An invasive cardiac and open heart surgical programme in Barbados: historical aspects and early results

Heart disease represents the leading cause of death in Barbados and the Organization of Eastern Caribbean States (OECS). The North Shore University Hospital, N.Y., through its Lifeline Programme offered the only regular outlet for approximately 450 patients who had cardiac surgery there between 1982 and 1992. A changing US health care policy, however, predicted an end to this programme and in 1989 a decision was made to develop a cardiac catheterisation and an open heart surgical programme at the Queen Elizabeth Hospital (QEH) in Barbados, to serve Barbados and the OECS. This programme was implemented in December 1993 and between then and September 1995, 231 patients, aged two weeks to 75 years, underwent cardiac catheterisation. Of these patients, 186 were suspected of having coronary artery disease (CAD), 21 of having congenital heart disease (CHD) and 24 of having valvular disease. Fifteen patients were from countries other than Barbados, 70 have had open heart surgery (with a surgical mortality of 2.8 percent) and 12 have had closed heart procedures. One hundred and twenty-four (124) trans-oesophageal echocardiograms were done. A successful cardiac surgical programme has been set up at the QEH in Barbados with the cooperation of the Government and the private sector. The results are excellent and the spinoffs to the hospital have been many. In particular, a significant improvement in "critical care". What is more important, however, the programme has been set up at a "low" cost and is cost-effective, saving the country significant foreign exchange. Plans are in place to introduce Interventional Cardiology in the near future (AU)

Acute purulent pericarditis in children caused by haemophilus influenzae

Acute purulent pericarditis caused by haemophilus influenzae is an unusual condition, especially in childhood. In most cases, respiratory symptoms are the presenting features, and children aged less than 4 years are most often affected. A high index of suspicion and aggresive microbiological and cardiological evaluation are often warranted to make an early diagnosis. We herein report two cases of pericarditis caused by H.influenzae in children aged less than two years. Pericardiocentesis was performed in each case. Early recognition, rapid diagnosis and aggressive medical and surgical therapy are paramount in the successful treatment of this condition (AU)

Acute purulent pericarditis in children caused by haemophilus influenzae

Acute purulent pericarditis caused by haemophilus influenzae is an unusual condition, especially in childhood. In most cases, respiratory symptoms are the presenting features, and children aged less than 4 years are most often affected. A high index of suspicion and aggresive micorbiological and cardiological evaluation are often warranted to make an early diagnosis. We herein reported two cases of pericarditis caused by H. influenzae in children aged less than two years. Pericardiocentesis was performed in each case. Early recognition, rapid diagnosis and aggressive medical and surgical therapy are paramount in the successful treatment of this condition.

Outcome of kawasaki disease in Barbados

Kawasaki disease (KD) often presents as an acute multisystem febrile illness which is most often self-limiting. During an 11-year period, 39 patients with KD, aged 11 weeks to 15 years (mean 2.5 years), were admitted to the Queen Elizabeth Hospital, Barbados. Eighty-seven per cent of children were less than 4 years of age. There were 26 males (67 percent) and 13 females (33 percent) with a sex ratio of 2:1. A peak occurrence was observed in 1985 and the mean hospital stay of cases was 12.7 days. Treatment regimes included antibiotics in 36 patients (93 percent), aspirin in 32 (82 percent) and steriods in 3 (7 percent). Major complications were observed in 11 patients (26 percent), with these being gastrointestinal bleeding in 1, broncho-pneumonia in 3 and cardiac abnormalities in 7 (18 percent). Among the latter were abnormal proximal coronary arteries in 5 patients (2 with dilatation and 3 with aneurysms) and carditis in 2. Other complications included croup (1), hydrops of the gallbladder (2), paralytic ileus (1), and abnormal focal neurological signs in two patients. There were no deaths. Follow-up ranged between one month and four years. Although KD often presents as a benign self-limiting illness, it is extremely important to make a diagnosis early in the course of the illness, institute appropriate therapy and be on the alert for possible fatal complications. (AU)

The incidence of congenital heart disease in Barbados - abstract

The incidence of congenital heart disease (CHD) in Barbados was studied by reviewing all the clinical and echocardiographic records of infants born with CHD in the three years 1988 - 1990. The initial diagnosis was made on clinical evaluation, and was confirmed by echocardiography - real time and doppler - in all cases. Patients with more severe heart disease also had their diagnosis confirmed by cardiac catheterization, at surgery, or by autopsy. During the study period, 68 out of 12,352 liveborn infants were diagnosed as having CHD - an incidence of 5.5/1,000 live births. The male: female ratio was 1:1 and 8.8 percent of infants with CHD had chromosomal abnormalities. Sixty-eight (68) per cent of the infants were asymptomatic on initial evaluation. Thirty-four (34) per cent were diagnosed in the neonatal period and 94 per cent in the first year of life. Venticular septal defect was by far the most common lesion (47 percent) followed by pulmonary stenosis (26 percent). Tetralogy of Fallot (7 percent) was the most common cyanotic lesion. Twenty-three patients (1.9/1,000 live births) had severe CHD, 11 of these have had surgery, and 9 are awaiting surgery. Three patients died before surgery could be performed. This study examines for the first time the "true" incidence of CHD in a population in the Caribbean. The results indicate that the incidence is very similar to that of other countries where studies cite an incidence of 4 - 8/1,000 live births (AU)

Thrombolytic therapy in acute myocardial infarction in Barbados: report of initial experience with intravenous streptokinase - abstract

It has been shown in the last decade, that intravenous throbolytic therapy is associated with a significant reduction in mortality, when given early in the course of an acute myocardial infarction (MI). Streptokinase, a bacterial-derived protein plasminogen activator, was approved for use at the Queen Elizabeth Hospital in June 1990 and thrombolytic therapy for acute MI commenced in October 1990. During the next 13 months, 129 patients were admitted to the Queen Elizabeth Hospital with the diagnosis of acute MI, and 35 of these (27 percent) received intravenous streptokinase. Nine other patients who received streptokinase were subsequently proven not to have infarcted. Forty-three per cent (43 percent) of the patients received thrombolytic therapy within six hours of the onset of symptoms, the ideal window period for treatment. Using non-invasive clinical criteria, reperfusion was suspected in 77 percent of patients. No major complications were seen. Three (3) patients had mild allergic reactions, and mild hypotension and bradycardia were seen in 19 patients. One patient who did not have an acute MI but an acute aortic dissection developed a hemiparesis which resolved within a week. There were 6 deaths recorded, all thought to be unrelated to streptokinase, but rather due to the extensive nature of the infarct. We have reported on a protocol-controlled series of patients given thrombolytic therapy for acute MI in Barbados, and have concluded that it can be given safely and effectively in carefully selected patients (AU)

Cardiac services in the Southern Caribbean - abstract

It has been long recognised that heart disease is the most common cause of death in the Caribbean accounting for 26 percent of the annual deaths. Improved non-invasive diagnostic techniques i.e., echocardiography and electrocardiographic stress testing, have allowed easier and more accurate diagnosis of cardiac diseases. The population of the region (Trinidad and Tobago, Barbados and the OECS countries) is approximately 2 million. A conservative estimate would place the numbers of patients with congenital, rheumatic and ischaemic heart disease that would benefit from cardiac surgery or therapeutic cardiac catheterizations each year at 600. The facilities are not as yet available in the region. In response to the sheer level of unsatisfied demand for such facilities, a cardiac surgical programme has been established between the Caribbean and North Shore University Hospital in New York whereby the Caribbean patients are referred and undergo surgery at North Shore at nominal cost. The non-invasive diagnostic work-up is done in the Caribbean, and includes a cardiologist travelling to some OECS countries with a portable echocardiogram machine and conducting cardiac clinics. Since the programme started in 1982, 423 patients have been referred to New York; 394 have had cardiac surgery or therapeutic cardiac catherization procedures. The surgical results have been excellent, with a mortality rate of 4.3 percent. While the importance and success of the programme is noted, it only provides cardiac surgical care to a small percentage (<10 percent) of patients from the region, on an annual basis, leaving the vast majority unattended, resulting in a tremendous back log of patients needing this critical care. It is therefore imperative that cardiac catheterization facilities and an active open heart surgical programme be developed to serve the needs of the region (AU)

Epidemiology of kawasaki disease in Barbados - abstract

Kawasaki syndrome (KS) often presents as an acute multisystem febrile illness which is most often self-limiting. During an 11-year period, 39 patients with KS aged 11 weeks to 15 years (mean 2.5 years) were admitted to the Queen Elizabeth Hospital, Barbados. Eighty-seven percent of children were less than 4 years of age. There were 26 males (67 percent) and 13 females (33 percent) with a sex ratio of 2:1. A peak occurrence was observed in 1985 and the mean hospital stay of cases was 12.7 days. Treatment regimens included antibiotics in 36 patients (93 percent), aspirin in 32 (82 percent) and steroids in 3 (7 percent). Complications were observed in 11 patients (26 percent), with these being cardiac in 7 patients (18 percent). Among the latter were abnormal proximal coronary arteries in 5 patients (2 with dilatation and 3 with aneurysms) and carditis in 2 patients. Other complications included croup (1), gastrointestinal bleeding (1), dilated gall bladder (2), paralytic ileus (1), bronchopneumonia (3), and abnormal focal neurological signs in 2 patients. There were no deaths. Follow-up ranged between one month and four years. We recommend that although KS often presents as a benign self-limiting illness, it is extremely important to make a diagnosis early in the course of the illness, institute appropriate therapy and be on the alert for possible fatal complications (AU)

The Caribbean and New York: the heart connection - abstract

An association between North Shore University Hospital, New York and the Caribbean region started in 1982, whereby Caribbean children needing cardiac surgery were operated on at North Shore at no, or nominal, cost to the patient. During the last 6 years, 239 patients were referred for cardiac surgery 107 from Trinidad, 69 from Barbados, 19 from Jamaica, 18 from Saint Vincent, 17 from Saint Lucia, 4 from Dominica, 2 from Antigua and one each from Anguilla, Grenada and Nevis. Fifty of the patients were catheterised in Barbados between 1982 and 1985, and 55 were catheterised at Brookdale Hospital, New York, in 1986 - 1987. The other patients were catheterise at North Shore. Two hundred and sixteen (216) patients have had surgery - 180 open and 36 closed heart. Four had pacemaker implantations, 3 balloon valvuloplasties and 2 balloon atrial septostomies. There were 7 operative deaths (3.2 percent mortality) and 4 late deaths. An analysis of the programme points overwhelmingly to its high degree of success. Over the last 2 years, the programme has expanded to include 4 other major hospitals in New York. The programme is critically dependent on a system of co-operation and co-ordination between the referring and accepting physicians. Well-developed links have also been developed wihtin the wider New York based West Indian community. These links provide crucial logistic support to both patients and their families, thus increasing the economic viability of the programme while decreasing the trauma associated with the physical dislocation of extra-regional surgery. While the success of the programme is noted, it should in no way detract from the need to accelerate plans aimed at the development of an active open-heart surgical programme in the region (AU)

Hypertrophic cardiomyopathy experience in Barbados - abstract

Hypertrophic cardiomyopathy is defined as ventricular hypertrophy without identifiable cause, and althought it usually involves only the ventricular septum, it may involve the left and right ventricular free walls as well. A retrospective study was made of patients with this diagnosis seen in a cardiolgy practice and at the QEH during the period February, 1982 to November, 1985. Echocardiography (M-Mode and Real Time) was used to make the diagnosis in all patients, using standard echcardiographic guidelines. Eithteen patients, 15 men and 3 women ranging in age from 31 to 73 years, were diagnosed as having hypertrophic cardiomyopathy. Exertional dyspnoea, palpitations and chest pain or tightness were the main presenting symptoms. Most patients had mid-systolic murmurs in the aortic areas and at the apex. ECGs were abnormal in 12 patients, with LVH and ST, T-wave changes being the most common abnormalities found. M-Mode echocardiography revealed asymmetric septal hypertrophy (ASH) in 14 patients and systolic anterior motion (SAM) of the mitral valve in 13. At real time echocardiography, ASH was seen in all patients, with involvement of the entire septum in 12 and with hypertrophy involving the sub-aortic area in 3, and the mid-septal area in 3. Eleven patients required treatment with drugs, 9 with áblockers, and 2 with calcium antagonist drugs, mainly with good results. Hypertrophic cardiomyopathy, although uncommon, does occur in Barbados, and often presents with symptoms similar to ischaemic heart disease and congestive cardiac failure, and with murmurs that are often mistaken for mitral incompetence or aortic stenosis. The diagnosis is readily made by echocardiography. áblockers and calcium antagonist drugs are the treatment of choice, rather than digitalis, diuretics, and vasodilators which often make the symptoms worse (AU)

Complications of Kawasaki disease - abstract

Kawasaki disease or mucocutaneous lymph node syndrome (MCLS) is a clinical entity of unknown aetiology affecting mainly infants and young children. It is an acute inflammatory illness whose underlying angiitis affects multiple organs, resulting in high fever, mucocutaneous involvement, cervical lymphadenopathy, and potential complications, the most serious being cardiac disease. Predominantly found in Japan, it is increasingly being diagnosed in other countries. The diagnosis is made by exclusion of other inflammatory illnesses, scarlet fever, Steven-Johnson syndrome, viral exanthemata and collagen vascular disorders. We present a five-year restrospective study of eleven cases seen in Barbados; seven males and four females, aged between three months and thirteen years. Complications seen include carditis and coronary arteritis. Two patients had carditis, one had ST, T-wave changes on ECG and elevated CPK, and one had an arrhythmia. Three patients had suspected coronary artery aneurysms seen on real time echocardiography. Four patients had hepatitis, two hydrops of the gall-bladder and one aseptic meningitis. Treatment is non-specific and consists of supportive treatment and high-dose followed by low-dose salicylates in an attempt to decrease platelet aggregation, thrombotic occlusion of the coronary arateries and subsequent sudden death from myocardial infarction or rupture (AU)

A review of the initial two years of a cardio-diagnostic programme in a small island community - abstract

In January 1982, regular right and left cardiac catheterizations and angiography, and detailed examination of cardiac structures in dynamic motion by Real Time (2-D) echocardiography were started at the QEH. During the past 2 years, 64 patients - 45 from Barbados, 7 from St. Lucia, 4 each from Dominica and Trinidad, 3 from Grenada and 1 from Antigua (age 3 weeks to 64 years) underwent cardiac catheterization and angiography with no mortality and minimal morbidity. All of the patients had Real-Time Echocardiography prior to catheterization, and the correct (catheterization) diagnosis was made in all but 5 cases. Thirty-one patients have undergone cardiac surgery - 17 at North Shore University Hospital in New York by special arrangement whereby there was no cost or nominal cost to the patient: 3 at the hospital of their choice in North America; 5 at UHWI in Jamaica, and 6 at the QEH. Eight of the 17 patients going to North Shore have been recatheterized, and our echo and catheterization diagnoses remained unchanged. The other 9 patients underwent surgery without recatheterization, and our echo and catheterization data were confirmed at surgery. There have been 2 operative deaths and 2 late deaths. All of the other post surgical patients are significantly improved and most are living normal or near normal lives. This Report shares the initial 2 years' experience of a Cardio-Diagnostic programme at the QEH, and the subsequent surgical results. Real-time (2-D) echocardiography in our hands has been accurate (92 percent of the time); cardiac catheterization has been safe; and the surgical results are satisfying (AU)

Mitral valve prolapse in Barbados - abstract

A retrospective study was made of patients with primary mitral valve prolapse (MVP) seen in a cardiology practice and in the Queen Elizabeth Hospital from February, 1982 to November, 1983. All the patients were diagnosed by history and by the typical auscultatory findings of a mid-systolic click and /or late systolic murmur. Echocardiographic confirmation was made in all patients. One hundred and twenty-two patients, aged 2 to 65 years, had clinical and echocardiographic evidence of MVP. Eighty-two were female, and 39 male. Most patients were between 10 and 30 years. Chest pain and palpitations were the most common presenting symptoms, with excessive tiredness, dizziness, shortness of breath and syncope often seen. Three patients had severe chest pain that warranted admission to the ICU to rule out myocardial infarction. ECG's were abnormal in 34 patients (28 percent). Twenty-three (19 percent) had arrhythmias, and 9 had ST, T-Wavw abnormalities in the inferior leads. Two patients had pre-excitation syndrome without arrhythmias. Forty-nine patients had severe enough symptoms or arrhythmias to warrant treatment with á Blockers. There has been no significant morbidity or mortality. Mitral Valve Prolapse appears to be common in Barbados, especially in young women. General Practitioners should be aware of this disorder, as although it is usually benign it may be associated with severe chest pain, significant arrhythmias, and syncope. Many patients in the past have been labelled as "Neurotic" and treated with tranquillisers. Antibiotic prophylaxis against infective endocarditis is recommended (AU)

Kawasaki disease in Barbados

The mucocutaneous lymph node syndrome (Kawasaki Disease) is reported in three Barbadian children. This appears to be the first report of the condition from the West Indies. The disease should be suspected in any paediatric patient who presents with an acute febrile illness associated with lymphadenopathy and skin and mucous membrane changes which are unresponsive to antibiotic therapy. Patients should be carefully investigated for cardiac complications which contribute significantly to mortality and morbidity from the disease (AU)

A review of the first two years of the clinical application of echocardiography at the Queen Elizabeth Hospital, Barbados - abstract

Echocardiography was first used extensively as a non-invasive cardio-diagnostic procedure in the late 1960's and early 1970's. Since that time, it has become invaluable as a reliable, reproducible and easily performed investigation which encompasses a wide range of clinical applications. The procedure has been in use in the English-speaking Caribbean countries for a period of only 3 -4 years, and in Barbados for the past 2 years. The reports of all echocardiograms performed over the 2-year period were reviewed and recorded together with other relevant data. A total of 710 echocardiograms were performed. The age range of patients studied was < 1 year (31 patients) to > 74 years (19 patients), with 30 percent of echocardiograms being performed on patients <14 years of age and 14 percent on patients >54 years. Of the 710 echocardiograms, 473 were carried out on outpatients, and 223 on inpatients; 14 were unrecorded. The listed indications for requesting an echocardiogram were suspected or process: congenital heart disease, 246; acquired valvular heart disease, 185; coronary artery disease, 42; mitral valve prolapse, 117; pericardial effusion, 53; suspected cardiac pathology, 85; postoperative assessment, 39; pre-cardioversion, 7; and routine requirement in minoxidil study, 43. On several occasioins more than one indication was listed as the reason for requesting the study. A detailed analysis was undertaken of the echocardiograms of patients in the previously mentioned diagnostic categories together with patients who subsequently underwent cardia catheterisation. The financial cost of the servicing and repair of the echocardiographic nachine used together with cost of re-usables over the 2 years was BD$20,714.00. The results of this study indicate that echocardiography, though relatively costly, has become a very useful, widely applied and highly recognised non-invasive cardio-diagnostic procedure in Barbados (AU)