Cardiac Surgery for Rheumatic Heart Disease in Kigali, Rwanda – Part 1

Andrew J.B. Pisansky, M.D., M.S.
Resident in Anesthesiology at Brigham and Women's Hospital
PGY-4

February 16, 2019

For over 12 years, Team Heart has been bringing teams from the US to Kigali, Rwanda in order to provide cardiac surgery to patients with rheumatic heart disease, typically due to sequelae of untreated strep throat.  Prior to our arrival as part of the operative team, there had been months of planning by the coordinators back in Boston, Denver, and Vermont.  Additionally, for several weeks before we arrived, the cardiologists from Team Heart had staffed many hours of clinics during which the operative candidates were screened for surgery.  Unlike in the US, underweight patients were more of a concern than overweight, and our cut-off for patient size was 30 kg (more than a few of our actual patients were no more than one or two kilograms above the cut off weight). 

On our first day at King Faisal Hospital in Kigali, we set up our operating room and attended the patient selection finalization meeting.  The operating room started out looking relatively empty, but we soon filled it with the familiar sights and sounds of anesthetic machinery and medications, the cardiopulmonary bypass machine, and surgical equipment.  At the patient selection meeting, our entire team for the week (about 60 individuals of all specialties from the operating room to the step-down unit) met for a conference to discuss the final list of patients for our trip.  We would operate for 8 days and do 16 cases in total. 

The first few days required an adjustment to our usual work flow.  There was no electronic medical record.  All lab values traveled in the chart with the patient.  All records of the anesthetic were documented on carbon copy paper forms. The pumps that delivered our usual cardiac medications were from the US, but different from what we typically used.  The motto of the American Society of Anesthesiologists is one word, “Vigilance.”  It quickly became clear that we would be caring for some of the most advanced cardiac pathology I had ever seen (certainly far worse than we typically see in Boston) while also operating in an unfamiliar environment.  Although our systems in the US make redundancy in safety commonplace, it was clear that vigilance would play more of a part in our work than was typically the case.

We worked through progressively more difficult cases during the week.  Our first case, severe mitral regurgitation for a mechanical mitral valve.  But soon we progressed to combined valvular lesions: severe mitral regurgitation with moderate mitral stenosis and severe aortic insufficiency, or severe tricuspid regurgitation, severe mitral regurgitation, moderate aortic insufficiency, severe pulmonary hypertension and right ventricular dysfunction for mitral and aortic valve replacement as well as tricuspid valve repair.  These are typically the tales of textbooks and lecture halls, but we were managing this advanced pathology in patients as young as 16 years old, many of them with weights in the mid 30-kg range and a blood volume less than half of what we typically encounter in US patients. 

However, by halfway through the week, the team had found a rhythm.  Everyone worked in relative harmony.  Each day brought about 2 more successful operations.  4 days down, 4 to go.