Evolution of cardiac therapies, Health News, ET HealthWorld
By Dr Sharath Reddy Annam
New Delhi: Medical science is ever changing and has been evolving rapidly for the last two decades. These evolutionary innovations are transforming solutions for critical problems to less invasive and low risk with better survival. With the landmark and pathbreaking innovations, cardiac treatments are available for conditions which couldn’t be treated in previous eras. Bypass surgery, widely known to people, has served many patients giving them a new lease of life filled with quality. Growing expertise of cardiac surgeons and advancing technology transformed these surgeries into minimally invasive, providing faster recovery with smaller scars. However, risk of bypass surgery outweighs percutaneous procedures due to known reasons which makes it mandatory for treating clinician to do risk-benefit analysis of all options and suggest that with greater benefit and lowest risk. This entirely changed the process of decision making, usually done by either cardiologist or cardiac surgeon independently, to a team approach called “HEART TEAM DECISION MAKING”. This approach would minimize the bias in the decision-making process as the shared knowledge and experience would nullify the blind spots of different specialists in the team. Nevertheless, the healthcare landscape of INDIA is largely dominated by individual practitioners rather than teams except for major institutes or continuously updating specialty centers with dedicated teams. Giving care to high-risk heart problems (CHIP-CTO procedures) without dedicated teams at various stages of treatment, would compromise the results and survival after procedures. Evaluation, Procedure planning and execution of these patients needs similar attention and precision needed for space launches. This in my opinion is a very apt comparison for broader understanding.
What are CHIP and CTO interventions:
Cardiac interventions like angioplasty with stent placement don’t pose major challenges in 80% of indicated patients. Nevertheless, the same procedure in a patient with heart pumping dysfunction, coexisting other organ dysfunctions (liver, kidney or lung issues) and complex heart vessel blockages is very challenging due to high procedure related complications. Presence of multiple aforementioned factors has incremental lowering of safety of cardiac procedures both Angioplasty with stent and bypass surgery. Such patient scenarios are thoroughly studied and extensively analyzed by the heart team before signing off appropriate therapy keeping patient concerns and preferences in mind. A decade before most of these patients were sent either for bypass surgery or medical therapy if turned down by the surgical team. With the advent of mechanical circulatory support devices, gadgets to handle complex heart blockages like calcified lesions and CTO and coronary imaging methodologies, these patients can now be offered with percutaneous therapies.
Mechanical circulatory support device – percutaneous LVAD (Impella)
This is a major breakthrough in treating patients with pumping dysfunction with complex heart blockages (calcified blockages, blockages in left main coronary arteries etc.). This is a pump placed into the heart from the groin or axilla blood vessel, which maintains blood flow and pressure during procedure related disruptions in heart pumping. Unwavering hemodynamics by Impella provides cardiologist adequate uninterrupted procedural time for predictable PCI plan execution. Treating multiple vessels, CTO and calcium modification takes longer procedural time which further mandates stable blood pressure. After completion of the procedure Impella can be removed immediately or a few hours to days later based on the need assessed by various parameters. VA-ECMO can be used as a low-cost alternative in such patients but with some caveats. When these devices are used, opening up all blockages is the key for operators to give best long-term outcomes. Hence these procedures should be done by operators with high procedural success.
How is calcium handled during angioplasty procedure?
Calcium deposition occurs on long standing blockages, more frequently seen in elderly, diabetics, and renal dysfunction patients. If unhandled, calcium doesn’t allow stent expansion to its fullest potential leading to higher chance of re blockage or sudden blockage with blood clot formation. Therefore, calcium depositions should be adequately modified before stent placement by using suitable devices among the plethora of options available on the shelf. Rotablation, IVL, cutting balloons and lasers are the different tools used for ablating or breaking calcium. Hence availability of these equipment and operator expertise in using them plays a major role in achieving optimal angioplasty resulting in these complex heart vessel blockages.
How does imaging make a difference in such cases?
Intravascular imaging gives more detailed information of blockage extension, characteristics and calcium deposition enabling operators to tailor procedural decisions as appropriate as possible. Furthermore, calcium distribution and thickness can be assessed to decide on calcium modification, and adequacy of calcium modification can be confirmed before stent placement. Stent expansion can be more objectively measured with imaging, and this information translated into interventional decisions can change long term outcomes and survival. In certain situations, during angioplasty, often in CHIP cases, the procedure can’t progress without imaging to unravel the issue.
In conclusion, heart interventions in sick hearts, in comorbid conditions and/or complex blockages are very challenging and need expert operators with all the gadgets to achieve best success. These procedures (CHIP and CTO) are definitely life saving for those with high risk for bypass surgery, turned down by a surgeon or not willing for surgery. These procedures can’t be done in all centers as it needs a team of experts to give appropriate care at every level of clinical course. Needless to mention that patients should reach out to dedicated CHIP/CTO centers for best procedural success and outcomes. This article is to educate people on this kind of heart intervention so that they can reach the right place at the right time as the referral hierarchy in our country is not organized well yet.
Dr Sharath Reddy Annam, Senior Consultant Interventional Cardiologist, Director of TAVR & Structural Heart Disease, Medicover Hospitals
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