"We get a lot of elderly patients with complex medical problems. With the help of rotational atherectomy, we can improve the quality of their life" - Dr Purushottam Lal, chairman, Metro Heart Institute, Noida
Gopi Chand Sharma, 82, had severe chest pain in July. He was diagnosed with a critical block in the left main artery. The lesion had calcified, so it was not a fit case for balloon angioplasty. Doctors could not even perform an open heart surgery. Dr Purushottam Lal, head of interventional cardiology and chairman, Metro Heart Institute, Noida, decided to use an old method: diamond drilling or rotational atherectomy, followed by stenting. “We get a lot of elderly patients with complex medical problems,” says Lal. “With the help of rotational atherectomy, we can improve the quality of their life tremendously.”
In some cases, bypass surgery is risky, especially if the patient had undergone open heart surgery. Take, for instance, Lakshmi Narayan Singh, 81, who underwent a bypass surgery in 1997. Severely diabetic, he had a massive block in one of the main arteries. Again, rotational artherectomy was the preferred treatment in his case.
With the range of treatments available today, doctors choose what suits the patient best. They believe that the best thing about the latest technologies is that they allow them to treat the young and the old with equal ease. “These treatments help us improve the quality of life of our elderly patients,” says Dr S.K. Gupta, senior cardiologist at Indraprastha Apollo Hospitals, Delhi.
Nowadays, doctors also use transcutaneous valve replacement therapy, a minimal invasive method in which them use a catheter to replace the heart valve. It is preferred in elderly patients who may not tolerate the trauma caused in surgery. In another interesting case, a pacemaker was implanted in a 102-year-old patient at Fortis hospital, Delhi.
Doctors study the cases minutely before carrying out any intervention on their patients. What helps them is an array of new tests by which they can predict the benefit of the intervention in advance. For example, the new FFR (fractional flow ratio) test can check pressure in an artery in case of a blockage and tell a cardiologist the ratio of pressure before and after the block occurred. It also helps the doctor in deciding whether the patient requires angioplasty. Similarly, optical coherence tomography helps find out the accuracy of the placement of the stent implanted by a cardiologist.
The emphasis, says Gupta, is on patient-centric treatments. The idea is to ensure faster recovery. “We are using robotic surgery to perform bypass surgery. Doctors are using arterial grafts for bypass, which increase the life of the procedure and reduce the trauma caused to the surrounding tissue. Special pacemakers have been devised to replace many interventions and surgeries,” says Gupta.
These days, coronary heart problems affect not just the young, but also infants. Early this year, an 18-hour-old baby was diagnosed with a heart defect called obstructed critical total anomalous pulmonary venous connection (TAPVC). The infant was brought to Fortis Escorts Hospital, where Dr K.S. Iyer performed a complex open heart surgery involving muscles, valves and arteries to correct the congenital defect.
Doctors say it is the pre- and post-operative intensive care that allows them to carry out such complicated surgeries on small babies. Mohali-based neonatal intensivist Dr Sunil K. Agrawal says that they recently operated upon a newborn pre-term baby who weighed just 1.9kg.
The baby’s heart rate was as low as 50. (The normal heart rate for a newborn is 120-140.) There was a congenital complete heart block (a block within the electric circuit of the heart causing the heart rate to drop too low to sustain survival) in the mother’s womb itself. It had critical stenosis of the pulmonary valve. In simple words, the heart valve was too tight to function.
The doctor performed a C-section in the 32nd week of pregnancy. On the same day, a temporary pacemaker was implanted to support the baby’s heart. The pulmonary heart valve was also dilated using balloon technique. The next day, a permanent pacemaker was implanted. “The baby was so small that the pacemaker couldn’t be fitted in his chest. Rather it was placed in his abdomen area,” says Agrawal.
The fact that doctors have been able to treat such complex cases shows the significant improvements in cardiac care in India. “There is nothing more gratifying than saving a dying patient,” says Dr Devi Shetty, founder of Narayana Hrudayalaya. “Early this year, a 30-year-old man came to my OPD. He was diagnosed with pulmonary embolism and was told by many doctors that lung transplant was the only option. Lung transplant is a high-risk surgery with a low 5-year survival rate.”
Shetty suggested a life-saving surgery that is still not available at many centres in India: pulmonary endarterectomy, an invasive procedure to treat a blockage in the artery of the lung. “The patient who was left to die and was living on oxygen support walked out of our hospital on the seventh day of the surgery,” says Shetty. “It was a second life for him. That’s the power of medical science.”
With coronary artery diseases spreading like epidemic across age groups, there is a need to put emphasis on their prevention. “I advise my patients to invest in a blood pressure monitor and keep tabs on their blood pressure,” says Shetty. “A controlled blood pressure reduces one’s risk of getting a heart attack by 50 per cent. I also ask all my patients above 40 years to undergo a CT angiogram to rule out any percentage of blockage in their artery. It is not because they need an intervention; it is because then they adhere to a healthier lifestyle.”