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Percutaneous Coronary Intervention and minimally invasive procedures are helping patients at high risk of heart attacks.

Complex Angioplasty Why you will no longer need a risky open heart surgery
Thursday, November 16, 2017 - 08:02

 

Almost every third Whatsapp forward these days is about heart attacks, and identifying symptoms of heart attacks.

It is a serious issue, and as Indians we are prone to greater risk - due to our high-fat, cholesterol heavy food, and poor exercise and lifestyle activities. Additional environmental factors also complicate the problem, and as a country we are treating it as a high priority.

The Registrar General of India reports that about 24% of all deaths in India, and about 32% of adult deaths are caused by coronary heart diseases, with the World Health Organisation treating it as an issue of extreme importance. Some estimates say that about 1.6 million Indians have some form of heart ailment.

We know largely what causes heart attack: blocks or clots in the arteries that prevent blood flow into the heart, causing it to go into cardiac shock - that is, it cannot pump blood effectively. What we do not have a great understanding of, is how and when are these blocks formed, and how to effectively treat them. Further, we do not always understand the risks involved in such treatment.

But Dr. Y Vijayachandra Reddy - YVC to colleagues and his satisfied patients - knows all that and much more. 

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Acute Heart Attack Management: No More Surgery

A senior Interventional Cardiologist at Apollo Hospitals in Chennai, Dr. YVC is one of the pioneers of angioplasty in India. He says that Angioplasty is now a routine, minor procedure. It was not always so, but due to the work of doctors like YVC, and due to the advances in medical care, and research based, evidence based medical procedures, we have arrived at a point where an accurately diagnosed heart attack can be treated instantly, and effectively. Yes, your uncle’s Whatsapp forwards are useful.

The best treatment for an acute heart attack - referred to as myocardial infarction - is a procedure called Emergency Primary Angioplasty. In this procedure, even a 100% block in the vessel supplying blood to the heart - known as the culprit artery or culprit vessel, is opened up and a stent is placed inside the vessel, which will “crush” the blocks and allow for free flow of blood. A stent is a small mesh-like tube. This procedure has been a standard of care for a long time now, and in expert hands, it is performed swiftly and gives excellent results. The pity, says Dr. YVC, is that only 8% of Indians have access to the procedure. Awareness or the lack of it, access to good hospitals with a fully functional Cathlab, and availability of experts being significant reasons. “In fact, the advanced nature of healthcare in any country can be measured by how many patients can access primary angioplasty,” says Dr. YVC.

However, primary angioplasty has its risks. And the expertise of the doctor, and the facilities available at the hospitals, marks the difference between life and death.

Compassionate Angioplasty, or Dying Patients Angioplasty, is slightly more risky. This is when cardiologists know that patients who are at high risk, with a large heart attack extending over a large part of the heart muscle. Here, patients may go into cardiogenic shock. In some cases, the electrical activity in the heart is unstable, the lungs fill up with fluid, and blood pressure is low, and dropping further. The outlook is bleak for such patients. And speed of the paramedical response, and skill of the doctor is of prime importance. The cardiologist needs to quickly identify the site of the block, approach it and open the block up, and ensure blood flow into the heart resumes as quickly as possible.

“The door to Cathlab time should be very very short, in fact the standard of care says it should be under 15 minutes time,” says Dr. YVC. 

Trans Radial Angioplasty: through your hand, to your heart.

Earlier treatment for these conditions was done with open heart surgeries - complicating the risk involved, especially for patients who had other symptoms and conditions - such as diabetes, or kidney failure. Surgeons may be afraid to perform open, risky surgery when they encounter “ongoing damage” - a heart attack in progress.

These days angioplasty is done using minimally invasive procedures and cutting-edge medical devices. 

The technique is called Percutaneous Coronary Intervention (PCI), where the cardiologist will make a small opening in the hand of the patient, and insert a catheter (wires and tubes) into the a primary artery, and will approach the blocks near the heart. Once there, the doctor will blow a balloon up to push the blocks away and out of the path of the blood flow. Once Dr. YVC is satisfied that the heart is beating normally and blood flow is perfect, he will remove the catheter, and close the opening in the hand. This form of angioplasty - called the Trans Radial Angioplasty - was pioneered in India by Dr. YVC

In certain cases, the doctor may also implant a stent which holds the artery wall up, pushes the plaque against the wall, and ensures blood flow is free.

Doctors sometimes encounter other complications during angioplasty. Sometimes, patients present with mechanical or structural anomalies in the heart, such as ruptures in the artery wall, or holes in the heart muscles, Left Main Coronary Artery diseases, Chronic Total Occlusion, and Bifurcation Stenosis.

A bifurcation stenosis is when the blocks - stenosis - is situated at a point where the artery branches into two - and it is extremely important to remove both blocks at the same time.

Dr. YVC performs a similar PCI procedure  for Bifurcation angioplasty, in which special techniques are used to clear the blocks in both the main vessel and the branch. He is one of the pioneers in primary angioplasty, having performed the first procedure in 1995. He also has performed the most number of such procedures - across the country and perhaps the world. High volumes, in the doctor’s case - means that his expertise and his experience allows him to give more and more patients the most effective cure, with the least possible pain. Practice, indeed, does make perfect.

This also allows experienced cardiologists to work on more complex, more risky cases, and expand the body of knowledge on medical care, even further.

“Is there a role for surgery in acute heart attack management? Yes, there are some instances when the patient may have multiple blocks in all the vessels, which in a stable patient means Bypass surgery is the answer. However, in acute heart attacks, when the patient’s life has to be saved immediately and the time to organise a surgery is limited, the culprit artery is opened up with angioplasty, and if possible any other severe blocks are also removed at the same time.”

With angioplasty procedures, Dr. YVC has seen mortality rates dropping to less than 5%, even in acute heart attack conditions.  What that means is we are slowly but surely reaching the “advanced country” stage, where the health and long life of all Indians is a given. “Can such complex procedures be performed everywhere? Every hospital? Yes! That is the vision and hope that we should work towards.”

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