‘World Heart Day’ is an annual campaign for spreading awareness about heart health among people across the world. Celebrated on 29th September globally, the theme for 2022 is “Use Heart for Every Heart.” The campaign rests on three key pillars to encourage action in the right direction – Use Heart for Humanity, Use Heart for Nature, and Use Heart for You.
Each year, a huge percentage of people suffer from cardiovascular diseases. In fact 24.8% of all deaths in India occur due to heart diseases (Global Burden of Disease). However, this can be changed by making just a few small changes to our lives. In line with this year’s theme, World Heart Day is an opportunity to stop and consider how we can use heart for humanity and beat cardiovascular diseases.
Controlling risk factors such as diet, smoking, physical activity, and blood pressure can hugely reduce the risk for heart disease. However, despite leading a healthy lifestyle, heart diseases can occur. The good news is that treatment and medical care for cardiovascular diseases in our country is unparalleled.
Leading hospital chains like Apollo Hospitals have pioneered novel technologies to treat heart diseases. They have seen high success rates even for the most complicated surgeries for both adults and children. With structural heart interventions and complex heart procedures, our medical care is at par with international standards.
Beating Heart Disease with Novel Techniques
Hospitals such as Apollo Heart Institutes have championed novel and highly effective procedures to treat cardiovascular diseases. In fact, they have introduced a slew of non-surgical and minimally invasive techniques such as Transcatheter aortic valve implantation (TAVI), Transcatheter mitral valve replacement (TMVR), and Minimally invasive cardiac surgery (MICS). For heart patients, especially those at a high risk of post-surgical complications, these procedures are a boon. The benefits for patients are significant – pain and bleeding are minimized and discharge times are reduced.
For instance, Apollo Heart Institutes recently performed a TAVI procedure on a 76-year old without open heart surgery. Interestingly, the procedure’s success rate in India is 95%. Led by interventional cardiologists of Apollo Heart Institutes, the procedure was a success and the patient’s condition improved remarkably.
Headways are also being made in Pediatric Cardiology with a high degree of success. In another instance, Apollo Heart Institutes successfully performed a PDA (patent ductus arteriosus) device closure from the neck on a 4-month-old. In babies, the margin of error is extremely narrow and doctors must display a great measure of ingenuity and presence of mind. The paediatric cardiologists of Apollo Heart Institutes, Navi Mumbai did a stellar job of saving the infant’s life, making good on the institute’s vision - ‘To be a leader in structural heart disease solutions.’
Nipping Heart Disease in the Bud
To keep cardiovascular diseases at bay, one can take small measures every day. While family history and genetics can’t be altered, individuals can invest time in exercise and eating right, apart from controlling smoking and obesity. Gender is also a risk factor, with men being at a far greater risk than pre-menopausal women. Stress and social isolation can also increase the risk of cardiovascular diseases.
To mitigate risk, it is important to periodically visit the doctor and get a few simple checks – blood glucose, blood pressure, cholesterol, etc. Individuals with a genetic history of cardiovascular diseases ought to get regular check-ups after the age of 40. It’s important to invest in heart health by taking small measures every day – Use Heart for You, as urged by the theme for 2022.
It’s unfortunate that access to treatment for heart diseases is not the same in all parts of the world. Over 75% of deaths occur in low-to middle-income countries. As citizens, we must get involved, even if in small part, with local activities to spread awareness and Use Heart for Humanity. Lastly, it’s time to Use Heart for Nature by contributing to a cleaner and healthier planet.
This World Heart Day, make yourself a promise to eat healthy, exercise, and pass the message on to loved ones.
1. In your opinion, what is the greatest need to address in cardiac care for children?
The greatest need is early detection of congenital heart disease (CHD). CHD, by definition, is present from birth. Over 2-3 decades, the prevalence of CHD has remained constant at 8 per 1,000 live births.
There are multivariate factors to this, the most important being when the parents are biologically related to each other. This greatly increases the risk of CHD. It’s also important to stay alert in the case of a family history of hear disease. Parents must get a fetal echocardiography around 20 weeks of gestation during pregnancy. If CHD is present, the ECG will help in understanding if the condition is treatable or not, which can help parents make vital decisions in time.
The younger the parents, the higher the chance of CHD. Another thing to look out for is risk associated with IVF procedures, where it is 2-3 times more than normal conception.
2. What are the early warning signs of congenital heart disease that parents need to watch out for?
Early recognition of CHD is important to treat the condition in time. Mothers should especially look out for feeding difficulties and abnormal behavior in the child such as sweating on the forehead and irritability. If the child is not sleeping comfortably after meals or if the skin shows a tinge of blueness, the child should be evaluated by a pediatric cardiologist. Again, an ECG is recommended.
3. What is a myth related to congenital heart disease you wish to bust?
I wish to see the perception surrounding CHDs change. When parents learn that the child has a hole in the heart, they lose all hope. This needs to change. In the last couple of decades, 99% of cases of Ventricular septal defect (VSD) have been treated. The child can live a perfectly normal life.
In palliative care, we make sure the child leads a near normal life even after multiple surgeries. In one instance, a woman who’d conceived through IVF had the fetus in a critical condition in the womb. Our team delivered the baby using a balloon procedure. We saw excellent outcomes and the baby was completely fine.
1. What are some advancements in valvular heart disease treatment that have benefited patients?
Previously, valve diseases were treatable only through invasive procedures like open heart surgery. The biggest advancement that has happened in the field is the development of minimally invasive procedures like Transcatheter aortic valve replacement (TAVI) and Transcatheter mitral valve repair (TMVr) therapy.
All patients want an intervention that results in the least damage and delivers maximum benefits. In the past, if some defects like leaking or narrowing of valves occurred, treatment was only possible through open heart surgery. Now, valve defects can be repaired without surgery.
An incredible advancement over open heart surgery is MitraClip for mitral valve regurgitation and other diseases. This defect occurs when the mitral valve starts leaking; we use MitraClip to stop this leakage and restore the heart’s normal function. Complex blockages that were hitherto not treatable through angioplasty are now being treated with advanced technology – balloon procedures, laser techniques, and cameras guiding treatment.
2. What are your views on initiatives like World Heart Day?
It is no secret that heart disease is the No.1 killer in the world, and India tops that list. We are the world capital for blood pressure and diabetes – diseases that are directly related to cardiovascular troubles. What is even more alarming is the rising incidence of heart disease in younger age groups – 20-30 year olds.
World Heart Day is an appreciable initiative to spread awareness surrounding cardiovascular health. We need such initiatives to encourage our population to focus on their heart health and take steps to improve it. The good news is that heart diseases are lifestyle diseases. This means all individuals can take small steps to maintain a healthy lifestyle and reduce their risk of heart disease.
3. After COVID-19, do you see people’s awareness changing about cardiovascular health?
During COVID-19, we saw an increase in heart diseases. The situation was worsened by the fact that people were unwilling to take action and visit the hospital. We saw many patients dying due to neglect as well. After the pandemic, we have seen patients becoming more aware. They now understand the COVID-19 can precipitate heart disease and now proactively look after their heart.
1. What are the latest advancements in valve replacement techniques and technology?
India has a high disease burden of valvular heart diseases, including both mitral and aortal valve stenosis. The good news is that minimal invasive replacement procedures are now being adopted over conventional surgical ones.
Transcatheter mitral valve replacement (TAVR) is one such minimally invasive procedure to replace a diseased mitral valve. Here, the patient can be discharged in as less as 48 hours and resume their normal life in a few days.
Apollo Heart Institutes has also started robotic valve replacement procedures where only a tiny (8 mm) incision is made. The patient is discharged in just a couple of days. The benefits of such minimally invasive techniques are numerous. The patients experience reduced bleeding, pain, and infection compared to traditional surgeries.
Recently, I led a TAVR procedure for a 72 year old male patient suffering from severe aortic stenosis. He was also suffering from kidney disease. When he was admitted, he was put on a ventilator. Traditional surgical intervention posed a high risk for this candidate. Our TAVR procedure was incredibly successful for this patient, who was discharged in just 3 days. Recent advancements in replacement techniques have thus made it easy for even patients with co-morbidities to bounce back and lead a normal life.
2. What are some risk factors individuals need to control for valve stenosis?
Nearly one-third of valve diseases globally occur in India. We are seeing an increased instance of degenerative aortic valve disease in the geriatric population. This can be easily prevented by making lifestyle changes.
The first risk factor to be controlled is smoking, which is strongly associated with the calcification of the aortic valve. Individuals must also keep their cholesterol levels in check. Other than this, diabetic and high BP patients must also manage their condition to reduce their risk of valve disease.
Another risk factor to keep in check is bacterial infections, especially those causing a sore throat. These can directly affect the valve’s health. It’s important to also practice good dental hygiene to protect your heart’s health.
1. You’ve been recognized as a pioneer in heart transplants in India. How difficult was it to achieve this feat and what is its significance for the Indian population?
In 2015, I led the team that performed the first successful inter-city heart transplant in Maharashtra. This is 47 years after India's first heart transplant in 1968, which was unsuccessful. In August 2015, we transplanted the organ from a brain-dead patient – bringing it from Pune to Mumbai. One of the biggest challenges for me was convincing fellow cardiologists and hospital owners about the feasibility of this technique for patients dying of heart failure.
In terms of significance, you can think of it like this. Countries like Pakistan have developed nuclear weapons but they haven’t yet performed a heart transplant. Even rich Gulf nations and most of the Western world hasn’t achieved this feat; only a few Western nations have. One can understand what it means for a so-called third-world nation to achieve this. This is truly a gift to the population of our country.
2. What is a patient’s quality of life after a heart transplant?
Most patients dying of heart failure only live a couple of months. After a heart transplant, life span increases by 5-10 years. With immunosuppressive agents we prescribe, patients enjoy a quality 10-15 years. The medical field has only recently started believing in heart transplants. Hopefully, we will see more adoption as awareness surrounding organ donation increases in our country.
3. What is the cost of a heart transplant?
While it is an expensive operation, this shouldn’t deter the common man from seeking treatment. Many charities are now involved in medical fundraising. Patients can easily seek financial aid and extend both the quality and quantity of their lives with a transplant.
1. What does World Heart Day mean to you as a cardiologist?
We celebrate World Heart Day on the 29th of September every year. This is an excellent opportunity for cardiologists and medical care practitioners to educate the population on the risk of heart diseases.
We’ve recently seen a paradigm shift in the burden of heart disease in India with the number of patients steadily increasing. Especially distressing is the fact that more and more young people are dying of heart attacks. World Heart Day gives us a chance for us to inform people on how they can protect themselves from this deadly disease.
2. What is your view on how technologies like computer vision and deep learning will help cardiology?
Technology is changing the world, and this holds true for cardiology too. In angioplasty, we now have advanced third-generation stents that are immensely benefiting patients. Then there are new imaging techniques that allow doctors to insert micro cameras inside arteries and capture high-resolution images. These work
exceptionally well for angioplasty. Procedures such as MitraClip and Transcatheter aortic valve replacement (TAVI) are also made possible through technological advancements. These are especially beneficial for older patients who are high-risk candidates for traditional surgery. In fact, we now have the technology to install pacemakers without surgery in as much as 20 minutes.
I’m also happy that we now have dedicated tools to calculate risk score for the Indian population. Previously, we had to rely on Western measures. All of these tech-backed advancements are increasing patient lifespan and reducing post-procedure complications.
3. What are the modifiable and non-modifiable risk factors for heart disease?
We must understand that while we can’t do anything about non-modifiable factors like genetics, we must actively take steps to control the modifiable ones. In fact, 80% of patients who visit a cardiologist already have a combination of risk factors.
We have to especially focus on modifiable factors like smoking, diabetes, hypertension, cholesterol. All of these conditions increase the risk of heart disease by nearly 3 times. Another factor is a sedentary lifestyle. There is a reason sitting is called the new smoking.
Then there is stress, which is afflicting more and more young people in metros with hectic lifestyles. Gender is also a factor – men have far higher risk of heart disease compared to pre-menopausal women.
1. When is Coronary artery bypass grafting (CABG) surgery indicated?
In heart disease, there are typically three modalities – medical management, angioplasty, and surgery. The SYNTAX trial, one of the most widely accepted trials, assigns scores that we use to determine which route to take. The scoring is derived by complexity of disease; a score below 21 needs medical intervention only. Between 21-30, the patient needs angioplasty and above 30, surgery is required.
2. What is benefit of surgery over other treatments?
Every patient wants four things from treatment – that their symptoms disappear and their quality of life goes back to normal, prevention of further heart attacks, improved pumping function, and surviving their full lifespan.
If 40% of patient’s blood supply to heart is affected, we can meet the first 3 goals through medicine. However, if more than 60% of blood supply is affected, the only way to meet all 4 is through surgery. Doctors must explain this to the patients. We go ahead with surgery only when the patient is at a low risk (<5%) – is active, has at least 10 year remaining lifespan, and is fit enough. If patient’s risk exceeds 5% and they have a remaining lifespan of 2 years or less, we go for angioplasty. A patient who is bed bound and high risk should not go for surgery.
3. What are some misconceptions around heart disease? What do you wish people are more aware of?
After having treated 20,000 families and having seen hundreds of cases of heart diseases in the same family, I can say that the most important thing to be aware of is genetics. Despite having family history of heart disease, people don’t take adequate precaution. Today we have easily accessible technology to check your heart health – simple to use ASCVD risk calculator apps. I urge everyone with a family history of heart disease to check their score. If a parent has heart disease, one should be checking ASCVD score and checking their cholesterol at the age of 20 – these are guidelines in the public domain. There also needs to be more awareness around sugar and its relationship to heart disease. Several studies have proved how sugar remains the most dangerous legal drug. To prevent heart disease, we need to exercise more, cut sugar, and always put prevention before cure.
1. How advanced is minimal invasive CVTS in India compared to Western nations?
Minimal invasive CVTS procedures were first practiced in the West 20 years back, bt without successful results. This is why it wasn’t commonly adopted for many years. In 2005, the US and Germany saw some success with the technique and around 2008-09, it picked up pace in India. It is still, however, not a very popular procedure in India. It remains concentrated to a few surgeons and centres. This is because it requires a lot of upskilling and training for surgeons. Despite thousands of centres practicing cardiac surgery, just 50-odd offer full-fledged minimal invasive surgery.
2. How does minimal invasive CVTS benefit patients compared to bypass surgery?
Earlier, our only option to treat patients with coronary artery disease was bypass surgery. For old patients and those with comorbidities, conventional bypass posed risks.
In conventional bypass, the sternum is split and a big (18 cm long) incision is made. Because the bone is split, there is a risk of the patient developing an infection. Globally, the risk of such infections stands at 3-4%. Patients also suffer more blood loss, pain and psychological trauma after conventional surgery.
All of these issues are done away by minimal CVTS. In this procedure, a much smaller incision (5 cm) is made and the bone isn’t cut. While the surgery remains the same, the approach is entirely different. This translates to huge benefits for patients – the risk of infection is almost zero and pain and blood loss are reduced. 60% of my patients don’t even require blood transfusion after the procedure, provided their hemoglobin levels are good. The recovery time is incredibly short – 3-4 days compared to a week or more in bypass surgery. The scar is small and hidden from view – this has tremendous psychological implications for the patient.
As surgeons, we are hopeful of moving towards more minimally invasive procedures.
3. A sedentary lifestyle is often blamed for heart troubles. What can people do in a situation where they have to put in certain hours at work and lead a largely sedentary lifestyle?
Given our modern lifestyles, we should deliberate more over risk factors, especially family history of cardiac problems. While we can’t change our genetic makeup, individuals with a history must get annual health checkups starting at the age of 40 to detect anomalies and prevent the onset of disease.
If you do lead a sedentary lifestyle, make it a point to dedicate 30 min at least 4 days a week to engage in aerobic exercise or brisk walking.
If you have other risk factors such as thyroid, diabetes, smoking, etc. – keep them in check. If you are obese, try to reduce weight through exercise and diet.
1. Which are some new developments in CVTS you are excited about?
Minimal invasive CVTS is a field that is rapidly progressing. We are seeing some exciting new developments like robotic procedures. In conventional surgery, we would make an incision in the patient’s chest to repair defects. We are now able to close those defects through minimal access. For the patient, this is highly beneficial in terms of reduced recovery times.
One of the latest developments Robotic coronary artery bypass graft surgery (CABG) where we only need to make tiny incisions. This technology is also available in Apollo Hospitals Navi Mumbai and we’re making progress on this front.
2. How affordable is this procedure for patients?
Currently, minimal access surgery is expensive because of the expertise and instrumentation involved. The cost is roughly 1.5-2 times that of routine surgery. But these procedures are highly beneficial for the patient. In the future, as more advancements are made, and more cardiologists are trained to perform these procedures, the costs will go down.
1. How risky is minimal invasive CVTS compared to open heart surgery? How much time does it take for the patient to recover?
The risk involved in both procedures is similar, but is slightly lower in minimal invasive CVTS. This procedure, in fact, results in shorter discharge times. Patients are more satisfied as compared to open heart surgery since their recovery is faster – in about 7 days, the patient can resume their normal life.
A small percentage, around 15% of patients may take slightly longer to recover. Recovery time also depends on how fit the patient was prior to surgery, how much exercise they get, their nutrition, and the complexity of the surgery.
In general, minimal invasive CVTS is very safe when the right patient is chosen for the procedure. We don’t operate on candidates who are extremely sick or require an unusually complex procedure.
2. Could you give us a recent case example where the procedure worked exceptionally well for a patient?
Recently, I had a 32 year old male patient who had suffered from Covid. As a result, he had developed some complications in his heart. The patient suffered from symptoms like breathlessness for a long time but didn’t seek treatment.
When we saw his echocardiogram, we realized his mitral valve was leaking valve. This was causing breathlessness and bouts of serious coughing. The patient was reluctant to go for open heart surgery so we performed a robotic mitral valve procedure on him. This is a newer technique that has excellent outcomes for repairing valve defects. He was discharged the very next day; in traditional open heart surgery, the patient takes a much longer time to recover.
Minimal invasive CVTS is nothing short of a boon for patients – trauma is reduced and recovery is much faster. In fact, this also works well for elderly patients who take longer to recover after traditional surgery.