CHIP and Hope: How doctors are crossing the final frontier in treating major heart attacks

There are heart attacks, and there are heart attacks. In India, health care, for a lot of us, has advanced to a stage where we can quickly identify and take prompt action to save lives. Given that as a nation, Indians are at greater risk of heart attack, governments, institutions, and hospitals have taken great efforts to spread awareness about heart diseases, and invested in research into medical care to ensure no one is denied life-saving care when needed.

At Apollo Hospitals, Dr. Y Vijaychandra Reddy and his team of interventional cardiologists are more prepared than any other hospital, for they truly understand the risks and the value of human life.

Dr. YVC, as he is known to colleagues and the large number of patients he has treated, pioneered many of the procedures that are today being practiced across India. Complex Angioplasty for heart attack management, Complex PCI (percutaneous coronary intervention) through Trans Radial route are just some of those.

He has seen the specialised field of heart attack management expand, with more and more hospitals taking up the important job of caring for people. However, as doctors expand their knowledge, and see more and more patients, they encounter situations and conditions that call for greater care and better techniques.

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Sometimes, underlying anatomical complexities could present further risks for the cardiologist. “The one big issue in performing the angioplasty, is the surprises that one can find. In about 10% of the patients, once you go into the heart, you find the terrain is very, very complex, or sometimes not encountered before. PCI for Left Main Coronary Artery Disease (LMCA), Dying patient angioplasty, Angioplasty on patients who have sustained cardiac arrest, Acute on Chronic Total Occlusion lesions, only surviving graft vessel angioplasty etc are some of those.

“This is called CHIP - Complex High Risk Indicated PCI. Some centres, and some skilled cardiologists, are devoloping CHIP procedures, to save even these high risk patients.” CHIP involves a lot of factors - primarly highly skilled and experienced doctors, advanced equipment, and a well-oiled team of doctors, paramedics, nursing and support staff. 

Complex Conditions, Complex Angioplasty

In LMCA, the major arteries supplying the heart, will develop stenosis - deposits of plaque. This severely restricted blood flow into the heart could lead to acute heart attacks. The treatment for LMCA till recently was the Coronary Artery Bypass Graft - a surgery we in India know as open bypass. But studies have shown that bypass surgery could result in higher rate of strokes in patients. Most importantly many of these patients do not give us time even to get them shifted to operation theatres. Therefore even in acute presentations - such as a sudden heart attack, with LMCA present, angioplasty is the best option according to the doctor.  In many instances, patients with high risk coronary heart diseases also have other co-morbid conditions - such as diabetes, kidney failure, lung diseases and more, or are slightly older, and more frail. In such situations, open bypass surgeries are extremely risky, and angioplasty might be the only life saving option.

“Traditionally, angioplasties were done from the groin - the femoral artery. But we have pioneered the Radial Angioplasty technique.” That is, the doctor will approach the heart through an artery in the hand. Once diagnosis is confirmed, patients are given specialised medication to thin their blood, and are moved to the cathlab - a highly sterile, specialised unit inside the cardiology wing of Apollo Hospitals. Here, cutting edge medical technology and the latest equipment allow doctors to “see right into the heart” of the patient, and perform minimally invasive, but life saving procedures. A needle entry is made into the artery, and a sheath is introduced. Doctors then approach the heart and cannulate it. Once there, stents are introduced into the blocked area, blocks are either crushed and pushed against the arterial wall, and blood flow is restored

Left Main Angioplasty gave patients and doctors a lot of worry earlier, but with current techniques of Interventional Cardiology, and with the expertise gained by performing the technique over a number of years and number of patients, means that one can treat it effectively, ensuring better long-term results.

The Last Frontier: Chronic Total Occlusion

Blocks in the artery can occur suddenly - leading to heart attacks. This is called Acute Occlusion. While it is a complex condition in its own right, doctors are today able to handle it easily, with angioplasty delivering good results in the long term.

But, blocks can occur in the artery, over a long period of time. The condition builds up slowly, and patients may not be aware of it. This is Chronic Total Occlusion, or CTO. CTO, describes a condition that has complete or almost complete blockage of a coronary artery for a period greater than 3months. The blocks are caused by heavy buildup of atherosclerotic plaque  - fatty deposits, calcium, and other particles in the blood. The 3months cut-off period is important, as till that time, clots are composed of softer material, which allows the doctors to cross the block with the catheter while performing angioplasty. From the end of the 3rd month onwards, the blocks become thicker, and crossing the point of blocks would become highly difficult.

The longer the delay, the more challenging the condition, with the blocks calcifying - that is, becoming hard as rocks.

One study estimated that about 50% of those with some heart risks could have CTO.

In Dr. YVC’s experience, these blocks - often very hard, could be 100% of the artery, and for more than 3 months, exponentially increasing the risk of a heart attack. “CTO Angioplasty is the final obstacle to successful interventional cardiology, the last frontier,” says Dr. YVC.

In CTO Angioplasty, the interventional cardiologist will again approach the blocked artery via an opening in the hand - the Trans Radial approach, and using a catheter, will bore through the atheroscelerosis - the plaque deposits. Then, the doctor may use a balloon to push the block away, or if required perform more complex procedure called Rotablation. Rotablation involves a small drill-like device that is attached to a motor at the end of the catheter, which rotates at a high speed, to scrape the deposits away. Once the Rotablation process is finished, the cardiologist may choose to place a stent in the artery or not.

Recanalisation of the CTO vessel - that is, creating a channel through which blood can flow obstruction free in the blocked artery, has improved angina levels of patients - with the risk of heart attack downgraded from high, to moderate or even sometimes low.

Untill recently, CTO was treated almost exclusively using bypass surgeries - CABGs. However, developments in PCI techniques, and more refined screening and examination process for CTO, and much more advanced imaging devices have allowed Dr. YVC and other interventional cardiologists - at Apollo and other hospitals around the world, to find a high degree of success in treating patients.  In some case, CTO PCI procedures have also reduced risk of further bypass surgeries. Earlier, success rates with PCI was about 50-70%. “My success rate is about 95%,” says Dr. YVC which is in par with the Current International Standards.

CHIP, And Hope

At Apollo, PCI for Left Main Coronary Artery Disease (LMCA), Dying patient angioplasty, Angioplasty on patients who have sustained cardiac arrest, Acute on Chronic Total Occlusion lesions, only surviving graft vessel angioplasty qualify, also associated severe co-morbids with high risk for open heart surgeries qualify  for CHIP: Complex, High-Risk Indicated PCI.  Dr.YVC and the team have created a highly effective treatment protocol for CHIP patients. The team works around the clock - doctors are always on call, to ensure that when a CHIP patient is referred to the hospital, valuable time is saved. Each step in the care ensures that there are no gaps, and the cardiologist have every report, test, X-rays and images, and all other pertinent information to accurately diagnose and identify issues, and perform the complex, trans radial angioplasty procedure smoothly and effectively.

“We can be the difference between loss of life, and hope for a future,” says Dr. YVC. 

This article has been produced by TNM Marquee in association with Apollo Hospitals.