Kenya performs heart valve replacement without anaesthetic

The first aortic valve replacement procedure without the use of formal general anaesthesia has been conducted in sub-Saharan Africa at Aga Khan University Hospital.

Doctors conducted the operation recently at the hospital on an 83-year old female patient with a narrowed aortic valve and was considered unfit for general anaesthesia. The procedure lasted for less than two hours and was conducted while the patient was awake, receiving only local anaesthesia (paracetamol) with mild sedation.

Valvular heart disease affects many Africans and is commonly related to rheumatic heart disease. While many patients can be managed with mediation, a large number of patients will require heart surgery in order to treat the problem. In most cases, heart valve surgery involves opening the chest, stopping the heart, and connecting the patient to a heart-lung bypass machine while the surgeon replaces the heat valve. The trans-catheter aortic valve implantation (TAVI) procedure has recently been introduced to enable patients who cannot undergo open heart surgery due to technical reasons have this procedure performed using two punctures in the groin.

Before the procedure, the patient is given paracetamol and the skin at the hip area is numbed where a cut of 2-3 inches will be done. A guiding wire then navigates through the artery and aorta into the heart. Once the tip arrives at the aortic valve, it acts as a guide to the catheter. In many patients paracetamol is the only pain relief they require.

The procedure involves squeezing a valve into a small narrow tube which is delivered over a small wire introduced through the groin to the heart.  The heart valve is made of a memory metal, which springs back into its original shape once the tube is removed.  The margin for error with this kind of procedure is less than 6mm, so the level of expertise required and technology needed is quite advanced.

Conducting this procedure on a patient while awake poses an extra challenge since the patient may move and dislodge the valve.  Previously, the heart valve implant gave you a single attempt but new valves and systems have developed which allow an imperfectly positioned valve to be repositioned. Positioning of the heart valve is key and if positioned wrongly, it causes blood leakage causing more strain on the heart.

So far, patients undergoing TAVI in sub Saharan Africa have had their treatments done at Aga Khan University Hospital. Normally the treatment requires the use of full general anaesthestic and special imaging using an ultrasound probe introduced through the food pipe (oesophagus).

One of the challenges for this procedure has been the need for oesophageal ultrasound, but with the development of technology and improved expertise, doctors have developed techniques for performing the whole procedure guided by only the advanced x-ray images available at specialised hospitals.

Dr Jeilan emphasised the advantages of this procedure including no cutting of bones, almost negligible blood loss and infections are reduced as the incision is small and the patient does not require intensive care monitoring which means that the patient can be allowed home earlier than most other patient.

The first lady to undergo this procedure was discharged 3 days after the operation.