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"Second opinion" rules out heart surgery unit at WCH

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A paediatric cardiac surgery unit won’t be re-established in South Australia following a “second opinion” of expert clinical advice, released after the recent deaths of four babies at the Women’s and Children’s Hospital.

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SA Health is set to double down on a recommendation not to re-establish a surgical service at the WCH, but a heart-and-lung life support service is likely to be established within a year.

It follows a week of controversy after doctors, including one of the state’s leading obstetricians, Associate Professor John Svigos, last week claimed a lack of cardiac surgery resources at the Women’s and Children’s Hospital had contributed to the deaths of four babies in the past month.

Adelaide is the only mainland capital city that does not have a paediatric cardiac surgery unit or a vital life-support machine known as Extra Corporeal Membrane Oxygenation (ECMO) Support Service, which replaces the function of the heart and lungs, meaning critically ill babies and children instead have to be transferred interstate.

SA Health said last week patients who require “complex paediatric cardiac surgery” were usually sent to Melbourne’s Royal Children’s Hospital “as it remains the safest option and offers the best care for our children and their families”, but in light of COVID concerns have instead been going to Sydney.

SA stopped paediatric heart surgery in 2002 because of low case numbers, with a recent review rejecting calls to reinstate it.

Health authorities this afternoon released a “second opinion” on that review, sought from three top cardiologists.

WCH Network CEO Lindsey Gough told reporters: “That second opinion fully supports the recommendations of the first review.”

The findings argue while “it may be possible to set up a [surgical] programme that could work for a period of time… the risks of failure would be high and the consequences could well be severe, not only for the individual team members but also for the administration and reputation of the institution”.

The authors, Dr Tom Gentles, Dr John Beca and Dr Nelson Alphonso, noted there had been several “high profile system failures in Paediatric Cardiac Surgery [which] have most often occurred at low-volume centres with few participating cardiac surgeons and/or low staff morale”.

“There has been a trend away from small volume centres internationally [and] it would be difficult to justify the establishment of a low volume unit based on a single paediatric cardiac surgeon in Adelaide,” they found.

However, they added, “in relation to the recommendation to establish an ECMO programme in Adelaide, we do not consider the absence of Paediatric Cardiac Surgery to be a contra-indication”.

“There are many such programmes internationally, with excellent outcomes,” they said.

“We agree that a paediatric ECMO program should be established in Adelaide.”

However, they added that they believed the estimated 10-20 patients a year the original review suggested could require the ECMO without related surgery “to be optimistic and most likely unrealistic”.

Gough said WCH clinicians were “working very closely at what [a standalone ECMO service] can look like”.

“Once the clinical team has come up with a solution they believe is achievable for SA – we will be doing that, yes,” she said.

She said the review and “second opinion” – along with recent public comment by dissenting clinicians – would be considered by the WCH board, declining to speculate on its likely decision.

“I think I would have to say I will leave the board’s decision to the board,” she said.

“They will consider all of those opinions and make fully formed conclusions as to where we go from here.”

An open letter from a dozen senior WCH clinicians published last week by News Corp rejected “misinformation” being peddled by critics, saying: “In line with a recent external review we, as a group, do not believe that there should be paediatric cardiac surgery in SA until a safe, high-quality and clinically sustainable service can be assured with outcomes equivalent to national and international standards.”

However, the group remained open to a local ECMO service if it was proved “viable” and could lead to improvements in care.

But Svigos has argued establishing an ECMO service without a cardiac unit was “a dangerous proposal”, telling ABC Radio last week it “flies in the face of the UK, USA, Australia, New Zealand where they do not have a freestanding ECMO unit in any of those countries”.

“It’s not safe, it’s not doable, we need a cardiac surgery unit with a dedicated paediatric cardiac surgeon as well as ECMO,” he said at the time.

Associate Professor Jayme Bennetts, a paediatric cardiac surgeon at the WCH, today told reporters “most institutions do [ECMO services] that are associated with a cardiac surgical service”.

“ECMO is a high risk service associated with complications and high mortality just because of the nature of the indications of which babies are supported in the first place,” he said.

“Those risks mean that if you establish a service you have to be able to provide enough support structure and expertise around that that allows you to deal with complications and make sure you’re not actually exposing babies to a higher risk than if you had no service.

“There are current discussions underway about how that service can be established – how that can be done in a safe manner that allows that service to be delivered.”

Clinicians are considering either a service supported by an interstate team or a full standalone service.

Asked whether a cardiac surgical unit was now completely off the table, he said: “It’s not that there might never be a service, it’s that at the moment the numbers don’t allow for those justifications to exist. That may change as things evolve and services change.”

Senior cardiologist Dr Gavin Wheaton, who is the medical director of paediatric medicine at the WCH, said he wanted an ECMO service established as soon as possible and he believed that would happen “within a year”.

“There are examples of ECMO services without an in-house cardiac surgeon elsewhere and we’ve certainly had a recommendation from the experts that we’ve consulted with that we can and should develop such a service in South Australia,” he said.

“I believe we can do that safely and it’s our undertaking to do that work as quickly as possible.

“We guarantee that children will have ready access to high quality surgical services whether that be in Sydney or in Melbourne.”

SA Health is conducting a review into the recent four baby deaths.

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