Wednesday, December 29, 2010

MALAYSIAN INTERVENTIONAL CARDIOLOGY 1980-1990

I did my undergraduate medical studies in the University of Malaya from 1970-1975. During the junior clerkship, the consultant teaching me my early clinical skills was a very nice American gentleman, the late Dr Ward Kennedy. He was an eminent cardiologist from Seattle, Washington, USA, who worked out how to calculate left ventricular ejection fraction correctly from an LV cineangiogram. He was a big name and he was my teacher. From him, I became interested in cardiology. I must say that he was not so proficient in in neuro signs and symptoms or in gastero signs and symptoms. He was very good with murmurs and cardiac signs. No, I am not here to talk about undergraduate days.
The other important reason was that Dr Kennedy was here to help set up the cardiac unit in University Hospital ( as it was then known). He was a personal friend of the late Prof TJ Danaraj and his wife Prof HO Wong. The three of them, together with Prof NK Yong ( Cardiac Surgeon and professor of Surgery ), set up the first cardiac unit in Malaysia, I believe in 1968. Prof Wong and Dr Kennedy wil do the cardiac work-up and confirmatory angiography ( at that time, there was no echocardiogram ), and Prof Yong will operate. The priority at that time ( a priority decided by Prof TJ Danaraj and Prof HO Wong ) was to treat mainly congenital heart disease, which was the first form of corrective cardiac surgery practiced here and in the West. It was indeed very rewarding to see a "blue baby", turn pink after corrective cardiac surgery. Of course at that time, surgical techniques were developed only for the most common and easiest to correct, as cardiac surgery itself was at its infancy. We saw alot of ASDs, VSDs, Tetralogy of Fallots, Coarctation of Aorta, some Transpositions of Great Vessels, and the rest were rare, or died before reaching us. We also saw much Chronic Rheumatic Heart Disease and we were quite good at listening to murmurs.
After my graduation in April 1975, I was asked to stay behind in UH, to join the cardiac team, at that time centered on Ward 4A of UHKL. The team, at that time in 1976, consisted of Prof Wong as head of department, Dr KT Singham ( now in Australia ), and Dr Anuar Masduki. I was the most junior and was in the position of clerking in patients, preparing them for cardiac catherisation, and when time permitted, also holding on to the distal end of catheters. I learn that most of the equipment for the cath lab was donated by the China Inland Mission. via USA, and we were reusing catheters, which nonetheless work safely and well. In this way, I horned my skills, and got my first taste of cardiology, first hand.
The late Prof TJ D, as he was affectionately called, was a very strict disciplinarian, and inculcated in all of us a strong sense of discipline and responsibility. It was always patient first. The business of medicine NEVER entered into our minds, or any of our discussions. He had a great passion for medicine and medical education.
After passing my MRCP primary, I decided to go to UK-Glasgow to write my part 2. I did a short attachment ( about 1 month ) in Glasgow Royal Infirmary ( GRI ), to get use to the Glaswegian accent. After passing my part 2, the Consultant in GRI offered me an SHO's ( senior house officer ) post, as it was vacant. It was a paid job and I could get training. So I stayed in Glasgow for 18 months to be trained in coronary angiography. My supervisor was Dr Ross Lorimer at the GRI. I could see then then coronary angiogram was discovered in USA and was gaining popularity. At about the same time, my colleague, the late Dr Nik Zainal, was training in St Mary's Hospital, London, also in coronary angiography. After 18 months, I told Dr Lorimer ( the GRI cardiology consultants were very nice to me ), that it was time for me to go home to serve. They very nicely offered my job to another Malaysian. When I wrote back to UH, they told me that they do not need anymore cardiologist, so the job was given to someone else.
I return to UH as a medical lecturer in 1980, and again join the cardiac team together with Dr KT Singham, Dr A Masduki, and rotating MOs and HOs. The work was still mainly congenital heart disease and Rheumatic Heart disease. Coronary Heart Disease was deemed to be a rich man's disease and as the cardiac list was very crowded ( with congenitals and rheumatics ), there was no place or time for coronary artery disease. The cardiac surgeon also feels the same. They would rather operate on congenitals and rheumatics. We all, the UH group felt that at that point, with so much congenital heart disease, it was more worthwhile to cure a child with congenital heart disease. He will have a fruitful future for himself, his family and the country. So the UH emphasis was in congenital hearts and rheumatic hearts.
But, in the government side, they see things differently. The late Dr Nik Zainal, was trained to do coronary angiography by the Sones technique. He had a cardiac surgeon trained in Melbourne, Dr Rozalli who was also trained in Bypass surgery. For the both of them, their training in congenital heart disease investigations and surgery were minimal. Coronary artery disease was a disease of the rich and richer and had lucrative private practice possibilities. So the GHKL team ( this was before the IJN ) was concentrating on adult CAD ( coronary artery disease ), and the UH was doing mainly congenital hearts and rheumatic hearts, right up until, Dr NK Yong and later Dr Saw HS left.
So there we were, cathetherising congenital hearts and rheumatic hearts. But almost once a year from 1982, Dr Joe Eravelly ( a prominent physician in KL ), will bring a VIP to UH with Dr Singham's permission, for angioplasty. He would also arrange for Dr Simon Stertzer ( an innovator of the balloon angioplasty technique ), to come and perform the angioplasty. Dr Stertzer would bring his own catheter, and do the case in the UH angio lab with Dr Singham and Dr Masduki assisting. So UH did do the occasional balloon angioplasty by the visiting Dr Stertzer.
In 1984, I left UH to join Pantai Bangsar Medical Center, and started the angiogram program there. When Pantai wanted to start a cardiosurgical program there, I arranged for Dr HS Saw to come up from Singapore, to do some cases, beginning with close heart surgery. More of that later, if we have time.
In June 1985, I obtain practising rights in SJMC ( Subang Jaya Medical Center ), to do angiogram cases there. Those patients, after coronary angiograms, who had important disease were referred to Singapore for Bypass Graft surgery by Dr HS Saw. Even then we had heard of angioplasty as a technique, being done in Switzerland and USA. However, I felt that the technique was just being developed and not yet matured. We were watching the scene. In fact, Dr A. Greuntzig, the innovator of the balloon angioplasty technique, came by Kuala Lumpur, to give a talk. sometime in the mid 80s ( I forgot exactly when). The results that he showed were impressive, but I felt needed some more confirmation, by more workers in this field.
In late 1987, a few of us, had a discussion and decided that it was time for Malaysia to learn and use the balloon angioplasty technique to treat our patients. I organised for 3 of us, one from the government ( Dr Robayaah Z ), one from the university ( Dr Samuel Ong-HUKM ), and myself to fly across to St Francisco to attend a live demo course run by the St Francisco Heart Institute ( SFHI ) in the spring ( April ) 1988. The course directors were Dr Richard Myler ( one of the innovators of the balloon angioplasty technique ), Dr Simon Stertzer ( another pioneer of the balloon angioplasty technique ) and Dr David Clark ( senior consultant cardiologist at SFHI ). At the live demo sessions, we felt that the technique was well established and that we could master it. We decided that we should make a start. At the last evening of the live demo course, at the gala dinner, I took Dr David Clark aside and ask if he would be agreeable to come to Malaysia, to help us start the balloon angioplasty program in Malaysia. He was most keen.
So I began to get it organised upon my return.
It was October 1988 when we planned for Dr David Clark to come. He also brought along his very good friend, Dr Tim Fischell ( now head of cardiology and director of cardiac cath lab at Western Michigan University at Kalamazoo ), to help so that they could work independently in two centers. We had organised about 10 cases per center, at three centers ( SJMC, GHKL, UHKL ) to do the cases. All the patients knew that we were doing this cases first time, with the help and supervision of the American experts. The centers also were in agreement and gave their consent. Cardio surgical back-up was arranged for all the participating centers. We obtained temporary practising certificates for Dr Clark and Dr Fischell. Dr Clark and Dr Fischell stayed in KL for 10 days, to do the cases with us. The first 5 cases in each center was done with the Americans as the first operator, and when they feel that we were proficient enough, we will do the case and they would assist us. We were all told to keep a log book and to document all the cases well. They also advise that we should choose single vessel disease and simple cases first. We all had to arrange for cardio-surgical backup ( this was the days before cardiac stents ). Dr Simon Yap, use to standby for me. Dr Clark and Dr Fischell, both came gratis ( no pay ). We sponsored their tickets through the device company ( USCI Bards ).
After their departure, I began to do cases with Dr K Chin assisting. There were so many cases that before long, I had clocked 100 cases. I kept a registry as taught, and presented my cases at the quarterly academy of Medicine scientific meeting, regularly. The first hundred cases were submitted and published in the Malaysian Medical Journal. Our results were comparable with those overseas. I tried to show that with all new procedures, we must keep a logbook, publish our figures regularly and present it to the medical community to comment and correct. Peer review was important.
Over at the government centers, I hear that my colleagues there were much slower to progress. Some went overseas again, to train further. So in balloon angioplasty, the private sector was far more progressive.

Tomorrow I will write about the development of stents, viz bare metal stents.

2 comments:

Chin Yit said...

Dr Ng,
It is very interesting indeed.
i believe such account of events must offer intense feelings of nostalgia.

Ainur said...

Dr. Ng! Pioneer of Angioplasty in Malaysia! Malaysia Boleh!