The medical team that surprised itself

​Dr. Issam El-Rassi and his team regularly perform life-saving heart surgery on babies and children at AUBMC’s Children’s Heart Center (CHC). Recently, they conducted a study including all the patients operated on during the last five years, to see how their practices compare with the best pediatric heart care in the world. Lebanon is considered a “developing middle income” country with about 10 percent of the resources of a well-supplied operation. The results of the study, which surprised the team most of all, were published in the July 30, 2020 issue of Frontiers in Pediatrics/Pediatric Cardiology.

“We struggle with equipment. We struggle with supplies. We have brain drain,” El-Rassi says. “It’s how developing countries are. Plus,” and he laughs as if what he is about to say defies belief. “We have a negative budget! Our growth is negative.”​

And yet, the study showed outcomes comparable to those of North American and West European centers, with overall mortality below 3 percent, even when you adjust for age and complexity. “I know when our team works together, they work with all their heart,” El-Rassi says. Dr Fadi Bitar, the director of the CHC explains, “ As a Hospital registered under the New York charter, we follow the American standards in everything we do; but I did not expect us to have the same results as the American Society of Thoracic Surgeons.” When the study was published, the team of physicians, nurses, anesthetists, cardiologists, and intensives saw how good they are. They were getting congratulatory emails, and even went viral on Whatsapp.

The challenges to pediatric heart surgery in Lebanon have only been compounded by COVID-19. Reached one October night in his office, El-Rassi talks about his next day’s patient, a six-month-old baby. “Unfortunately, tomorrow’s patient has tested positive for COVID-19. We have to protect our team and postpone this surgery for at least 14 days. Most difficult is when a patient can’t wait that long.”

When asked how they persevere, El-Rassi says, “Working, doing this job, is our reward. It’s as if we’re addicted to the outcome. When I finish surgery, I’m so happy because the baby is well. We each take pride in the part we play. Otherwise, politics, finances, morale, the coronavirus are so negative. This gratifies us.”

On Thursdays, El-Rassi can be found one hour south of Beirut in Saida at Hammoud Hospital, where the UNHCR helps fund pediatric heart surgeries for Syrian refugees. “If I decide to be sick one week and not go there, a patient will pay the price. They have a team at the hospital, but I am the only surgeon.” Twice a year, El-Rassi is joined at Hammoud by surgeons from Riley Hospital for Children in Indiana in the United States. “When they come, we get a lot done. We can operate on 12 to 18 children a week.”

Globally, about 1 percent of all babies are born with congenital heart disease, which is the biggest killer of babies under a year old. In most cases, surgery can save them. The CHC study at AUBMC focuses on how to finance heart surgeries and the strength and expertise of each team member. El-Rassi says the study gives hope to other under-resourced countries. “We are trying to tell the rest of the developing world that they also can achieve this standard with limited resources.”

The CHC has a partnership with the government, the AUB Medical Center, and the outside philanthropic group, Brave Heart. Without that arrangement, it would be impossible to afford the approximately $26,000 surgery for any baby.

In summary, the study says a successful pediatric cardiac unit can be achieved with:​

• A properly designed and well-equipped modern facility, preferably in a university hospital setting.
• A well-trained, experienced, and dedicated medical and paramedical personnel.
• A well-planned financial strategy that includes a partnership between a philanthropic organization, a private university hospital, and the public sector which allows the pediatric cardiac program to function without financial loss, thus achieving long term sustainability.