Project Pacer International Brings Cardiac Electrophysiology to East Africa

   Project Pacer International, a nonprofit Boston, Massachusetts based organization that is dedicated to the provision of cardiac therapy to indigent patients in the developing world, recently completed its first visit to Nairobi, Kenya. Project Pacer International was founded in 1988 and has a long track record of providing pacing and electrophysiology services (as well as interventional cardiology) in the developing world.    Our main focus in the last 20 years has been in India and South America. In Bolivia, where Chagas’ disease is endemic and the need for pacing therapy is substantial, we have developed a close relationship with local cardiologists and now have an active practice of more than 200 patients with implanted devices.¹ Recently, however, we have broadened our horizons to include Morocco, and now Kenya.    Our host institution was the Aga Khan University Hospital, Nairobi (AKUHN), located in suburban Nairobi. The Aga Khan University Hospital is a well-funded private, nonprofit 254-bed institution dedicated to the needs of the people of East Africa. This teaching institution provides opportunities to staff and physicians alike as part of the Aga Khan Development Network, dedicated to improving the living conditions and opportunities in over 20 of the poorest countries in the developing world.    As the economic development of Africa continues, tobacco consumption as well as other cardiac risk factors increases and the prevalence of heart disease consequently rises.² Treatment options for patients in this resource-poor society are limited. To date, patients in East and Central Africa in need of device-based or interventional cardiac electrophysiology therapy have to travel abroad to receive treatment, often venturing to South Africa, India, Europe or the U.S. As a result, the treatment is cost prohibitive for the vast majority of citizens.    The interventional cardiologist at AKUHN, trained at The Western Pennsylvania Hospital in Pittsburgh, Pennsylvania, along with his staff had coordinated in advance the evaluation of patients to be considered for electrophysiology procedures. Our visiting group comprised of 2 electrophysiologists and 2 cardiovascular technologists with extensive EP lab experience. Together, we evaluated all of the patients and selected many of them to undergo elective procedures over a 4-day period ranging from catheter ablation to cardiac resynchronization defibrillator implantation.    Since this was our first visit to AKUHN, our preparation had to be thorough in an effort to be prepared for any obstacles encountered along the way. This preparation started approximately 2 years before we traveled, since there was a need for the physicians to obtain medical licensure in the Republic of Kenya and we needed exact confirmation of the recording equipment configuration and connectivity as well as the time needed to gather the necessary supplies. All we knew was that the hospital had an interventional catheterization lab with a Siemens Sensis EP recording system, which was used daily for coronary, interventional radiology and valvular interventions but had never been used to support electrophysiology procedures since it was installed in 2008. Consequently, we packed a Boston Scientific EPT-1000 radiofrequency generator (donated by Lahey Clinic), and a Medtronic model 5326 programmable external stimulator; we brought guide sheaths, introducers, quadripolar, decapolar and ablation catheters as well as connectors (all donated by St. Jude Medical and Boston Scientific). We also packed a number of implantable leads, pacemakers, defibrillators, CRT devices and associated accessories (donated by St. Jude Medical and Medtronic). In total, we had 8 hockey bags full of equipment in tow when we checked in for our flight to Nairobi. Shipping this material in advance was not a viable option given the possibility of delays in Customs and the potential for heavy importation taxes, which can usually be avoided when the material is hand carried through the airport.    While the 2 EP physicians were evaluating patients for the procedures, the technologists were setting up the lab for procedures scheduled to start the next day. The evaluating physicians were joined by keen senior Registrars, outpatient clinic nurses and staff that were very enthusiastic in learning therapeutic options for the patients with heart rhythm disorders. There were a few technical glitches with power supply conversion and regulation, but with the assistance and ingenuity of the impressively resourceful Biomedical Engineering Department at AKUHN, we were able to assure safe operation of all the equipment.    We started the next day with great enthusiasm, discussing our strategy over breakfast for our first procedure. The first patient was a middle-aged man with a narrow complex tachycardia we thought to be AVNRT. We arrived at the hospital soon thereafter, only to find the lab staff beginning an emergency procedure on a patient with cardiogenic shock due to an acute MI. Having the opportunity to observe them work under considerable duress in a critical situation requiring active CPR during 2-vessel coronary intervention and intra-aortic balloon pump counterpulsation, it quickly became apparent how skilled and dedicated this team was. Fortunately for us, this same vigor and enthusiasm was demonstrated by this incredible team throughout our stay.    Once the patient had been stabilized and transferred to the intensive care unit, we were ready to start our first EP procedure. The staff assisted us in patient preparation and instrumentation, and we were quickly underway. The tachycardia was easily inducible and the diagnosis of AVNRT was quickly confirmed. We then successfully ablated the slow pathway, and all of this was accomplished to the astonishment of the staff at AKUHN as they had anecdotally heard that EP procedures typically last many hours. From this point it was clear that the lab staff was hooked and they wanted to know and do more. During informal lab teaching sessions we discussed anatomic substrates and the necessary conditions for re-entrant arrhythmias to occur; we talked about pacing techniques and the ability to make differential diagnoses based on the observed phenomena. Their enthusiasm was contagious and invigorating for all. From there, with our first successful procedure under our belt, we treated a number of patients with both AVNRT and WPW syndrome; this included a young woman who was 34 weeks pregnant and who had had syncope during 2 episodes of life-threatening pre-excited atrial fibrillation related to a left posterior pathway. Our hosts also got a flavor for the tenacity and perseverance that is sometimes required for EP procedures during a prolonged and technically challenging case of right-sided accessory pathway.    We were also presented a number of patients in need of device therapy, particularly CRT-Ds. Given the common skill set of cannulating coronary vasculature, the interventional team at AKUHN was again thrilled to have the exposure and be part of the procedure. We offered instruction on different techniques employed to cannulate the coronary sinus (CS) and navigate to the target vessel, as well as finding and troubleshooting pacing vectors. The lab staff were highly inquisitive and wanted to know all the nuances of device therapy, which we were more than happy to expound on. We left programmers for all the devices that were implanted, and are confident in the knowledge and skills of our Kenyan colleagues regarding follow up and troubleshooting of any device problems that may occur. Additional teaching was provided in formal CME lectures and in informal sessions with medical and cardiology trainees; during these opportunities to work with our Kenyan medical colleagues we gained much insight into their high level of training and experience and to their selfless dedication to patients in what is often a difficult working environment. We returned to the U.S. both humbled and invigorated by this experience.    It was a full week and everyone involved put in long days at work with immense effort. We were thankful to have such a gracious host institution and department, enthusiastic audiences for our teaching efforts, and most of all, happy to help the patients that were in need. The patients have been followed up in Nairobi and are all doing very well. No complications were noted, and all implanted devices are working well on post-discharge review and interrogation.    We look forward to continuing our relationship with the AKUHN team in the future, and invite U.S. or European based electrophysiology colleagues to contact us if they are interested in collaborating in this work. The team effort between Project Pacer International and AKUHN has demonstrated that cardiac electrophysiology procedures are feasible in East Africa.    Project Pacer International gratefully acknowledges the generous support of St. Jude Medical, Medtronic, Boston Scientific, and Lahey Clinic. For more information, please contact David Martin, MD, FRCP at david.t.martin@lahey.org

References

1. VivasY,Ferrufino O,Zurita C,Martin D.Cardiac electrophysiology in Bolivia. Heart Rhythm 2009;6:1076. 2. Gaziano TA, Bitton A, Anand S, et al. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol 2010;35:72-115.