Mending Hearts in Nicaragua

The UNC team performed percutaneous mitral valvuloplasties on patients León, Nicaragua, for two weeks.

The UNC team performed percutaneous mitral valvuloplasties on patients in León, Nicaragua, for two weeks.

By Matt Englund, Communications Specialist for UNC Health Care

In February, three UNC interventional cardiologists and a team of dedicated health care professionals travelled to Nicaragua to perform a life-saving, minimally invasive procedure on as many patients as they could, and to bring the best in cardiac care to a country without heart surgeons.

For many Nicaraguans, a diagnosis of a heart condition such as mitral valve stenosis – a debilitating complication that can be the end result of untreated strep throat – is grim news that offers little in the way of hope.

“If patients have the money, they can travel to another country to receive care,” said Michael Yeung, MD, a UNC interventional cardiologist and assistant professor of medicine at the UNC School of Medicine. “If they don’t have the money, they die.”

To help bridge this enormous gap, Yeung, along with a group of UNC experts including John Vavalle, MD, MPH; Alan Hinderliter, MD; Lucius Howell, MD; Joshua Vega, MD; Roman Baczara, RN; and Charlene Marie Whayne, RN, travelled to León, Nicaragua, as part of a medical mission called Project Health for León, aimed at bringing life-saving, high-level medical expertise to a country with no heart surgeons and not enough cardiologists to meet the developing nation’s medical needs.

“Medicine is a calling and a passion for us,” said Vavalle, associate professor of medicine in the Division of Cardiology and medical director of the UNC Structural Heart Disease Program. “It’s very gratifying to be able to use our knowledge and skills to help those who are suffering and who would not otherwise have access to the kind of care we provide.”

Project Health for León was originally started by physicians from the Brody School of Medicine at East Carolina University. In recent years, their medical missions have grown to include cardiologists and heart surgeons from across the state. In 2015, Yeung and Howell joined the mission, offering minimally invasive structural interventions for problems such as damaged heart valves, which can’t be treated with medication.

From left to right: A local provider, Lucius Howell, Michael Yeung and John Vavalle in the OR.

From left to right: A local provider, Lucius Howell, Michael Yeung and John Vavalle in the OR.

A Vital Procedure
For their trip this year, Yeung, Howell and Vavalle’s goal was to perform percutaneous mitral valvuloplasties on as many patients as they could in two weeks. This is a minimally invasive procedure in which a balloon is inserted into a mitral valve damaged by disease to improve the flow of oxygen-rich blood to the heart.

In Nicaragua, this technique is uncommonly valuable to patients suffering from mitral valve stenosis.

In the United States, strep throat is a common, if unpleasant, ailment that normally clears up after a course of antibiotics. But if left untreated, strep throat can lead to a much more serious infection called rheumatic fever, an inflammatory disease that attacks the joints, skin and heart, and can cause permanent damage to these tissues.

In some cases, the damage caused by rheumatic fever is so severe that it leads to mitral valve stenosis, a devastating heart condition in which a narrowing of the mitral valve restricts blood flow to the left side of the heart. This narrowing reduces the volume of oxygen-rich blood from the lungs, leading to fatigue and shortness of breath.

“There are antibiotics to treat strep throat available in the country, but there isn’t a network of care that’s able to deliver medication and other care when and where it’s needed,” said Howell, a cardiology fellow at the School of Medicine. “Part of Project Health for León is devoted to preventing these gaps in care by using every approach we have available in this country, from prophylaxis to surgery. The end goal is to eradicate rheumatic heart disease and the complications that come from it.”

The symptoms of mitral valve stenosis can be devastating, and they are all more tragic because it is a condition that is, by the standards of medicine in the developed world, preventable. This is why, Yeung said, the skills that he and his colleagues are able to bring to Nicaragua are so valuable.

“Only a few people are able to perform mitral valvuloplasties in North Carolina,” said Yeung. “The patients are happy because this minimally invasive procedure solves their problem, and they can go home the same day.”

Since shipping surgical supplies to Nicaragua takes months, the team packed everything they would need into hockey bags for the flight to León.

Since shipping surgical supplies to Nicaragua takes months, the team packed everything they would need into hockey bags for the flight to León.

An OR in a Hockey Bag
Planning the trip took Howell and his colleagues more than a year. They needed to get permissions from the School of Medicine in Chapel Hill, the University in León, the airline and the Nicaraguan government.

“We had to create a manifest of everything we were planning on taking,” recalled Howell, “right down to the pens and the hairnets.”

They also had to plan for every contingency that they might encounter.

“We had to prepare for the fact that we wouldn’t have any surgical back up for this,” said Howell. “Something that might not be life-threatening in an American operating room could be incredibly dangerous in León, so we had to be sure there was a way to fix it if something went wrong, like an accumulation of fluid around the heart or someone needing a pacemaker.”

Past surgical groups that have travelled to Nicaragua as part of the medical mission have shipped containers of equipment by boat, but that can take weeks or sometimes months. The other option was for the trio to carry what they needed with them on their backs.

“We packed our equipment into hockey-sized duffel bags and checked them with the airline,” said Howell. “This is a global health issue, but we were working to improve medical conditions in this country that is, in fact, very close. We had breakfast in Miami and by lunchtime we were in León.”

Once they were in country, it was time to get down to work. Howell said that as a fellow, the experience was incredibly enriching.

“Not only was I able to see patients with a disease that, in this country, you rarely see in such an advanced state, but because of the limitations of bringing such a small group, it gave me a chance to really step into a lot of different roles. One minute you’re a surgeon, the next you’re a medical Spanish liaison, and the next you’re a diplomat. It was a very invigorating experience.”

The trip gave cardiology fellow Lucius Howell experience as a surgeon, as a medical Spanish liaison and as a diplomat.

The trip gave cardiology fellow Lucius Howell experience as a surgeon, as a medical Spanish liaison and as a diplomat.

Leap of Faith
More than just an educational opportunity, this procedure is able to transform the lives of people suffering from mitral valve stenosis.

Vavalle recalls one patient in particular who years earlier was forced to quit nursing school because of debilitating symptoms. She was the first Nicaraguan patient the group performed the procedure on.

“The moment we had completed her procedure and wheeled her back into the recovery room, everyone was in tears – the patient, her husband, us,” Vavalle said. “Because we had just accomplished something that we weren’t certain we could do.

“There were a lot of unknowns when we went wheels up at RDU – customs, the state of the operating room, the availability of imaging equipment. And many of these patients had to travel a long way to get to the clinic, so we weren’t sure they’d be able to get there on time. We went to great lengths to ensure success, but it was a leap of faith.”

After her procedure, the patient asked Yeung how she could thank them. He told her that the best way was for her to return to nursing school so she can help others in her country.

“It was an amazing moment,” recalls Vavalle. “And it was exactly the kind of moment we went to León for.”