Heart Reconstruction

Welcome back to Daktari Cases.  It’s been a few weeks since I’ve posted a case; not because there has been a dearth of interesting medicine, but really because there has been a surplus.  In addition to the usual holiday busyness (and we do have a less commercialized version of that here), there was a nationwide strike of healthcare workers in government institutions.  The details and causes of which I’ll omit (because I’m sure I don’t understand them).  The result was a very full hospital and outpatient department at Tenwek, which always runs at full capacity, over the past few weeks has approached “two-to-a-bed.”  With the New Year has come a settlement, and the reopening of the government hospitals, good for the patients and a breath of air for Tenwek.

So, I’ll start 2014 with a story.  The young lady’s name is Soi.  She is a 20 year-old woman from a village about 15 kilometers away who was married last year and is expecting her first child.  She finds herself getting tired and short of breath as she enters her 4th month, and when she asks her mother, she learns that this is a part of bearing a child.  Reassured, she continues to go about her day as a young wife and mother-to-be, working in the garden, carrying firewood, cooking and cleaning.  She lives beyond the reach of the electrical lines and water system, and beyond the reach of our prenatal care.  She carries on with life in the cool lush dirt-floor equatorial sun until one day she can’t walk to the river.  Then everyone notices that something is really wrong.  And they find a driver with a car and take her to Tenwek.

I meet her in casualty (the ER), and she is clearly in distress.  Her initial vital signs are a heart rate of 164, BP 94/68, RR 30, pulse oximetry 82% on room air.  These are her initial chest x-ray and electrocardiogram.  Her heart is beating faster than it can fill up with blood and she is going into heart failure.  We have to slow her heart down or this downward spiral will get out of control.  We have to decide to try to use medicine to slow her rate down, or to cardiovert her with the electric shock of a defibrillator (it’s not a good idea to shock a patient when you don’t know how long she’s been in this rhythm (foreshadowing: it could cause a stroke), not to mention that I don’t want to shock a mom and baby).  After some calling around, we locate some drugs that were left from the last cardiac surgery team at Tenwek that will ease her heart rate down, and give her some diuretics to pull off some of the fluid that has collected in her lungs.  This happens over the course of the first night, and so as the beautiful African equatorial sun rises on the next morning, we start to ask “Why?”

Nothing in my medical education to date gave me an explanation of why an otherwise healthy 20-year-old woman would have this tachyarrhythmia as she enters her second trimester.  But the first storm has passed, and it’s time to get to the thinking part.  As I repeat her exam, and now that her heart rate is down around 100, I can hear new sounds: the “whoosh-thump-whoo” of a mixed systolic and diastolic heart murmur.  We are blessed at Tenwek to have echocardiography capability and this is what her echo looked like.  It shows an extraordinarily scarred and narrowed mitral valve with just a teeny jet of blood flowing through it, along with a very large blood clot in her left atrium.  This is a picture of severe mitral valve stenosis from longstanding rheumatic heart disease.  RHD is a disease of poverty from repetitive bouts of untreated strep throat.  She has been living, miraculously, with this severe heart disease, likely since her childhood.  Yet in pregnancy, her blood volume increases by about 50%, to accommodate the baby.  The way her body changes to nurture the baby has overwhelmed her damaged heart.  And the strain on her body will accelerate over the next few weeks; she won’t survive pregnancy without open heart surgery, and having that large clot in her left atrium gives her the added risk of a major stroke.

This is one of those times when I’m thinking about what it would be like to work in a walk-in clinic in Tennessee: “Oh, you have a backache, I’m sorry; here are some painkillers.” or “Is that a sniffly nose?  Should I give you some antibiotics (editorial note: NO!)” 

Anyway, I snap out of that daydream after about 1.4 seconds and call in a lifeline: Dr. Russ White, cardiothoracic surgeon extraordinaire.  I am SO thankful to work in a place like Tenwek with such awesome colleagues.  Yes, he’s seen this before. Yes, it’s a tough case with a lot of risks no matter what we do.  And Yes, we can do open heart surgery, replace her valve, remove that dastardly blood clot, and give her a chance to live.  The downsides: there’s very little or no chance that the baby will survive being on cardiopulmonary bypass, and there’s a fair chance that clot will travel up into her brain during the operation and cause a stroke, and the family will likely have to go bankrupt to pay for the operation and ICU care (even though it’s the cheapest open heart surgery in Africa).  We have a few days to weigh the risks/benefits while we try to optimize her health, and the family involves their community in a fundraising drive and all-night prayer meetings. 

At this point, we decide to go ahead with the surgery, and this is the point in the story where you come in.  Because many of you are our supporters, and I told the hospital finance department that we will pay to make this surgery happen.  The community in their village gave, the family sacrificed greatly, and we filled in what was lacking.  To the Operating Room…

The procedure was long and complicated.  The valve was deeply scarred into the surround heart muscle, the clot was hardened and calcified, making it difficult to remove (but able to be removed intact).  The baby didn’t make it through the procedure, and there were times when the survival of the mother was in doubt.  But this time when they shocked her to restart her heart, it beat in a smooth, healthy, regular 88 beats per minute.  Several days of recovery later, she walked out of the hospital and caught a ride back to her village, with a story of a miracle.  Reminds me of a story that the prophet Ezekiel told
-->: “I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh.” (Ezekiel 26:36).  And to those of you who are our supporters, this is your story too.  Thank you for giving and praying, so that we can be here, and giving so that people like Soi can be healed.  A piece of her new heart comes from you.