Four hours to a new life: Inside KNH's high-stakes heart surgeries

Every step was carefully calculated and timed. From the administration of anaesthesia to infection prevention, nothing was left to chance.

Once a patient was wheeled into theatre and positioned on the operating table, Ioban, an antimicrobial surgical drape, was applied.

At the table, the lead surgeon took charge, directing each stage of the procedure and giving instructions to the team on the incision and what followed.

In some cases, the incision was about nine centimetres, cutting through the skin and underlying tissue to reach the sternum, or breastbone.

An electric sternal saw was then used to open the sternum, giving surgeons access to the heart, the engine of the human body.

Throughout the operation, diathermy was used to seal blood vessels and control bleeding, helping the team achieve haemostasis.

Before the operation began, the team conducted a surgical time-out to minimise the risk of errors.

The patient’s name was called out, each specialist involved in the surgery introduced themselves, and the team confirmed the patient’s identity, type of surgery, expected duration, and anticipated challenges.

This was the scene witnessed at one of the main theatres at Kenyatta National Hospital (KNH), where 10 cardiac surgeries were successfully performed during a five-day mission.

The mission was conducted by KIBOS Health Foundation in collaboration with KNH, bringing together international specialists, doctors from KNH and some from Moi Teaching and Referral Hospital (MTRH).

The procedures included valve surgery and coronary artery bypass grafting.

The team introduced off-pump coronary artery bypass surgery at the national referral hospital, described as the first of its kind in Kenya and East and Central Africa.

At exactly 5.56pm, the mission closed as the 10th patient was wheeled out of theatre.

Prof Hiroshi Ninami, the lead cardiac surgeon, was cheered as he stepped out of theatre. It was the first time the Japanese surgeon, who specialises in heart bypass surgery and has more than 30 years of experience, performed surgery in Kenya.

“This is something I am used to. I have conducted more than 5,000 surgeries globally. I am happy these have turned out successful,” hesaid.

While KNH performs valve surgery using a heart-lung machine, coronary artery bypass grafting had become uncommon at the hospital.

Dr Simon Ndiritu, head of cardiothoracic surgery at KNH, said the last bypass operation he remembered at the facility was in 2003.

Ndiritu said the procedure was complex and required a highly specialised team.

Among the complex cases handled during the mission was a patient who had both coronary artery disease and mitral valve disease.

Prof Ninami and his team repaired the mitral valve and performed coronary artery bypass grafting during the same operation.

“I did not replace the valve. I repaired it. So, she still her own valve,” said Prof Ninami. “I repaired it. And also, I did the coronary artery bypass grafting at the same time.”

Ninami described the combination as unusual. “She had two operations. The valve operation and also the coronary operation. That was probably a unique operation here in Kenya,” he said.

Stopping the heart

The surgery took about four hours. For the bypass procedure, the patient’s heart continued beating. The surgeons later used a heart-protection solution to stop the heart for about an hour while the mitral valve was repaired. The valve problem was discovered during the operation.

During a visit by The Standard to the facility the following day, the patient had been extubated and was breathing on her own.

At the centre of the mission was  KIBOS Health Foundation CEO Dr Ambrose Samuel, who mobilised resources and brought together the multidisciplinary team of international specialists.

The mission was not only about operating on patients, but also transferring skills.

As the surgeries were performed, cameras captured the procedures and streamed them to doctors and other health professionals taking part in learning sessions.

Dr Samuel said the long-term goal was to strengthen KNH’s capacity to provide advanced cardiac care locally.

“KIBOS plays a bigger role, not only in Kenya, but all over the world. We are connected with doctors and all members are experts, including nurses, doctors, surgeons and cardiologists,” he said.

“KNH should have the capacity to provide that care,” he added.

For Dr Ndiritu, the 10 operations marked more than the end of a five-day mission. They offered KNH an opportunity to rebuild its capacity to perform coronary artery bypass surgery, including the off-pump technique, which allows surgeons to operate while the heart is still beating.

Of the 10 patients, six had coronary artery disease, in which blood vessels supplying the heart become narrowed or blocked, while four had valve disease, including rheumatic heart disease.

Dr Ndiritu said coronary surgery had become uncommon at KNH in recent years, with many patients with blocked arteries instead treated through catheter-based procedures known as percutaneous coronary intervention (PCI), in which stents are inserted to keep vessels open.

But some patients require surgery.

“What I do hope to carry forward from this project is that we will make coronary artery surgery a regular routine procedure that we do without needing to wait for assistance from outside,” said Ndiritu.

He said the off-pump approach was particularly significant because, to his knowledge, KNH had not previously performed coronary bypass surgery using the technique.

The challenge, he said, was the level of skill and experience required.

“The coronary vessels feed the heart. They are very, very central to how the body functions,” he said. “The vessels are very small, about two millimetres wide. To be able to operate on them well, you really need to be experienced, to avoid deaths.”

The 10 patients were carefully selected and the operations extensively planned because the team was apprehensive about restarting the service.

“Honestly, it was apprehension. We were not too sure if it would go well or not,” explained Ndiritu. But all 10 patients came through the operations without complications.

“I can say with a lot of confidence that this is not going to be the end. We will continue,” he said.

Ndiritu pointed to risk factors for coronary artery disease, including hypertension, diabetes, obesity and high cholesterol.

Changing lifestyles, including increased consumption of unhealthy foods and less physical activity, could contribute to more cases.

He urged Kenyans to undergo regular health checks, follow medical advice and take prescribed medicines consistently.

“Let people have health insurance so when there is a problem, it doesn’t become so difficult to get care,” added Ndiritu.

Prof Ninami said his biggest concern was not surgery itself, but what would happen to patients after they left the operating theatre. But he said he was reassured of quality care, by what he found at KNH.

“The post-operative care in the intensive care unit, the doctors, nursing staff were excellent,” he said.

Post-operative care

Prof Ninami said the KNH intensive care team was able to monitor patients closely and respond when necessary, allowing the surgical team to concentrate on the operations.

KNH critical care nurse specialist Purity Anampia, of the cardiothoracic unit, said all 10 patients were in stable condition, with some already preparing for discharge.

The five men and five women, aged between 23 and 74, were closely monitored for blood pressure, heart rate, breathing and oxygen levels.

To prevent infections after surgery, the hospital set aside two rooms specifically for the patients.

“We set up two rooms for infection prevention measures. They have low immunity and are likely to acquire infections. Any infection post-operatively is costly to the patient,” said Anampia.

Visitors were limited to one person at a time, with guests required to wear face masks.

We meet 40-year-old Augustine Mukira Ngatia from Mukuruine, Nyeri County, who was recovering after surgery.

Ngatia was filled with fear as he anxiously waited to undergo surgery. A friend had bluntly told him he was going to “meet his Creator”.

“Silently, as I was wheeled to theatre, I knew it was the end of my life. I knew my days had come to an end. So I was ready for any eventualities; my mind was prepared,” he said.

However, doctors had reassured him that the procedure was manageable and that he could recover.

“I did not imagine I would get out of the operating table,” he said. “They have done an excellent job.”

For 50-year-old Benard Egesa from Funyula in Busia, heart disease came as a shock. He had been going about his normal routine at home when he developed severe chest pain, shortness of breath and unusual fatigue. This was in April this year.

He sought treatment at a nearby clinic, where he was initially treated for what he was told was a blood infection. But his condition worsened and he was referred to Vihiga County Hospital, where tests showed the arteries supplying blood to his heart were blocked.

On the same day, he was referred to KNH as he was in a critical state.

“I was shocked, and I was so anxious,” he said. “Anything to do with the heart comes with anxiety.”

Fear

The fear extended to his family, with his wife becoming ill and developing high blood pressure after learning that he was going into theatre.

“Nilikuwa nimesikia mambo ya upasuaji wa moyo ni wewe na Mungu. So I knew it was life and death,” he said.

But three days after surgery, he was already exercising and feeling a difference.

“I am happy. My chest no longer feels heavy, and I do not have any pain,” he said.

However, even as patients recovered, Prof Ninami said what stood out during the surgeries was the young age of some patients.

In Japan, he said, patients undergoing heart surgery were typically around 60 years old. In contrast, in Kenya, the team operated on patients in their 20s and 30s.

Prof Ninami attributed the difference partly to rheumatic heart disease, which can develop after a childhood or adolescent infection and progressively damage the heart valves over many years.

He also linked heart disease to poor lifestyle and diet.

“But one of the difficult things here, I can tell you, is that sometimes I encounter very fat patients. They are also very diabetic patients. You know, in this country, people love to take sugar, sweets and such things,” said Prof Ninami.

“So diabetes is really bad. Diabetes and being overweight are the worst combination. Unfortunately, in this country, a lot of these patients need good food, exercise and to stop smoking,” he added.

For the experienced team, the operations were routine, with the longest taking about four hours.

Ninami said the bigger goal of the mission was to build KNH’s capacity to perform such operations safely and independently.

“Our mission is to make a good team in KNH, to be able to perform the heart operation with confidence and safety,” he said.

“We hope in five years, KNH surgeons will be able to perform the procedures on their own”.