Impact of International Fellowship Training Program on Paediatric & Congenital Cardiac Surgery Outcomes In A Low-Income Country

Dawood Kamal Mehsood; Intisar Ul  Haq; Muhammad Abdullah; Adnan Akram; Muhammad  Majid; Atif Nawaz

doi:10.51253/pafmj.v76iSUPPL-4.14185

Authors

Dawood Kamal Mehsood Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Intisar Ul Haq Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Muhammad Abdullah Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Adnan Akram Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Muhammad Majid Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Atif Nawaz Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan

DOI:

https://doi.org/10.51253/pafmj.v76iSUPPL-4.14185

Keywords:

Cardiac Surgical Procedures, Congenital, Fellowship, Heart Defects, Risk Adjustment, Treatment Outcome

Abstract

Objective: To compare post procedural mortality and procedural diversity in paediatric and congenital cardiac surgery before and after implementation of an International Fellowship Training Program (IFTP) at a national referral center in a low-income country.

Study Design: Comparative cross sectional study design

Place and Duration of Study: Department of Paediatric and Congenital Cardiac Surgery, Armed Forces Institute of Cardiology/ National Institute of Health, Rawalpindi, Pakistan, from January 2014 to December 2023.

Methodology: All consecutive patients undergoing Congenital Cardiac surgery falling under Risk Adjustment for Congenital Heart Surgery (RACHS-1) categories II–IV from 2014–2023 were included using universal sampling. Outcomes and procedural distributions were compared between two time-defined cohorts: pre-fellowship training program (2014–2018) and post- fellowship training program (2019–2023). Mortality and procedural distribution were compared between eras.

Results: A total of 3388 patients were included. The proportion of high-complexity (RACHS III–IV) operations increased significantly post-fellowship (59.2% vs. 40.8%, p < 0.001). Overall mortality declined from 9.4% to 6.6% (p = 0.004). The biggest improvements occurred in BDG (12.6% to 5.3%, p = 0.01) and ASO (54% to 39%, p < 0.05), while lower-complexity repairs (VSD and TOF) showed smaller yet consistent gains.

Conclusion: lower mortality and higher procedural complexity rates were observed in the post-IFTP era compared to the pre-IFTP era at AFIC. Structured exposure to advanced training environments enhances surgical capacity and patient survival in LICs.

Downloads

Download data is not yet available.

Author Biographies

Dawood Kamal Mehsood, Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Intisar Ul Haq, Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Muhammad Abdullah , Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Adnan Akram, Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Muhammad Majid, Department of Paediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Health Disease/National University of Medical Sciences (NUMS), Rawalpindi Pakistan

References

1. Salari N, Faryadras F, Shohaimi S, Jalili F, Hasheminezhad R, Babajani F, et al. Global prevalence of congenital heart diseases in infants: A systematic review and meta-analysis. J Neonatal Nurs. 2024; 30(6): 570–5.

http://dx.doi.org/10.1016/j.jnn.2024.05.003

2. Hoffman JIE, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002; 39(12): 1890–900.

http://dx.doi.org/10.1016/s0735-1097(02)01886-7

3. 33. Marhaba, Ahmed A, Gul J, Jan MA, Karim SA, Waqas M, et al. Prevalence and management of congenital heart diseases in Pakistan: A comprehensive cross-sectional study. Journal of Health, Wellness and Community Research. 2025; 75.

http://dx.doi.org/10.61919/gcxd5g74

4. Jenkins KJ, Castañeda AR, Cherian KM, Couser CA, Dale EK, Gauvreau K, et al. Reducing mortality and infections after Congenital Heart Surgery in the developing world. Pediatrics. 2014; 134(5): e1422–30.

http://dx.doi.org/10.1542/peds.2014-0356

5. Zheleva B, Atwood JB. The invisible child: childhood heart disease in global health. Lancet. 2017; 389(10064):16–8.

http://dx.doi.org/10.1016/s0140-6736(16)32185-7

6. Novick WM, Molloy F, Bowtell K, Forsberg B, Pavanić M, Polivenok I, et al. Pediatric cardiac service development programs for low- and middle-income countries in need of improving or initiating local services. Front Pediatr. 2019; 7(359).

http://dx.doi.org/10.3389/fped.2019.00359

7. Cpsp W.:::College of Physicians and Surgeons Pakistan. Edu.pk. [cited 2025 Nov 6]. https://listing.cpsp.edu.pk/weblink_new/training_program/fcps.php/

8. Dindi K, Cain MT, Odera A, Joyce DL, Joyce LD, Leta A, et al. Building cardiac surgical programs in lower-middle income countries. JTCVS Open. 2023; 13: 252–9.

http://dx.doi.org/10.1016/j.xjon.2023.01.009

9. International training fellowship programme. Nhs.uk. [cited 2025 Nov 6]. https://education.uhb.nhs.uk/clinical-education/medical-academy/doctors/programmes/international-training-fellowship-programme/

10. Furnaz S, Shaikh AS, Qureshi R, Fatima S, Bangash SK, Karim M, et al. Factors associated with poor outcomes after congenital heart surgery in low-resource setting in Pakistan: insight from the IQIC Registry-a descriptive analysis. BMJ open. 2023; 13(12). http://dx.doi: 10.1136/bmjopen-2023-078884.

11. Javed S, Bajwa TH, Bajwa MS, Shah SSA. Current status of paediatric cardiac surgery in Pakistan. Ann King Edw Med Univ. 2021; 27(2).

http://dx.doi.org/10.21649/akemu.v27i2.4542

12. Davison EJ, Singh SK, Jemec B. Global surgery fellowships—an investigation of opportunities, outcomes, and applicants. J Hand Microsurg. 2021; 13(3): 196–201.

http://dx.doi.org/10.1055/s-0041-1726672

13. Childrensheartlink.org. [cited 2025 Nov 6]. https://childrensheartlink.org/wp-content/uploads/2023/04/CHL-2022-Annual-Report-web.pdf

14. McMahon CJ, Penny DJ, Kim M, Jacobs JP, Casey F, Kumar RK. Achieving excellence in paediatric cardiac care in resource limited and resource plentiful settings and building successful care networks across different countries. Cardiol Young. 2024; 34(11): 2279–89.

http://dx.doi.org/10.1017/s1047951124026088

15. Giamberti A, Lo Rito M, Stellin G, Karl T, Frigiola A. Editorial: Pediatric cardiology and cardiac surgery in developing countries: Current needs and future perspectives. Front Pediatr. 2022; 10(1067193).

http://dx.doi.org/10.3389/fped.2022.1067193

16. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2016; 25: 75–8.

http://dx.doi.org/10.1016/j.ijoa.2015.09.006

17. Hinduja M, Yadava OP. First nationwide survey on the experience of Indian cardiac surgeons about international fellowship programmes. Indian J Thorac Cardiovasc Surg. 2018; 34(4): 525–9.

http://dx.doi.org/10.1007/s12055-018-0736-x

18. Kumar R. Training pediatric heart surgeons for the future: A global challenge. Ann Pediatr Cardiol. 2015; 8(2): 99.

http://dx.doi.org/10.4103/0974-2069.157020