HHNW feb 13, 2010

2010-02-14T08:46:00.002+02:00

Medical Blogspot – HHNW, February 13, 2010
After arriving en mass w/ upwards of 45 medical personnel, the task fell to receiving and organizing the tons of equipment brought to Kigali. Although there were some prepositioned supplies from the Boston and Australian teams, we intended to be self-sufficient. This goal, however, was thwarted by the misplacement by the airlines of 60+ of our 250 boxes of material sent. Through tireless work of many people, we were finally able to get all supplies into Kigali and through the customs maze.
Despite this initial handicap, we were able to start surgeries as scheduled. The pre-evaluations were extensive, having taken place months ago by a team lead by Dr Tim Bishop. He came w/ an echocardiographer and others in December 09 and evaluated more than 100 potential patients, from whom 30 were chosen to be most appropriate, i.e., sick enough to merit serious surgery, but not so ill as to be debilitated and potentially consuming resources and personnel in a vain effort. From the initial 30, 16 patients were ultimately chosen. Many considerations were made, not only the medical necessities, but also social ones. Of note is the consideration of support by family members, type of heart valve to be implanted, ability to follow up medically, etc. The consideration of the type of valve is particularly at once fascinating and vexing, as one must consider the limited longevity of a bioprosthetic valve (8-10 yr in mitral position, and possibly 12+ in aortic position) vs. the better durability of a mechanical valve. The former requires no anticoagulation but a mechanical valve patient must be anticoagulated for life, requiring the need for monthly monitoring and strict compliance w/ dosing and diet. This places extraordinary requirement on these patients, many of whom live very remotely and have very little access to medical care within hours of their village. As such we are endeavoring to find ways to allow less onerous restrictions and limitations. We have found an organization that can provide a durable and inexpensive bicycle for transporting the patient to medical care, while at the same time allowing the bike to be used for their livelihood, e.g. hauling coffee or other crops to market. Another consideration is the use of coumadin / warfarin in potentially childbearing females, since pregnancy is an absolute contraindication to the use of warfarin (highly teratogenic).
Thus far, there has been a remarkable success in this otherwise healthy group of patients, all of whom were NYHA functional class IV congestive heart patients. Unlike patients in the US and other developed countries, there is very little smoking, diabetes, emphysema or other chronic lung disease. Of the 10 patients operated to date (today is “rest day”) all have done well, w/ expeditious weaning within hours post-op, and early ambulation for all. In fact the first two patients WALKED the short distance to the “step-down” unit after about 18 hours of returning from OR! First two patients are leaving for home today, having been operated Feb. 8 (post op day # 5). Operations so far having included: mitral valve repair, with and without tricuspid repair; tetralogy of Fallot correction; correction of cor triatriatum; subaortic stenosis w/ web; ASD repair w/ PDA ligation; aortic valve replacement; and one “hat trick” of AVR / MVR / and TV repair. The latter patient was a G4P4 and had remarkably delivered a baby just 4 months prior and was very debilitated. She developed post op pneumonia, required bronchoscopy to remove plugging in LLL on post op day 3. She continues to improve, however, and is anticipated to move to step down soon.
One patient was cancelled unexpectedly due to HIV+ status. Others had to be rescheduled due to abnormally high INR, intercurrent medical problems, social issues, blood abnormalities (abnormal platelet antibody), etc.
There have been several “add-on” evaluations. Dr Hal Goldberg was asked to place a pacemaker in an elderly female w/ complete heartblock. She became asystolic just before placement of the subclavian access. She briefly required transthoracic pacing. There were no untoward sequellae and she is about to be discharged on post op day one. Dr Mike Williams was asked to evaluate a 14 year old and a 16 year old both of whom had severe CHF. ECHO remarkably showed similar findings of large RA w/ clot, and small thickened RV, which on literature review indicated an extremely rare condition of RV endomyocardial fibrosis. It is not only rare, but uniformly fatal (95% mortality at 2 yrs), and of course not surgically amenable. It appears to be isolated to subequatorial regions and there is suspicion of nutritional etiology.

More to come...
Dr. Sam Joseph
Pulmonary and Critical Care

Healing Hearts Northwest Medical Blog

HHNW feb 13, 2010