In my previous article I tried to explain some basic terms we use in cardiac surgery. These included closed heart surgery, open heart surgery, heart lung bypass, and coronary artery bypass grafting that is often referred to as CABG or cabbage. The term ‘heart bypass’ when used for CABG operation is not entirely correct. One important thing I mentioned last time was the difference between ‘stenting’ and CABG. And that stenting is performed by doctors that are called ‘interventional cardiologists’ while CABG is performed by cardiac surgeons.
Today I will briefly discuss treatment of heart disease called Percutaneous Catheter Interventions or PCI. This also includes angioplasty and stenting. These procedures are performed by specially trained medical doctors called interventional cardiologists. Here an interesting observation. Much of interventional cardiology developed over the last few decades. As such many of the ‘more experienced’ interventional cardiologists are self-trained and never received any formal training to perform these complex procedures.
There are three main areas of treatment where interventions or procedures performed by cardiologists are quite successful and in some areas they have mostly replaced cardiac surgery. The most well-known area is the treatment of heart artery blockages using catheter techniques. These treatments are referred to as angioplasty (angio-artery, plasty-reconfiguration) but that is now usually a part of implantation of coronary stents. The other two areas are treatment of heart valve problems and treatment of irregular or abnormal heart rhythms (heart beats).
In 1977, Andreas Gruentzig, a Swiss cardiologist, first performed a successful ‘angioplasty’ procedure for a blocked heart artery. Before that balloon catheters were being used to open up blockages in arteries providing blood supply to the legs. That procedure marks the beginning of the era of interventional cardiology. However, interventions using balloons were already being done in children with certain inherited problems and as mentioned above in opening up leg arteries but these were not as popular or as frequent as procedures on heart arteries. Today, perhaps, an angioplasty combined with a stent placement in a heart artery is probably one of the commonest forms of treatment for heart disease even in a poor country like Pakistan.
The angioplasty-stent procedure involves passing a catheter through an artery in the leg or in the arm back into the heart artery requiring treatment. Then under X-Ray control a wire is passed through the catheter past the blockage and then a special catheter with a small balloon covered with a wire mesh tube stent is passed over the wire and placed at the site of the blockage. The balloon is then filled up and in doing so it opens up the blockage and at the same time opens up the stent. The balloon is then removed. The stent stays in place and keeps the artery blockage open. When used appropriately by experienced interventional cardiologists, stent placement is an excellent treatment for heart artery blockages. Many different blockages can be treated at the same time using more than one stent.
Improvements that have made stents so successful besides improved stent design that has increased the cost of these stents dramatically are the discovery of two new types of medicines. First are different blood thinners that prevent these stents from getting clogged up with blood clots. The second types of medicines are ‘Statins’ that can help prevent further blockages by decreasing the amount of ‘bad’ cholesterol in the blood. Today if possible stent placement is the treatment of choice for simple heart artery blockages that produce problems. Certain types of blockages are still best treated with a CABG. Also a finite number of stents will close down in time and require a CABG for treatment. These arteries being bypassed surgically or treated with stents are about the size of the plastic ink tube of a ballpoint pen.
Another area where catheters passed through veins or arteries into the heart are used is to treat irregular heartbeats that cannot be controlled with medicine. Cardiologists treating such problems are called ‘electro-physiologists’. Most irregular heartbeats are actually due to electrical ‘short circuiting’ in the electrical system of ‘wires’ in the heart that conduct electrical impulses. Areas of short circuiting are identified by catheters placed in the heart and these areas are destroyed using ‘Radio Frequency Ablation’ that produces low level localised heat at the tip of the catheter. Prime Minister Nawaz Sharif had an RFA procedure performed five years ago that almost led to an unfortunate outcome.
The question many people are asking is about the exact nature of the operation the PM had almost four weeks ago. What we do know is that the operation was an open heart operation meaning that a heart lung machine was used to bypass blood from the heart. Beyond that we know that the PM probably had a CABG operation. However, many unofficial reports suggest that along with the CABG the PM might also have had an operation for his irregular heart beat. This is called the ‘Maze Procedure’. The reason why it is called a maze procedure is because the upper chambers of the heart are opened up and cuts resembling a maze are made and the heart is then put back together again. Whatever the exact nature of the operation might be reports are that the PM is rapidly recovering from the procedure.
I do not wish to address the ‘political’ implications of the timing of the PM’s operation but I will address some of the possible reasons why the PM and his family decided to have this operation done in England and not in Pakistan. First reason is that as far as I know the Maze procedure is not being done in Pakistan. The second reason is a bit more complicated.
Many medical centres are performing all sorts of heart operations and interventional cardiac procedures in Pakistan and in the Punjab. Unfortunately, few if any of these centres at least in the Punjab and possibly in all of Pakistan present the results of what they do on a regular basis. Whether their results are comparable to those of internationally established surgeons and cardiologists is an open question.
Until such time that dependable data about CABG and PCI results from local medical centres becomes available, I will be hesitant to suggest that people who can afford to have these procedures performed at reputable centres abroad get these procedures done in Pakistan. Contrary to popular belief results of these procedures do not depend just on the skill of the person performing the procedure. I have seen it happen often enough that a well done procedure ends up in an unfortunate result because appropriate care was not available after the procedure. This could mean inadequately trained ancillary staff, lack of supportive technology and unavailability of the latest medications.
Besides medical reasons mentioned above, most politicians in Pakistan try to keep their medical problems secret and for that reason travelling abroad to get medical treatment makes sense. This in a democracy is just not right since we do need to know that our leaders can function appropriately before we vote for them. But that is a topic for another day.