Cardiothoracic Surgery Partnership Completes Multiple Open-Heart Surgeries at MTRH

Twenty-year-old Monica had just begun classes at the University of Nairobi when she began feeling chest pain and shortness of breath while walking the short distance between her classes. The school nurse was concerned enough to recommend admission to a nearby hospital in Nairobi which determined that Monica had a severely enlarged heart with dysfunction of three of the four cardiac valves and very advanced heart failure due to rheumatic heart disease.

Dr. Emily Farkas and Monica

Rheumatic heart disease is endemic in Kenya and is the result of strep throat as a child that remains untreated and progresses to rheumatic fever. Over time, it aggressively targets heart valves so that many young men and women in their 20s-30s find themselves with multivalvular heart failure requiring cardiac surgery. Unfortunately, this surgery is unavailable at more than 95 percent of hospitals in Kenya. Monica was originally given a surgery appointment in two years.

Monica recalls experiencing health issues as early as 1st grade that included pronounced fatigue, breathing difficulties, and chest discomfort and being treated multiple times for presumed pneumonia at rural clinics with no ability to do diagnostic imaging. This pattern continued for many years until symptoms increased in frequency and intensity in high school, leading doctors to treat her with narcotic pain medication since there was no suspicion of a potential cardiac problem.

Monica with IU AMPATH team members, Dr. David Matthews (right) and James Millward, PA-C (left)

A few months after her diagnosis and with her symptoms worsening, Monica traveled to Eldoret alone for her initial evaluation at Moi Teaching and Referral Hospital (MTRH).  Under the leadership of CEO Dr. Wilson K. Aruasa, MTRH compassionately accepts payment from the Kenyan National Health Insurance Fund which covers essentially all hospital expenses, greatly increasing the possibility of surgery for the poor. Her timing was fortunate, and she was scheduled for surgery. In December, Monica underwent successful triple valve surgery to replace her severely damaged aortic and mitral valves as well as to repair her leaking tricuspid valve.

Her surgery was one of twelve performed through a burgeoning AMPATH cardiothoracic surgery partnership led by Professor Barasa Otsyula and Dr. Stephen Ondigo of MTRH and Indiana University (IU) cardiothoracic surgeon Dr. Emily Farkas. Every few months a team from the AMPATH consortium travels to Eldoret to provide one-to-one skill transfer in every aspect of complex cardiovascular surgery while serving people like Monica in critical need of open-heart surgery. A team from IU and Austin, Texas, is visiting again this month.

The launch of this effort benefitted greatly from the leadership of the late Nairobi cardiac surgeon, Dr. James Munene, whose contribution continues to inspire everyone involved. Moving forward, the hope is for IU AMPATH specialty personnel to continue to visit Eldoret approximately every eight weeks to support the MTRH cardiac surgery program, coordinating with MTRH and Nairobi colleagues for specialized training needs and in sourcing of needed equipment.

“This partnership is playing a key role in working with our team to offer services and transfer skills,” said Professor Otsyula, former Chief of Cardiothoracic Surgery at MTRH and former Dean of Moi University School of Medicine.

In addition to Dr. Farkas, the visiting team in December included: Dr. David Matthews, IU School of Medicine, Department of Surgery; James Millward, physician assistant from the VA; Brian Terreau, perfusionist from the VA, surgeon Dr. Vinicius Nina and Emily Matthews. At the end of the week the team received shukas (Maasai blankets) and traditional cloths.

The collaboration is building the infrastructure for these surgeries through the acquisition of specialized equipment that the team at MTRH has determined would be most useful. This has included a portable echocardiography machine used in the OR to guide surgery as well as in the ward before and after operations to assess cardiac function; an assistive device called an intra-aortic balloon pump to support weakened hearts before and after surgery; a heater/cooler machine that controls core body temperature safely during operations; and surgical instruments such as retractors and forceps.

Dr. Ondigo, chief of Cardiothoracic Surgery at MTRH, added, “The current collaboration is very good. It has assisted patients who had been waiting for surgery for a long time. The knowledge transfer from the visiting surgeons is very important training.”

“Integrating the teams has been fantastic,” said Dr. Farkas associate professor of cardiothoracic surgery at IU School of Medicine. “We don’t feel like there’s an ‘IU team’ and an ‘MTRH team‘. Rather, it feels like we’re one cohesive group working together toward a collective goal; some of us just have a longer commute time to work!”

MTRH, in collaboration with AMPATH Consortium member Duke University, has built a robust cardiology center of excellence and Moi University has established a fellowship in cardiology. Many of the cardiac patients are in need of cardiovascular surgery, so building surgical capacity is crucial. The team would eventually like to work toward an ACGME-approved cardiothoracic residency rotation in Eldoret. Additional ward space, a dedicated ICU, increased surgical theater space and perhaps even a comprehensive heart institute are on the wish list for the future.

Monica at home with her family one month after surgery

For now, with adequate funding, Dr. Farkas hopes to have an AMPATH Consortium team in Eldoret every 8 weeks for the next 3-5 years. In 2023, two of those rotations will be affiliated with Dell Medical School at the University of Texas at Austin under the direction of Dr. Rob Neely. Dr. Farkas has also enlisted the involvement of international colleagues from previous global surgery initiatives.

Current efforts are supported by grants from the Thoracic Surgical Foundation, the philanthropic arm of the Society of Thoracic Surgeons to both Dr. Farkas and Dr. Neely. This is made possible by industry partner Edwards Lifesciences' program called Every Heartbeat Matters, an initiative focused on impacting the lives of underserved patients, particularly those with valvular heart disease.

During her hospitalization in Eldoret, Monica expressed gratitude for the opportunity to have heart surgery at MTRH and for her symptoms to improve. She plans to continue her degree by returning to the University later this year.