Monday, July 3, 2017

Interventional Cardiology Training in Tanzania: Challenges and Rewards

Mazen Albaghdadi, MD MSc
Graduate Assistant, Interventional Cardiology
Fellow, Vascular Medicine and Intervention
Massachusetts General Hospital

Interventional Cardiology Training in Tanzania: Challenges and Rewards

Cath Lab Team

The cath lab team at the JKCI was very excited to schedule the many complex cases during my visit that they have been collecting over the past months. Each day, thus far, we have been working until around 8 or 9pm to perform elective complex cases that have been scheduled for this training visit as well as incorporating urgent and semi-urgent (ie, acute coronary syndrome, pre-cardiac surgery cases, etc.) into the schedule.  

The logistics of operating a cath lab are very challenging and require coordination between referring providers and interventional physicians to determine procedural appropriateness and timing, cath lab nurses and administrators to coordinate peri-procedural admission/in-hospital/discharge logistics between home and medical floors, cath lab managers to determine insurance coverage/financial issues, etc. The planning and follow up for a procedure can be more complex than the procedure itself. Cath lab operations are, I would posit, an art and a science, and a craft that has by no means been absolutely mastered to a Zen-like level of autonomous functioning by the 3+ different cath labs I have experienced back home in the States. It goes without saying that the ambitious effort to develop de novo catheterization services in Tanzania by the JKCI and Madaktari (the NGO that I am volunteering with here: is not immune to these challenges.

Accordingly it has been difficult to maintain a consistent 8AM start time in the cath lab here at the JKCI but progress is being made. I have recommended a few suggestions including having the general cardiology fellow take responsibility for the cath lab schedule the day prior and then having the entire cath lab team “run the list” the morning of the procedures to determine appropriateness, triage of case order, etc. We have attempted to implement these recommendations and the lab has been very receptive.

After several long days in the cath lab and rounding on patients before and after procedures, a few cases standout. A 36yo male patient with a recent inferior MI who had a residual (sub)total occlusion of the LAD that we were able to recanalize successfully with the use of over 50mm of drug-eluting stents.
Before revasularization

After stent placement
Our chief cath lab technologist and supply manager went to great lengths to ensure we had the appropriate equipment including literally running back and forth between the cath lab and the central supply to obtain the necessary stents (another logistical issue that needs resolution). A 20 yo male patient with a ventricular septal defect (VSD) who needed to undergo right heart catheterization but team hadn’t performed this procedure for over a year and were concerned about placing a 7F sheath into the relatively small statured man; he was ultimately found to have significant left to right ventricular shunting (almost 5:1) and warrants closure (percutaneous vs surgical tbd). Another 40yof with end stage rheumatic heart disease (RHD) in cardiogenic shock with cardiac cirrhosis, renal failure, and pulmonary hypertension. She did not have any cardiac cath procedures but I encountered her in the ICU after rounding on some of our post-percutaneous coronary intervention patients. She had marked abdominal ascites and was in severe respiratory distress, and I recommended a paracentesis. She had previously had multiple paracenteses over the past few weeks, which were performed using an angiocath needle (usually used for IV placement) but it was clear that her ascites was becoming refractory in the setting of inoperable RHD and decompensated heart failure. However placement of a traditional peritoneal drain (generally only performed for refractory ascites for palliative purposes) was not possible as there are no formal paracentesis kits in the hospital. A visiting Chinese ICU physician recommended placing a central line into the peritoneal space which he did successfully and allowed for gradual/safer removal of her ascites without repeat abdominal puncture over the course of the following several days with improvement in her shortness of breath.

Working with my Tanzanian and international colleagues and caring for the incredibly gracious patients with a surprising degree of advanced atherosclerotic and non-atherosclerotic CVD has been eye-opening and amazingly rewarding. I hope the benefit has been mutual and look forward to my return visit.

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