The treatment of badly damaged heart after multiple heart attacks is a very challenging situation as far as the Coronary Artery Disease is concerned. With each heart attack, some cardiac muscle cells go dead and cannot be revived. So, more the number of heart attacks, more the damage if no intervention is done during the crucial period. If the number of cells going dead is large, it leads to a scar formation and then ultimately thinning of the heart muscles, which do not participate in the pumping of blood. Heart function goes down, which is called EF or ejection fraction. The size of the heart precisely of the left chamber i.e. left ventricle increases and it loses its geometrical, spiral shape necessary for adequate pumping of the blood. This leads to repeated heart failures and accumulation of fluid in the lungs leading to breathlessness and loss of active working routine.
Dr Virendar Sarwal
This is why it is a famous quote “Time is muscle”. If someone is suffering from heart disease or Coronary Artery Disease, he should get the required treatment as soon as possible without much wait and should aim at saving the heart muscle from dying.
Once the terminal or end stage heart disease sets in, very few options are left as far as treatment is concerned. The commonly done bypass surgery becomes very high risk as heart muscles have lost their reserve and may behave erratically. Due to stress of surgery, the heart may not sustain normal blood pressure and perfusion to other organs of the body and may require high drug support after surgery. So the success chances go down. For this reason, these patients are generally categorized into high-risk end stage heart disease, and are offered only heart transplant as modality of treatment. Heart transplant itself is a rare surgery because of non-availability of donor hearts and is also very expensive to maintain throughout life to avoid graft rejection.
In our country, the facilities for heart transplant are very few and even in western countries, there is a huge waiting list for these patients. Many of them cannot make it and die waiting for the donor hearts. Also, heart transplant is a very expensive programme to maintain for the organisations and requires special teams and skills. These patients suffer a lot during the rest of their life, as they suffer from repeated heart failures, repeated hospitalisations and deep dents on their pockets. Also, the quality of life is very low with great restriction on the activities and the exertion levels.
This is one group of patients that requires a lot of help and special care and a very minutely chalked out treatment plan. Beating Heart Surgery showed some hope to these patients in terms of reducing the risk towards Bypass surgery. But still, post-operative course is generally very hectic. Intra-Aortic balloon pump is “the device” for these patients which when instituted before during or after bypass surgery helps a lot in giving relief and hastens the progress after surgery. It sustains the human physiology before and during surgery, especially when the stress is highest and there is a lot of swelling in the heart as well as body. It helps in two ways, one it increases the pressure at which the heart muscle is supplied blood in relaxation phase. Secondly, it reduces the load on the heart so that it has to work less.
But all said and done, the strength of heart muscle is very important for weaning these patients of the blood pressure maintaining drugs and the intra-aortic balloon pump support. The muscle has to be viable and not dead or scarred before surgery so that when it gets its nutrition back after bypass surgery, it starts working slowly and takes the full load of the heart in maintaining good blood pressure for adequate perfusion of all organs including kidneys, liver, brain, and lungs.
Till now, we had some specialised tests available like Dobutamine Stress Echo or stress thallium or resting MUGA (Multigated Acquisition) scan to tell us to some extent whether there is any viable muscle available in a patient who has badly damaged heart with low heart function. But they were not very reliable and dependency of these investigations to decide about bypass surgery was not very accurate. PET-scan (Positron Emission Tomography) was available in western countries, which was very close to assessing the viability accurately in quantifying the risk and to see the benefits of bypass surgery. For last one to two years, we have this investigation available in India also and is basically based on glucose uptake of the heart muscle cells. It predicts fairly accurately how much of the heart muscle is viable which will improve if given blood through bypass surgery. All the more, if combined with the stress thallium, the accuracy further increases.
It is very essential to offer these terminally suffering patients a durable and long-term solution or treatment to improve their quality of life and also to save them of repeated hospital admissions and expenses. Also, it saves a lot of resources for the state, as these patients are then pulled out of heart transplant list.
In the last two years, we did about 15 such cases, in some of them documented with PET-scan for viability of heart muscle, coupled with beating heart surgery and surprisingly, all of them did very well. They were out of the hospital within 7-9 days of their surgery and heart function at the time of the discharge itself increased to almost double i.e. around 30-35% from 12-20%. This helped them to get back to their active life to a great extent without further hospitalizations. All of them are in constant follow-up and doing very well.
So, before we declare these patients unfit for bypass surgery, we should investigate them thoroughly and make a very serious attempt in finding out all the positive signs for viability of heart muscle and then offer them bypass surgery on beating heart. Still the communication to the family about the pros and cons of the procedure and the risks involved should be very clear and all their queries should be answered in great detail so that it becomes a combined effort willingly and in a positive direction. This will help in saving a lot of lives, saving a lot of resources and adding life to years for such patients.
As such, all effort should be made not to reach this stage of end stage heart disease by maintaining:
1. Good life style
2. Good dietary control
3. Avoid smoking
4. Avoid excessive drinking
5. Regular exercise
6. Some form of relaxation from routine stress of life
7. Controlling blood sugars in diabetics
8. Adequate control of hypertension
9. Regular routine health check-ups once a year after the age of 35 years
And most importantly, if someone is detected to be having coronary artery disease, one should not wait for repeated heart attacks before coming for bypass surgery. Treatment or intervention should be got done as soon as it is indicated because you must remember “TIME IS MUSCLE”
— by Dr Virendar Sarwal
Wednesday, October 17, 2012 published at www.alatimes.com