Stories From the Field:

TANZANIA

Cardiac Catheterization in Tanzania

Nino Mihatov, MD, Clinical Research Fellow in the MGH Cardiology Division, traveled to Tanzania for an intensive one-week immersion with Madaktari Africa, an NGO that is advancing the capabilities of the cardiac catheterization in sub-Saharan Africa.

Given the overwhelming support I received from my co-fellows and division faculty and staff, I thought I’d share with all of you my experience in Dar es Salaam, Tanzania. First off, I’m indebted to Doug Drachman and Doreen DeFaria for the fellowship’s support of my attendance, Kristin Giambusso and the MGH Global Health Institute for providing a generous travel grant, Madaktari Africa and Maarten Hoek for all the local logistical organization and execution, Meg McCleary for facilitating MGH catheterization (cath) lab coverage and for sharing best practices of our own lab, Ricky Cigarroa and Emily Lau for covering my own MGH cath lab responsibilities, and the entire JKCI staff for warmly embracing our visit.

During Mike Valentine’s MGH Cardiovascular Grand Rounds in January of this year, he highlighted the work in Tanzania of Madaktari Africa, a US based NGO, of which MGH’s own Mazen Albaghdadi is a key volunteer. Madaktari had helped establish Tanzania’s first cath lab and facilitated Tanzania’s 1st PCI in April 2015 at Jakaya Kikwete Cardiac Institute, more commonly known as JKCI. JKCI is the principle cardiovascular referral center in Tanzania located on the grounds of the country’s largest tertiary care center, Muhimbili. Madaktari aims to advance JKCI’s procedural competencies through the “train-forward” model where specialized volunteers work alongside local clinicians to advance local capabilities, at all times aiming for the local clinician to serve as the primary operator. This was Mazen’s 3rd visit to JKCI and it was immediately apparent the trust he had built over his prior visits with the staff as both a consummate interventionalist and educator.

We arrived early Sunday morning and hit the ground rounding at 8AM Monday with an enthusiastic welcome from the entire JKCI and cath lab staff. The JKCI Cath Lab welcomes a “camp” of visiting operators on a quarterly basis, ranging from 1-2 Madaktari volunteers to more traditional medical mission trips that visit the JKCI and operate independently to perform a variety of invasive procedures. Patients were carefully selected in advance, based on a pre-procedural estimation of complex coronary disease, for Camp Mazen. Most of the physicians mentioned their particular enthusiasm for Camp Mazen and Madaktari as it focused on developing local procedural skillset rather than patient throughput.

I was struck with how quickly I felt at home with the cath lab infrastructure. Mirroring much of the MGH Cath Lab, JKCI has a comparable state-of-the-art single room Siemens setup with a breadth of basic diagnostic equipment but some limitations in interventional equipment. As a consequence of the relatively recent increase in the prevalence of ischemic heart disease, clinical evaluations are still evolving. Limited intermediate risk stratification tools (MIBI imaging is not available, the primary but limited non-invasive modalities are ETT and stress echo) guide a lower threshold for coronary angiography referral. Patients in whom more complex PCI or CABG is necessary are often referred to India for said procedure with expenses covered by the Tanzanian government.

I can’t underemphasize the comradery and enthusiasm of the entire cath lab staff – despite days that began before 8AM and ended often after 8PM, the constant enthusiasm motivated our ongoing involvement. We all ate a daily communal lunch. With rapid room turnover, we assisted in 23 cases over 4 days (Thursday unexpectedly happened to be a national holiday and an opportunity for Mazen and I to explore the natural beauty of Zanzibar). In parallel, we developed a more standardized procedural reporting form and protocols for post-procedural management with the aim of achieving international accreditation standards.

While Mazen spent the bulk of his time dedicated to procedural aspect, I tried to share some of the developed systems of our own lab in hopes of helping improve their work-flows. For example, physicians use a blank order sheet to write by hand each of the post-procedural order. We referenced the MGH standard post-procedural order set to transform what used to be a blank post-procedural order form with inherent post procedural variability to a standardized checklist for the management of radial and femoral access. In parallel, JKCI continues to strive to develop a centralized cath lab registry that that will hopefully begin to elucidate the burden of coronary disease in sub-Saharan Africa. To that aim, we shared with the staff the NCDR data collection templates as one example of a developed centralized registry.

This experience helped to begin to contextualize for me the burden of coronary disease in sub-Saharan Africa. Historically, there has been an emphasis on communicable diseases in this region and a complimentary development of efforts by associated medical sub-specialties aimed at combating communicable diseases. This experience helped me appreciate just how necessary cardiology’s involvement is on a more global stage as the burden of non-communicable disease becomes more prevalent. I welcome any additional thoughts or reflections and thought in conclusion I’d share Madaktari’s website for those who might be interested in volunteering: https://www.madaktari.org/