The cardiologist watches the screen carefully as his hands work. On screen, a living heart pumps, while a small wire threads its way across the image, an embroidery exercise far finer than the most delicate needlepoint imaginable.
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This procedure provides new hope, without highly invasive surgery, for high-risk patients whose hearts are struggling because of blockages in their arteries.
Many patients receive drugs to promote blood flow and for pain, as well as drugs to thin the blood, and they have to limit their physical activity. And for many, that’s not life.
By contrast, this procedure, at the cutting edge of medical science, offers a much better chance of living without pain for years to come.
“A patient can be either high risk because of co-morbidities - other diseases such as kidney failure, lung problems or a weak heart muscle - or because he or she has high-risk anatomy. In these two instances today, the narrowings in the blood vessel are located in the left main artery (similar to the trunk of a tree) with others in a relatively inaccessible place,” explains the cardiologist whose hands guide the tiny wire.
His name is Dr Farrel Hellig, and he’s practicing his fine motor skills in a theatre at Netcare’s Sunninghill Hospital.
Interaction
In these high-risk cases, a select group of interventional cardiologists like Dr Hellig are working at the very edge of what is technically possible.
And while he works, Dr Hellig is helping his peers learn by watching him at a distance: this procedure is being shown by satellite transmission to a television monitor in a lecture room some ten to fifteen kilometres away from the Netcare cath lab, to a group of cardiologists at the Crossroads Institute in Illovo.
The delegates are able to communicate with Dr Hellig, and he can ask for their input and advice; as the first, most difficult case proceeds and everyone gets caught up in the moment, offering suggestions, talking among themselves about options, while puzzling over the obstacles.
It’s a Friday in February 2007, and Dr Hellig and his team are presenting to a mixed group of delegates, under the guidance of Professor Jean Renkin from the UCL St Luc University Hospital, Belgium, and Dr Tom Mabin, a well known cardiology expert from the Western Cape.
Dr Hellig has two patients lined up; one is high-risk because he’s elderly at 78, has moderate renal failure and has a blockage in a difficult place; the other is high-risk because, at the age of 69, he’s already had two by-passes, one in 1982 and one in 1994, so he would not be able to withstand another. He too has a blockage of the left main artery.
Both are sedated, but conscious, and will be able to talk to the operators throughout the procedure, letting the cath lab staff know if they feel any pain or unusual symptoms.
The audience watches
On this Friday, the audience can watch - and provide input - as stenting is done on patients who would quite likely not have been offered bypass surgery.
With the aid of new technology and in the hands of a doctor with good skills and intensive experience, these two men will get a new lease on life.
And a group of experts will go back to their practices with the kind of experience that, in years gone by, you could only achieve by donning scrubs and standing in the theatre, enhanced by the interaction among the group.
Outcomes
The first case proceeds with some difficulty to tackle the major obstacle plaguing the patient, blockage of the left main artery, but when it comes to the second obstacle, Dr Hellig’s team try patiently, over and over, to ‘cross’ the lesion (that is, to get the guide wire through the blockage, enabling them to insert the balloon and stent); they thread through a rotablater, a minuscule ‘drill’, to try and clear the obstacle.
It whines like a goblin’s pneumatic drill, battering away at a lesion which is largely calcium and therefore as hard as bone.
From Netcare Sunninghill, Dr Hellig confers with the delegates watching from the Crossroads Institute, and makes his decision; the major problem has been dealt with, so although it would be nice to open up this blockage as well, he is going to withdraw.
The patient has kidney issues, and too much exposure to the contrast dye necessary for this procedure is not a great idea. This blockage can be revisited, if required, another day.
Withdrawal proves a small battle in itself, and is a testament to the strength of the material making up the lesion. “It’s an incredible feeling,” comments Dr Hellig. “It feels like the wire’s being held by a pair of pliers, and you just can’t shift it.”
The camera hones in on his hands tugging carefully but strongly. Once again, it’s clear that Dr Hellig’s hands-on experience is informative for the group in the lecture room.
Patient recovery
The patient will go on to recover well, with improvement in heart function due to the success of the first part of the procedure. He will be home within a few days (longer than other patients purely because the medical team at Netcare Sunninghill needs to ensure the dye has been completely flushed from his system to protect the kidneys).
By comparison, patient number two is a dream. The ‘wire’ goes in beautifully, crossing the left main lesion without fuss, and the procedure appears as effortless as such delicate work can be.
This patient suffered from severe effort limitation due to pain; he will go home the day after stenting, able to go back to more normal life almost immediately, in stark contrast to his previous by-passes, where he was out of action for some weeks and not up to speed for months.
What are angioplasty and stenting?
Angioplasty and stenting have been offered to heart patients for a number of years. In an angioplasty, the interventional cardiologist inflates a small balloon inside a blood vessel narrowed by atherosclerosis.
The balloon is inflated inside the blood vessel, opening it up and facilitating the flow of blood. In many cases, the cardiologist will follow this procedure by inserting a stent - a very small wire mesh tube - which holds the artery open and supports it. With time, the artery lining grows over this mesh.
All of this is done with the aid of a catheter that is inserted through a blood vessel such as the artery in the groin or wrist. This catheter is a guide and a ‘conveyer belt’ that assists the operator to get the balloons and stents to the site of the narrowing.
The vessels are flooded periodically with contrast dye that shows up on the X-ray, and allows the cardiologist to ‘see’ what he is doing. When you consider that the artery is about 3 mm wide, you can understand why this is such delicate and painstaking work.
Atherosclerosis - the build-up of plaque made up of cholesterol, calcium and fibrous tissue on the artery walls - is a common cause of heart disease, ranging from angina (pain in the chest, especially with effort) to the excruciatingly painful and potentially fatal heart attack.
By-pass or stenting?
In most cases, stenting is offered to relatively healthy patients as an alternative to by-pass surgery, which involves opening up the chest cavity by cutting through the sternum, and bypassing the blocked blood vessels, and replacing them with sections of vein or artery taken from the patient’s legs, arms or chest.
While this is a well-practiced surgical procedure with good results, many patients prefer a less invasive approach and need to get back to work. There are cases, such as in this course, who are very high risk for by-pass surgery.
By-pass has been the preferred treatment of many cardiologists because of complications of angioplasty and stenting, primarily the risk of restenosis, or re-blockage of the artery, which has until recently been especially likely during the first six months after the procedure in about 20 to 25% of cases.
Now, however, says Dr Hellig, that risk has largely been dealt with: stents come with a dose of drugs applied to their surfaces which ensure, over 90%, that restenosis does not take place. (This new technology does present a slight risk of clotting later, but at 1% that seems to balance out the restenosis risk that has been removed by the drugs.)
“Usually, these days, stenting is of long-term benefit - in the vast majority of cases, there’s a cure of that particular blockage. And unlike by-pass surgery, you can perform repeat stenting more easily than repeat bypass surgery. The new stents with drugs have revolutionised the procedure,” says Dr Hellig.
Distance education
How do you learn these precise, delicate procedures? One way is to make it the focus of your working life, as Dr Hellig has been able to do at his practice at Netcare’s Sunninghill Hospital; but many cardiologists in the field don’t have the time or the back-up necessary to do so. That’s where education sessions like this one come in handy.
The Crossroads Institute is the educational partner of Baroque Medical, (supplier of some of the equipment used during the angiography procedures at Netcare’s Sunninghill Hospital).
The Institute provides an opportunity for learning in a highly interactive environment, with open discussions and sharing of experiences among delegates, under the leadership of world-class speakers whom share their vast knowledge and experience with local delegates.
(Press release, Network Healthcare Holdings, April 2007)
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