26 February 2018

Uganda: Mulago's Breakthrough Heart Bypass Surgery

Kampala — The doctors and the patients tell their story

Victor Ndawabo, 58, a Congolese national, was unusually lucky from the moment doctors first discovered he had coronary artery disease (CAD).

The condition which presents with dangerous blockage in the vessels that carry oxygen-rich blood to the heart is often fatal since it tends to develop with few symptoms.

Doctors call it 'a silent killer' because some patients - usually older men of 45 years and above-- are unaware they have a problem until they suddenly collapse.

They may develop symptoms like palpitations and shortness of breath and crushing pain in the chest (angina) which has been described as similar to someone carrying a heavy weight on the chest.

Doctors say the pain could be made worse by exercise, for instance climbing stairs, but if the blockage is severe, one will get pain even when at rest.

Luckily for Ndawabo, he did not collapse. But he experienced the immense pain in the chest and started finding it almost impossible to get on and off his bed. When he failed to get treatment in his country, he headed to Uganda and the Uganda Heart Institute (UHI).

Doctors at the institute found Ndawabo's two arteries had been blocked. It was a severe condition and they resolved to conduct a form of surgery called Coronary Artery Bypass Grafting (CABG), which is the third line of treatment in such cases. Normally they would have started with first line treatment--medical therapy--involving taking medicines to control the risk factors for CAD such as high blood pressure and to stop blood clots from forming in the arteries of his heart. If that failed, they would go to second line, which involves procedures that involve putting stents (really gutters) in the blood vessels to keep blood flowing.

But Ndawabo's condition was so severe that the doctors resolved to conduct the Coronary Artery Bypass Grafting (CABG).

Once again Ndawabo was lucky because this procedure, local medical experts say, would have been impossible in Uganda if he had come to the institute three months ago.

Getting the equipment

Dr William Manyilirah, a consultant cardiothoracic surgeon who led the surgery team says doing CABG requires an Internal Mammary Artery (IMA) Retractor, which allows doctors to lift one half of the patient's breast bone and gain access to and harvest the affected blood vessel. The Internal Mammary Artery Retractor was only acquired last December and Ndawabo was the second patient to benefit from it.

Ndawabo was admitted for surgery on Jan.31, but a team of 14 experts led by Manyilirah had a week before done the first successful surgery of the kind that involved bypassing three arteries of the heart of a 45-year-old Ugandan patient.

Despite doing several of these procedures in South Africa where he trained for four years, Dr. Manyilirah had not done any in a Ugandan medical facility.

The only time the institute conducted such surgery (a double vessel CABG) was in early 2016. But it was supervised by a visiting South African professor of cardiac surgery and the patient developed complications and had to be taken back to theatre.

The surgery took unusually long because of lack of prerequisite equipment at the time, improvised equipment was used to perform the CABG.

"We didn't have enough modern equipment. You have to be exceptionally skilled to use the ones they used in 2016," Manyilirah says.

Another important set of equipment are the micro instruments (dissectors, scissors, and needle-holders, among others), very fine small instruments to handle small vessels.

Manyilirah says the surgery is done in three stages. First, the experts begin by harvesting the grafts (arteries and veins) from the breast bone, forearm or legs. Then they disconnect the heart and lungs and connect them on a heart-lung machine for the surgery. The third stage is the actual grafting (connecting new vessels). Finally, the patient is taken off the heart-lung machine to allow the heart and lungs to function on their own.

"It's called a bypass because if you got an obstruction here," he says pointing to a dummy heart he used to illustrate what they did, "We don't unblock it; we actually put a new vessel."

In Ndawabo's case, the surgeons harvested an artery from behind the left half of the breast bone and a superficial vein from the leg and connected it in front of the blockage.

Although it involved arresting the heart and lungs, this was not an open heart surgery but rather doctors worked on the surface of the heart. It appears that after these successes, more patients are lining up for similar procedures.

Dr Manyilirah says patients who undergo the bypass surgery should be able to leave hospital in about five to six days but he extended hospital stay in order to monitor the patients well. While the first patient left on the eighth post-operative day, Ndawabo left on the ninth day.

"One spent three days in ICU and another four, but a day or two in ICU is enough under normal circumstances," he said, noting that the procedure alone lasts five to six hours.

Until now, the Institute which received about 500 patients with coronary artery disease last year, has been doing mainly coronary angiography - a procedure that uses a contrast dye and X-ray pictures to detect blockages in the coronary arteries. At least four to five patients undergo this procedure every week.

Some of these patients undergo a stent operation, where a small metal mesh tube that is expanded inside the artery is placed to allow blood to flow efficiently.

Eventually having bypass surgery offered at the Institute means patients will not incur huge costs on medical services abroad.

Challenges ahead

But Dr. Tom Mwambu, one of the surgeons behind the procedure told journalists on Feb.09, that the challenge is that people who want treatment may not get it at the time they need it.

Mwambu, a consultant surgeon who trained both in Japan and India, says despite upgrading the Institute to start doing complex heart procedures in 2013, Uganda Heart Institute only has one operating theatre and only one catheterisation lab.

He said while they have capacity in terms of human resource to do three bypass surgeries per week, the facilities they need to do this are lacking.

"Many patients are waiting. They should be attended to when they walk in but we can't work on them immediately. Even the critical care team can't handle many patients at once," he said. He said ideally, the country should install more theatres.

Dr. John Omagino, the Institute's Executive Director agrees and says they plan to set up more theatres once they get their independent facility and shift from Mulago Hospital complex where they are currently attached. Already construction of the facility valued at $65million is under way.

"We are now an autonomous institution but we are still transitioning from being under Mulago Hospital. When we get a new home, we will get more theatres, more labs and recruit more staff," he said.

Currently the institute has four surgeons and two are in training. It has 12 cardiologists, eight for adults and four for children.

Omagino says of the 12,000 patients visiting the institute annually half are found to have heart disease and therefore have to be treated by that small team. And, 85% of all heart diseases can be controlled with simple lifestyle changes.

For Coronary artery disease for instance, the risk factors are uncontrolled high blood pressure, smoking, a lot of alcohol consumption, diet high in fat, obesity, family history and aging.

Manyilirah explains that blockage results from a chronic process involving slow reduction in the size of the lumen of the blood vessel caused by deposition of abnormal fats or cholesterol. With time as it builds up it narrows the lumen.

What sparks a heart attack is a clot caused by turbulence in blood flow at the narrowed segments of the artery and the heart ends up not receiving blood leading to irregular heart beat which gives little blood to the body.

"I was anxious when Dr William told me about this," Mr Ndawabo told The Independent on Feb.09 when he was being discharged from hospital, "I feared it was difficult."

"My health is now good. I can talk, I can eat, I can walk. I am satisfied," the man who is now part of the history of cardiology in Uganda said. He is also unusually lucky.


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