Although the human body is capable of regenerating itself, with each of our organs further capable of renewing and regenerating itself many times through our life spans, the normal wear and tear, and our lifestyles and diet causes certain unseen problems. A vulnerable, and critically important organ is the heart.
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.
This is where Dr. Sengottuvelu, Interventional Cardiologist, Apollo Hospitals, Chennai comes in. An Interventional Cardiologist - and Apollo Hospitals in Chennai has some of the most highly trained experts in this growing new field of medical care - is a specialist who uses precision techniques, cutting-edge devices and medical equipment, and years of experience, to go straight to heart of the problem and solve it.
Interventional Cardiology to the rescue
Dr. Sengottulvelu and his team in Apollo are actively bringing some of the latest techniques and medical care processes from around the world, to India. Many of these advances in medical science are at-least 3-5 years ahead of many other hospitals in the country. Radial Angioplasty (which Dr. Sengottuvelu pioneered in India in 2003), Bifurcation PCI (2004), Intracoronary Imaging (2010), Bioresorbable Scaffolds (2012), Transcatheter Aortic Valve Replacement (2015), are just some of those.
Of these, Transcatheter Aortic Valve Replacement (TAVR), also known sometimes as Transcatheter Aortic Valve Implantation (TAVI) is at the most cutting edge of all. A technique which allows a cardiologist to replace a malfunctioning valve in a patient’s heart, in a minimally invasive procedure using catheters (wires & small tubes) and a collapsible, compressed valve, that is put into place without cutting open the chest.
Transcatheter Aortic Valve Replacement for a longer life
Dr. Sengottuvelu says, “We’ve been looking at structural heart diseases. Even about 15 years back we couldn’t have imagined valve replacement without open heart surgery, but today it is possible. Again, we are one of the first few centers in India to start this procedure.”
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TAVR is used for a condition called Aortic Stenosis. There are four valves in the heart, which regulate blood flow from one chamber of the heart to the other, facilitating oxygenation of the blood. The Aortic Valve - on the left side, is the major valve that connects the chamber to the Aorta - the main artery that takes blood from the heart to the rest of the body. This valve, over a period of time, due to wear and tear, becomes thickened and narrow. Calcium deposits collect over the valve too, causing it to become rigid, limiting its ability to open and close effectively. This condition is called Aortic stenosis.
Aortic Stenosis usually happens due to aging, but occasionally some people may be born with this condition. A bicuspid aortic valve - in which the aortic valve only has two cusps, instead of the more regular, common, 3 cusps, also causes stenosis.
Breathlessness, chest pain (angina), general fatigue or tiredness even while doing routine, light work, palpitations of the heart and heart murmur, fainting - are some of the symptoms associated with Aortic Stenosis. Once symptoms are felt, the condition rapidly deteriorates and in such cases, without a doctor’s accurate early diagnosis, it might lead to sudden death.
Dr. Sengottuvelu and his team performed their first TAVR procedure in 2015 using the first-generation core-valve. The patient was in a very serious condition, and did not have other treatment options. The valve was then not available and approved in India, and the doctors had to get a special license to import it.
Since 2015, he has performed the TAVR procedures using several new generation transcatheter heart valves for over 20 patients. In most cases, his patients - of advanced age - have been refused surgery at other hospitals because of other complications - such as diabetes or kidney failure. Given that till recently, valve replacement was an open-heart procedure, this was extremely risky in these usually frail, old patients with multiple other co-morbid conditions.
Columbia University Medical Centre, USA and the Presbyterian Hospital in New York, USA (and other partner organisations) studied over 350 patients with aortic stenosis, all of whom were deemed to be at high risk for surgical valve replacement. The study looked at the causes of repeat hospitalisations, serious other complications, or death (if any) of these patients. The results showed that of those who underwent the TAVR process, rate of death was 30%, compared to 50% for those who underwent regular, non-TAVR procedures.
Among survivors at 1 year, the rate of cardiac symptoms was lower for patients who had undergone TAVR compared to those who had received standard therapy (25.2% vs. 58.0%)
Another study reported by the Cardiovascular Research Foundation shows that at 5 years, patients with TAVR have fewer repeat hospitalisations, and a longer, much more durable life experience than those with standard valve replacement surgeries.
This is even truer of Dr. Sengottuvelu’s patients too. All 20 patients who underwent TAVR at Apollo Hospitals, Chennai, have recovered fully from their heart ailments, and look forward to a better life now. One of the doctor’s patients, a 80-year-old man who was bedridden and unable to move before TAVR, is able to walk into the clinic without help. “He called me for his 81st birthday celebration,” says Dr. Sengottuvelu, who has had a real impact in the life of many such people.
New Valve, New Hope
Today, transcatheter aortic valve replacement techniques approach via the biggest artery - which passes near the groin, on its way to the legs. This is called Transfemoral approach.
Dr. Sengottuvelu uses two of the most advanced technologies in the world - the self-expanding valve, and the balloon expandable valve. The self-expanding valve is compressed using ice, and will automatically decompress and take its original shape when warm fluid (water, or in this case, blood) flows through it. A balloon expanding valve will need to be expanded by inflating a balloon inside the valve.
Both valves are compressed and collapsed to fit into the catheter.
In the self-expanding type, once the replacement valve is in place, the doctor then proceeds to decompress it, and accurately positions it, and then removes the catheter. The new valve will then expand and push the old, malfunctioning valve to the sides.
In the balloon expandable valve type, once the valve reaches the heart, the cardiologist uses a balloon which pushes the replacement valve into place. Allowing for the heart to return to its full, normal capacity almost immediately. Dr Sengottuvelu says, “It is really gratifying that most of my patients improve quickly after the procedure.”
All of these techniques are performed inside the heart - within a space that is a fraction of a millimeter wide. This calls for precision, experience, and a steady hand. And the use of highly refined devices that allow the doctor to “see” through the heart without having to open it.
Dr. Sengottuvelu is also involved in studying valves made in India. These valves when they become available may eventually drive down prices, reducing the overall cost of the TAVR procedure, which would allow more Indian heart patients to benefit from this advanced procedure.
“That is really gratifying procedure as we are able to offer hope for several of these patients who have no other options,” says Dr. Sengottuvelu.