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Ann Thorac Surg 1996;62:1890-1891
© 1996 The Society of Thoracic Surgeons

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Correspondence

KISS Approach to Cardiac Surgery

The Heart Institute, 15 East St, Kilpauk Garden Colony, Madras 600 010, India

To the Editor:

We read with interest the concern of Dr Grover [1] about the escalating cost of cardiac surgery and the innovation of fast-track surgery by Dr Engelman [2] to cut down costs.

When Dr Victor was in the United States during 1969 to 1970 to observe open heart operations, he was ashamed to see patients from India coming to America for such operations. He returned to India in 1971 to establish open heart surgery at the Government General Hospital, Madras, which caters mostly to the poor and middle class. The challenges [3, 4] then were (1) too many patients, (2) lack of equipment (there were no ventilators or blood gas analyzers), (3) lack of trained nurses, and (4) meager funds.

This led us to evolve, since 1971, the KISS (Keep It Simple and Safe) approach [3–5] to open heart surgery, to help more patients with available funds, equipment, and staff.

Doctor Victor had learned from Mr Donald Ross, at the National Heart Hospital, London, that reliance on a bedside clinical commonsense approach was more important than dependence on gadgets. It was also realized that in "standard" practice of cardiac surgery, we alter physiologic situations, create problems, and spend time and money trying to revert back to normal physiology. We cool and rewarm; we sedate heavily and ventilate; we infuse too much and use diuretics and dialyzers to correct fluid and electrolyte imbalances. We paralyze the myocardium and await its recovery. In the KISS approach, we try to keep as close to normal physiology as possible, aiming to see an alert postoperative patient, fully warm, off the ventilator, and without inotropic support.

We find it is more satisfying to concentrate on patients who can be either cured or given excellent long-term palliation rather than to subject critically ill patients with incurable lesions to ego-satisfying operations that result in economic ruin of the family, emotional problems, and inevitable early demise of the patient.

The essential features of the KISS approach [3–5] are as follows:

1. Techniques to minimize bypass time and facilitate early extubation: We tailor the use of analgesics and muscle relaxants. Core cooling [6] is avoided, except when there is a need to protect the brain, as during operations for aneurysm of the aortic arch. Core rewarming used to correct drift of temperature is initiated sufficiently early so that body temperature is normal when the patient is ready to be weaned off bypass. Cardioplegia (3 to 10 mL/kg) is tailored to the anticipated duration of bypass. The dose should be related to the weight of the heart muscle rather than body weight! Components of fast-track surgery [2] aimed at early extubation are possibly more important than steroid therapy.
   
2. Economy in hardware: We use only two roller pumps: one for the arterial line and another for suction. Cardioplegia is infused manually through a simple infusion line. Instruments and devices indigenous to India have been devised [4, 7].
   
3. Innovative techniques: We vent and deair through the venous line without an additional pump circuit [8]. A single pericardio-pleuro-mediastinal drain [9] is routinely used.
   
4. Economy in disposables: Semidisposable cannulas [10], suckers, and vent catheters [4] are used. Autogenous pericardial rings have been designed for mitral annuloplasty [11]. Silk fabric patches [12] have been found satisfactory for closure of septal defects. Six to eight knots per suture save funds.
   
5. Minimizing monitoring: For simple operations, we avoid invasive monitoring. Central venous pressure is monitored using a side arm to the infusion line. Invasive arterial pressure monitoring is used only for critically ill patients. No monitor can substitute for a concerned, intelligent nurse, diligently watching the warmth of the extremities, comfort of breathing, electrocardiogram, and blood pressure.
   
6. Invasive investigations: These are minimized, especially after the advent of Doppler echocardiography.
   

Unfortunately medicine has passed from an altruistic era of charity [1], exemplified by Osler, the Mayo Brothers, and Albert Schweitzer, who set up gold standards for us to follow while we were medical students, to an era of industrialization and commercialization of medical care. Nations spend more on warfare than on welfare and health care. The profit motive drives industries, insurance companies, financial institutions, hospitals, and individuals.

The most hard-hit are patients in developing countries like India, where 300 million people live in poverty earning about US $20 per month. Even patients in the middle class find the cost of an open heart operation exceeding their life's savings, despite the cost in India being about US $2,000 compared with more than $20,000 in the United States. The KISS approach is more relevant today than in the 1970s [13, 14], with about half of humanity living without basic needs of life.

References

1. Grover FL. The bright future of cardiothoracic surgery in the era of changing healthcare delivery. Ann Thorac Surg;1996 61:499–510.[Abstract/Free Full Text]
2. Engelman RM. Mechanisms to reduce hospital stays. Ann Thorac Surg;1996 61:S26–9.
3. Victor S, Kabeer M. KISS approach to open heart surgery: fifteen years experience. In: Shetty KR, Parulkar GB, eds. Proceedings of World Conference on Open Heart Surgery, Bombay, India, 1985. New Delhi: Tata McGraw Hill Publishing, 1987:270.
4. Victor S, Kabeer M. KISS approach to open heart surgery. Indian J Thorac Cardiovasc Surg 1989–90;6:20–6.
5. Victor S, Nayak VM, Kabeer M. Cardiopulmonary bypass: keep it simple and safe. Australias J Thorac Cardiovasc Surg;1993 2:44.
6. Victor S, Kabeer M. Is systemic cooling essential for open heart surgery? Ann Thorac Surg;1990 50:334–5.
7. Victor S. Modified sternal retractor and internal mammary artery forceps for myocardial revascularisation. Indian J Thorac Cardiovasc Surg;1991 7:56–7.
8. Victor S, Kabeer M. Venting and deairing without roller pump. Ann Thorac Surg;1993 55:807.
9. Victor S, Kabeer M. Single drain (pleura, pericardium, mediastinum) after open heart operations. Ann Thorac Surg;1991 51:345–6.
10. Victor S, Kabeer M. Semidisposable venous and arterial cannulae. Indian J Thorac Cardiovasc Surg 1985–86;4:75–6.
11. Victor S, Nayak VM. Truly flexible D-shaped pericardial ring for mitral annuloplasty. Ann Thorac Surg;1993 56:179–80.[Abstract]
12. Victor S, Dare BJ, Dravidamani S, Madanagopalan P. Silk: a new promising heterograft. In: Wang ZG, Becker HM, Mishima Y, Chang JB, eds. Vascular surgery. Proceedings of International Conference on Vascular Surgery, Beijing, China, October 1993. Beijing: International Academic Publishers, 1994; 2: 660–2.
13. Victor S, Kabeer M. Relevance of KISS approach to open heart surgery beyond 2000 AD [Abstract]. The 12th Biennial Asian Congress on Thoracic and Cardiovascular Surgery, Tokyo, Japan, Nov 1995:S-16–8.
14. Victor S. Concerning health for all humanity. AustralAs J Cardiac Thorac Surg;1993 2:155.

Reply

Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Health Sciences Center and the Denver Veterans Affairs Medical Center, 4200 E Ninth Ave, Denver, Co 80262

To the Editor:

I have read with interest the letter from Dr Solomon Victor and his colleagues from Madras, India. This is a very timely letter given our changing health care environment with increasing emphasis on cost savings while at the same time trying to maintain quality health care delivery. Victor and associates appropriately emphasize keeping operations "simple and safe" and also emphasize selecting patients who are most likely to benefit from cardiac surgical procedures, so as not to waste scarce resources on those with a low expectation for a satisfactory outcome.

Victor and associates stress short bypass times and early extubation, minimizing the use of analgesics, muscle relaxants, and hypothermia. They advise simplifying the cardiopulmonary bypass set up, minimizing the use of disposables, avoiding invasive monitoring unless deemed necessary in higher risk patients, and not performing relatively unnecessary diagnostic procedures. By using these methods they have been able to hold the cost of cardiac surgical procedures to approximately $2,000 US dollars per case.

Doctor Victor has been far ahead of most of us by implementing "fast track" efficient cardiac surgery since the early 1970s. Many of us in industrial nations can learn much from our colleagues who perform their work in an environment of scarce resources.

This article has been cited by other articles:

				P. Ghosh Setting Up an Open Heart Surgical Program in a Developing Country Asian Cardiovasc Thorac Ann, December 1, 2005; 13(4): 299 - 301. [Full Text] [PDF]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frederick L. Grover Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Victor, S. Articles by Grover, F. L. Search for Related Content PubMed PubMed Citation Articles by Victor, S. Articles by Grover, F. L.