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My date with the surgeon’s scalpel, moulding a better heart

On this morning of the surgery, the medical team is awake bright and early for yet another round of riveting heart surgeries.

The doctors from Japan including  the innovator Prof Kanji Inoue spent the night at one of the hotels near the national referral hospital, KNH. The first surgery was scheduled to begin at 8.30 a.m promptly but it wasn’t until three hours later that it began.

It had to do with our ‘peculiar’ Kenyan habits.

The patient is travelling from Embu, about four hours away from Nairobi. In an earlier meeting with the medical team, she had promised to wake up early so she could make it to Nairobi in good time for the surgery.

And at cock’s crow she did wake up.

In fact she also prepared food for her family and tidied up the house before she stepped out to leave for Nairobi.

But something peculiarly Kenyan happened.

“Surveyor alikuja, nikamwonyesha shamba kwanza,” she later explained to the cardiologists that morning when she turned up fashionably late.

The gracious medical team waited for her to have a breather before she was orientated through a series of tests to reconfirm that she is ready for the heart surgery.

The patient this morning is 37 year old Lucy from Embu County. She has had Rheumatic Heart Disease for the last three and a half decades. ‘I can hardly work on my rice farm for more than 30 minutes without panting. I have been to the heart clinic for so many years since I was a child but my family could not raise the required amount to support my surgery,’ she says.

India has been on the cards as part of her treatment plan but when she was informed of the heart project at the Kenyatta National Hospital that would also involve the inventor of the Inoue balloon, she signed up as one of the beneficiary.

She meets the medical team led by Dr Murage and the team from Japan who take time to explain to her the surgery. She smiles. Then asks a question on how long the procedure will take but in all, she seems all ready for the procedure. She signs the consent forms and the same is affirmed by her brother who accompanied her to hospital this morning.

According to Prof Inoue, this treatment is preferred to save the patients from undergoing complicated and expensive heart surgeries. Prof Inoue, a Japanese cardiac surgeon, first developed the idea that a collapsed mitral valve could be inflated using a balloon made of strong yet pliant natural rubber. This went ahead to replace the open heart surgery and today, the balloon technique has become the most popular method for performing PBMV in most parts of the world.

What is PBMV and how is the procedure done?

A doctor uses a thin flexible tube known as a catheter that is inserted through an artery in the groin and threaded into the heart. When the tube reaches the narrowed mitral valve, a balloon device located on the tip of the catheter is quickly inflated to widen it and hence encourage better blood flow in the heart.

Are there instances that the surgery cannot be performed?

If a blood clot is found in the left side of the heart, surgery cannot be performed. It is advised that the patient is placed on blood thinners like warfarin for 3 to 6 months to dissolve the clot.

A heart test known as an echocardiogram is done to confirm the ‘disappearance’ of the clot. If the cardiologist established that it’s no longer there, this balloon surgery can be performed. It still there, a surgical intervention on the mitral valve along with removal of the clot is recommended.

The procedure can also be performed on pregnant patients but this calls for dexterity and extra caution which includes minimum radiation exposure and proper shielding of the abdomen and pelvic area.

This procedure cannot be performed during the first trimester to ensure that the formation of the organs of the foetus is complete. We used to call this organogenesis in biology, right?

Globally, the double balloon technology has been widely used in Western countries as compared to Asia where the Inoue single balloon technology is the preferred model. Through a collaborative effort between JICA and KNH, the technology is now fully paid for by the NHIF for its members at a cost pf Sh 450,000.

A January 1994 research paper by Dr Tsung Cheng from The George Washington University School of Medicine and Health Sciences, Washington, D.C comparing the Chinese and Western experiences of the Inoue single balloon and the double balloon technologies respectively concluded that the former was most preferred.

“Serious and fatal complications like the perforation of the left ventricle, stroke and death were much less common with the Inoue balloon than the double balloon catheter technique,” read excerpts of the paper.

The Inoue balloon is available in 4 sizes: 24, 26, 28, and 30 mm. To select the balloon size to be used for the heart procedure, here is a simple equation that the cardiologists use;

  • (Height of patient in cm divide by 10) + 10
Photo by camilo jimenez on Unsplash

The doctors use the Wilkins score to determine the suitability of the patient mitral valve in the heart to undergo this procedure. A score of less than 8 predicts a more favorable procedural, short, intermediate and long-term outcome including survival of the patient. The distinct features of the Inoue balloon technology include;

  • Inserting the Inoue balloon technique is faster compared to other methods
  • This technique is  less cumbersome
  • It requires less medical imaging time
  • It is manufactured of polyvinyl chloride with a balloon attached to the distal end
  • The balloon is two latex layers between which is polyester micromesh
  • Due to its   variable elasticity along its length, the balloon inflates in three distinct stages
  • The balloon section is stiffened and slenderized when stretched by the insertion of a metal tube.
  • The Inoue balloon allows simple progressive upsizing of the balloon without withdrawing the balloon from the left auricle.

Once the balloon is in place, the doctor’s hurdle in front of the screen that monitors the heart to confirm that there is no leakage of blood. Lucy is also in great health and for the next few minutes as the doctors wrap up the surgery, she wears a relaxed heart when Dr Murage confirms that she would be released to go home the following day.

The surgery was fully paid for by NHIF through a partnership with JICA and KNH.

When all is said and done, the procedure is over in under two hours and the patient is wheeled to recovery to the ward for an overnight stay before she is discharged to go home.

She looks forward to returning home tomorrow. She makes a phone call to her brother to confirm that all went well.

“Survey alileta riport (to mean the land surveyor) ?

Brother responds on the other end of the line.

Mwambie kesho nitakuwa nyumbani saa tisa, aniletee ripoti tuongee zaidi.


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