Tuesday, 13 August 2013

Advanced heart procedures come to Ibadan

We always have a quote by Margaret Mead at the bottom of each blog that says "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has", so when we hear from Nigerians really trying in their own way to change the trajectory of our country, it fills one with pride. Read this fascinating story by a colleague Tosin Majekodunmi on his journey back to University College Hospital. 

Advanced heart procedures come to Ibadan

There is a narrative that often describes the African healthcare sector. This is that the problems of Africa are confined mainly to infectious diseases and that chronic diseases and the technologies required to manage these in Western societies have no place in “third world” countries.

Similar to many African colleagues who practice their trade in these Western enclaves, I have often wondered whether our knowledge and skills have any place in our respective countries of origin. Thanks to the visionary leadership of the Chief Medical Director of University College Hospital in Ibadan, Professor Temitope Alonge, an opportunity arose recently to answer this question.


In response to growing evidence that ischaemic heart disease (a disease of the blood vessels supplying the heart muscles with oxygen that's severe enough to cause temporary strain on the heart or even permanent damage to the muscle) has become a public health challenge in Nigeria and other African countries, several efforts are being made to address this. An example of this is the new cardiovascular catheter laboratory, constructed at UCH Ibadan. This enables the visualization of the blood supply to through the heart and blood vessels so that blockages can be lfound. It was constructed and commissioned in 2011 but, until recently, no cases had been carried out a year after construction. In late 2012, a fortuitous meeting brought together Prof. Alonge with a Nigerian colleague, who also happened to be the Chief of Interventional Cardiology of Tri-State Cardiovascular in Delaware, in the USA; Dr. Kamar Adeleke and together they were determined that the catheter lab in Ibadan would be put to good use. They planned to open the lab with a series of cases by the middle of 2013 to demonstrate its utility and to hopefully provide a template for its use in the future.




The resident consultant cardiologists in Ibadan were happy to cooperate in finding suitable patients who would benefit from procedures carried out in the catheter lab. It was rapidly apparent that they were excited at the opportunity to offer more definitive therapy to their patients than they had been able to do until then. Eight patients were quickly identified with typical symptoms of suspected ischaemic heart disease. Dr. Adeleke assembled a team consisting of 2 nurses from his institution (Mrs. Adeleke and Bill Feteke) in Delaware and myself (a structural / congenital heart disease fellow in Toronto) to travel to  Ibadan to carry out the procedures. The majority of the equipment used was brought to Nigeria by the group from Delaware including some the commonly used catheter lab medications.

Mrs. Adeleke and Bill Feteke
On arrival, we undertook a tour of the facilities in the company of Prof. Alonge and many of the cardiologists at UCH. We then reviewed clinical status of the patients who were due to have their procedures the next day and consented them for their procedures. We then visited the catheter lab and I was pleasantly surprised to find it was the identical make and model as the catheter lab I was familiar with in Toronto. Introductions to the other members of the team who were to work with us from nursing staff, radiographers etc. were then carried out. Everyone we met was extraordinarily friendly and helpful and there was a great spirit of cooperation and camaraderie among all concerned to ensure the cases would be carried out safely and effectively. Particularly, memorable was Mrs. Ugo who was extremely rigorous in ensuring that the lab was kept clean and that everyone observed strict standards of hygiene and was appropriately attired prior to entering the laboratory area. We then set to work to ensure that our requirements for a safe working environment were met and all the equipment was in good working order.


I arrived very early in the morning along with consultant cardiologists from UCH to prepare the lab and the patients for the procedures planned. At 8am Dr. Adeleke performed the first case of coronary angiography to be performed in a public institution in Nigeria. This first case was a male patient who had symptoms suggestive of significant coronary artery disease based on prior clinical evaluation and investigation and was thankfully found to have no significant coronary artery disease much to the surprise of all involved. The catheter lab had functioned normally very much like any cardiovascular catheter lab in any other part of the world. Dr. Adeleke is a very skilled teacher very much in the mold of the stereotypical old master teaching his apprentices. Every step of this first diagnostic procedure was explained in great detail to the great numbers of observers in the monitoring room adjacent to the laboratory. At the conclusion of this first case, there was great applause and relief that all parts of the lab and the team had worked seamlessly together. The nurses from Delaware were busily involved in training the UCH nurses in the tasks required to prepare the patients for the procedure and in assisting during the procedure. Some of the consultants from the UCH also “scrubbed in” to observe at close quarters the intricacies of, in many cases, procedures they had only previously read about in textbooks. 

Dr. Adeleke and Dr. Majekodunmi performing an angioplasty with Bill Feteke assisting and Cardiothoracic Surgeon Dr. Paul Davis in the background.
Other members of the team observing procedures from the monitoring room


Subsequent cases were found to have complex patterns of coronary artery disease and we performed a number of coronary artery interventions, all successfully. Other cardiac complications were also observed, as demonstrated by the only female patient of the cohort who was appropriately referred for coronary angiography due to a cardiomyopathy (poor heart function) of unknown aetiology to exclude coronary artery disease as a possible cause. Prior to performing her coronary angiography, she volunteered that she had suffered a “fainting episode” while getting ready for the procedure that morning. We performed her procedure and found her to have normal coronary arteries. However, given her poor cardiac function and her history of a fainting episode without warning, she met criteria in both American and European Cardiology guidelines for implantation of an automated cardiac defibrillator to prevent sudden death from a heart rhythm abnormality due to poorly functioning heart muscle. This procedure has been shown to be life saving and to our knowledge has never been performed in Nigeria before. It is our hope that on our return to Nigeria, we will arrange for her to be fitted with such a device.

At the end of the cases, everyone was elated at the cases having gone so smoothly and that the team had functioned so harmoniously. Prof. Alonge himself, leading by example, was present throughout the cases and was extremely hands on in helping carry equipment, move patients and any other assistance necessary to move things along. At the discussion at the end of the day we were still astonished at the extent and complexity of coronary disease present in the patients we saw.

Neither should it be assumed that coronary artery disease is the only cardiovascular affliction of importance in Nigeria. Once our presence in Ibadan was made known, many more cases of cardiac disease were brought to our attention that had hitherto languished without definitive treatment being available for the vast majority. Particularly memorable was a 31yr old gentleman who was found to have an aortic root aneurysm of 7cm, which is at a level considered at high risk of rupture. He also had severe aortic valve regurgitation.  There is presently nowhere in Nigeria where this young man could have the complex and extensive operation, called a Bentall procedure, to protect him from the devastating complication of this condition i.e. aortic rupture as well as progressive left ventricular failure. He had been referred to India for an operation and was awaiting a visa at the time of writing. We also had to explain to him that his condition was serious and that in some circumstances, the condition can run in families and that all first-degree relatives needed screening with echocardiograms to ensure they also did not harbor this dreaded condition. He was incredibly thankful for his assessment despite the nature of the news provided.  It is our hope that with continued partnership with UCH, we will be able to have the required back up necessary, both in manpower and equipment terms, in the near future to perform these types of cases in Nigeria. It is beyond the scope of this article to mention the many cases of structural heart disease in children for which treatment in Nigeria is also not an option and only the very fortunate get to travel abroad to India for life saving treatment.

At the conclusion of all the cases, it was time to reflect on the enormity of what had been achieved at UCH, Ibadan and perhaps more importantly, what we had learnt. The procedures that we performed are commonplace in more advanced societies outside Nigeria and have been for the last 20yrs but nevertheless, UCH deserves every accolade it receives. A lot has been said and written about the problems of getting things done in Nigeria, however, to complete a major infrastructure project like the construction and commissioning of a brand new catheter lab and operating theatre, to bring together a team of diaspora Nigerians to work seamlessly in concert with consultants from a public institution in Nigeria on behalf of patients should not be underestimated. It demonstrates that where there are leaders with the appropriate talent, drive and vision, like Prof. Alonge working alongside motivated consultants seeking the best for their patients like the cardiologists at UCH, great things can be achieved.

The UCH, Ibadan Cardiac Team
Undoubtedly, there remain significant challenges and hurdles to surmount. These include the sustainability of diaspora-trained consultants to bring their knowledge and skills to Nigeria in a more permanent way. Robust and accountable methods of training to enable effective knowledge transfer from Nigerians in the diaspora to consultants in Nigeria need to be developed, fostered and encouraged.

The costs of this trip were borne entirely by UCH from existing budgets without recourse to federal government funding. The balloons and stents brought along for this trip alone cost in the region of $50,000. The patients treated on this historic trip were not charged but such treatment is not sustainable without some form of funding emanating from the government, patients or some combination of both going forward. There is hope that the nascent National Health Insurance Scheme may provide a partial solution to the funding problem but the industry requires careful regulation by the government to ensure adequacy of coverage.

All governments around the world are grappling with the implications present in treating growing numbers of patients with ever more expensive therapies. In future, patients from developing countries are going to demand ever more access to these treatments and their governments need to begin to make preparations to deal with this impending reality. Some would argue that the future is already present. They would also be wise to learn the lessons from mistakes already made by other countries and avoid unsustainable models of provision.

In the meantime, as healthcare professionals we need to recognize that we have a public health emergency of ischaemic heart disease on our hands. It has been widely prophesied that this epidemic lies in the future with increasing affluence and adoption of Western lifestyles and diets but the view from Ibadan suggests that it is already upon us. A brief sojourn around the town revealed a high incidence of central obesity in men, which was certainly not present when I grew up in Nigeria 25yrs ago. It is well known that ischemic heart disease is the leading cause of death in most Western countries and unfortunately it is rapidly achieving similar status in developing countries. Deaths from cardiovascular causes have already surpassed those of infectious causes in most developing countries like Nigeria. Public health measures such as dietary modification, weight loss, smoking cessation programs and exercise are vital weapons required in the armamentarium to fight this epidemic but interventions to deal with acute presentations will always be necessary as will the ongoing treatments to deal with morbidity in the survivors such as chronic heart failure and requirements for expensive life saving therapies such as defibrillators. All the patients treated at this time were adults but there is possibly an even greater deficit of care exists in the paediatric and congenital heart disease populations where many unnecessary mortality and morbidity occur due to lack of recognition and unavailability of treatment. This is an area we hope to address in conjunction with UCH and their paediatric cardiologists in the future in the realm of structural intervention.

I would like to conclude with an optimistic vision of the future. It is not one devoid of the obvious challenges of funding and infrastructure issues but with the combination of the deep wellspring of goodwill towards the motherland present in most Nigerian healthcare professionals in the diaspora accompanied by exemplary leaders such as Prof. Alonge and his colleagues at UCH, I am confident that the impending tidal wave of ischaemic and structural heart disease and its complications can be met with resilience and fortitude on behalf of the long suffering patients of Nigeria towards improved life expectancy and quality of life.


Dr. Tosin Majekodunmi – Adult Congenital and Structural heart disease Fellow
Toronto General Hospital
Email: tosinmajek@doctors.org.uk

Written on behalf of the Cardiac team at UCH, Ibadan. 




6 comments:

Anonymous said...

Thanks for sharing and a big congratulations to UCH for pulling it off. That is the transfer of institutional memory and practice to their facility. It confirms again that while the technology is vital, the skill and brain of the doctors and nurses remain the most important and expensive resource for crucial health outcomes

businessanswers said...

Thanks for the information. I wish such milestone will continue in Nigeria.
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Anonymous said...

That's amazing. I look forward to such progress and being part of such progress in the areas of Neurosurgery, neurology and interventional Radiology. Like correctly stated in the article infectious disease as a major source of mortality is slowly being overtaken in Nigeria and it's about high time we improved our mortality rates from surgeries. Very well done.

Anonymous said...

The feat of Invasive treatment of Cardiovascular diseases in a poorly functioning 'system' is massive and deliberate steps of financing, bilateral trade agreements with device companies need to be taken by concerned parties for sustainability.

The influx of diaspora physicians is greatly welcome to help jump start the system and overcomes the prevailing inertia and i commend the team from the U.S & Canada. The building, technology, skill set, all exist in Nigeria and in UCH but the inertia and other factors (seen and unseen) remain.

It is thus erroneous to assume that the Consultant Cardiologists have only "read about the procedures in textbooks". And I have credible information that no less than two Consultant Cardiologists, three cardiac nurses, two cardiothoracic surgeons and one cardiac rehabilitation therapist who work in UCH currently have had between 12-24 months interventional cardiology fellowships overseas in South Africa, Israel and India.

So going forward, the main thrust of progress lies in Political Will, Viable and sustainable Health Financing options, trade agreements between device companies(citing population figures and economic status) as well as apt and dedicated Overseas technical support to encourage fruits from available human and non-human resources. Such overseas technical support was demonstrated here and should be encouraged from time-to-time.

Well done.

abiodunfuoye said...

Nice to have you ppl in our state. just to start with... thxs

Susan@av canal repair said...

We are all glad that finally the cost-effectiveness of various interventions addressing the most relevant causes of heart disease are now being develop and being promoted in Ibadan. As we all know cardiovascular disease has become the leading contributor to loss of life in most countries and some governments have largely overlooked this disease thus investing in wrong priorities. We hope that your collaboration will implement effective and feasible strategies to help more patients in Ibadan who are suffering from coronary artery disease. Goodluck!