Friday, March 03, 2006

Remembering the Malaysian Angioplasty story

This is part 3 of the series on how angioplasty came to Malaysia. Part 1 and 2 are also available.

After obtaining the CVs of Dr David Clark and Dr Tim Fischell we handed them to the Ministry of Health for temporary practising certificates which would allow them to help us legally.

The centers chosen included the GHKL cath. lab, the University Hospital cath lab and the Subang Jaya Medical Center cath lab. All these centers also had active cardio-surgical teams, in the event of emergency.

We also began recruiting patients. The patients chosen all had either significant chest pains (symptomatic or a positive stress test reversible ischemia) to justify intervention. With the centers agreement, each patient was told that their cases would be done by American experts. They would have to bear the medical center charge, but not the cost of the balloons and catheters used (these were to be borne by the device companies).

All in all each center had lined up about 10-15 cases, varying from 1-2 vessel disease. There were some tough cases too. Dr Clark and Dr Fischell arrived on the 17th Oct. 1988, the day before the scheduled start and reviewed the cases. If I remember correctly, one or two of the cases were deemed unsuitable and sent for bypass surgery.

The suitable cases became the subjects of thorough case discussions. We had lined up two operators per center to work with the Americans. The plan was to have one American do the case with one local cardiologist, with two centers working independently, aiming to do three cases a day for 5 days a week. At the end of the training, there should be 4 trained angioplasty cardiologist in public service and 2 in private practice.

The Americans would be here for 2 weeks. We set it such that the evenings were "free and easy" and weekends were for tennis. It's always good to factor-in enough time for informal discussion where all of us had time to learn the "tips" and "tricks" of angioplasty from the experts.

The scheduled date for the training was 18th Oct. 1988. For the first week, the Americans were operating and the locals were learning. In the second week, it was our aim that the locals would be performing the procedures with the Americans there to watch and act as support.

Those two weeks were extremely educational. There was no mortality at all (thank God). I remember, we had one case in UHKL, where we used a lot of catheters. It was really tough and the Americans sweated it out with us.

One of my patients had chest pains the night of the angioplasty interrupting our dinner plans to go back to SJMC cath. lab to re-study her again. Eventually we found out it was just RCA coronary spasm. It was also a good first taste of the kind of "exciting" lifestyle we should expect once an active angioplasty program was set up.

Dr Clark and Dr Fischell, returned on the 2nd of April 1988 and agreed that we could consult them, long distance, should the need arise. After their departure, we agreed that we should start doing cases, and help each other.

Initially we had to be very strict in the cases we chose, starting with what we would now call type 1 lesions. As history records, the teams in public service was rather hesitant to start doing cases. They were doing less then 20 cases in the first year. We in private practice, were steadily doing cases, reaching 26 cases by the first year and 100 cases by the second year. We kept a very accurate registry and at regular intervals, this registry was presented at the quarterly Academy of Medicine meeting.

I remember presenting our experience when we had 20 cases, then 75 cases and then 100 cases, all with short term follow-up. We had to be transparent, as the public and medical community were rather sceptical about this new way of treating CAD. 1989 was still very much the era of cardiac bypass surgery and we were upstarts trying to establish a beachhead for angioplasty. We also found the registry very interesting as it taught us lessons about how we were doing. We learned that we were quite safe and that restenosis was our biggest problem.

I remember calling Dr Clark for advise and emotional support, when I dissected a proximal LAD lesion, the first one, and had to send the lady for emergency CABG. She had two vessel disease (CTO/RCA and a discreet type 1 lesion in the prox LAD). The RCA was done first, and done well. After changing the guiding catheter to the JL guiding, I started to wire the LAD lesion. It appeared to cross the lesion, but when I checked with a angiographic shot, I was horrified to not see the LAD. Thereafter, chest pains began, and "all hell broke loose". The cardiac surgeon was summoned and she was sent for emergency CABG. She did OK, but did suffer an anterior heart attack.That night I was very upset, and rang Dr Clark for empathy. I remember him telling me, "Welcome to angioplasty". He said that we all had to go through that. If you do enough angioplasty, you will meet acute closure.

Angioplasty in Malaysia, warts and all, had been born.

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