of

major complications, 80.2% of patients survived. A FTR for the

Tabula viva chirurgi

would have been a good indication of how

Mediclinic, Bloemfontein, fares as far as the care of patients with

major complications is concerned, but we lacked data for this to

be calculated. Table 8 might give some indication of the outcome

of the patients with one or more of the five major complications.

Of the patients with one or more major complications, 25% died.

Conclusion

It was not the intention to present these data as a benchmark for

the South African context, but it opens a window on a private

cardio-surgical practice in South Africa. The outcomes are in

line with those of established units and databases all over the

world. This is wisdom related to the scientific and technical

aspects associated with cardiac surgery and care. These findings

also bring a new wisdom to the fore, which allows the surgeon to

move from loneliness to solitude as a spiritual movement. The

disappointments of negative surgical outcomes should move on to

make the surgeon’s responsibilities a vocation instead of a burden.

This allows the surgeon to provide hospitality as an alternative to

hostility towards the patient.

Such a spiritual experience should

also have spiritual transformation as an outcome.

As part of

creation, physiological limits exist and surgical outcome is based

on these limits. Mortality and morbidity are time and again

linked to co-morbidity and surgical risk. This has implications for

the pastoral and spiritual care of the sick.

We thank Prof Christoff (JC) Zietsman, head of the Department of Latin

at the University of the Free State, Bloemfontein, who assisted with the title,

Tabula viva chirurgi

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