One of the top intervention cardiologists of India, Dr Ashok Seth, Chairman, Fortis Escorts Heart Institute, is behind many firsts when it comes to adopting new technologies for quality patient care delivery. He shares his passion for science and technology and how innovations can impact life of common man in an interview with Elets News Network (ENN).
Q Fortis Escorts Heart Institute is one of the foremost hospitals in the country known for adopting innovations in patient care. Tell us about some of the recent innovations in intervention cardiology.
Medical science is innovating in a big way. In cardiology particularly, innovations revolve around how to make every aspect of treatment least invasive and safer. For years, heart attack and coronary artery blockages could only be treated by opening up the chest and doing the bypass surgery. Even today, to repair the valves inside heart, chest has to be opened to cut open the heart, cut out the defective valve and replace it with a new one.
Then came the angioplasty technique—a procedure to open blocked arteries without surgery— and gradually we moved forward to explore new ways to do those very techniques, which are only done by surgery now, through non-surgical methods.
One of the biggest non-surgical technological innovations has happened in the area of valve replacement. The first such non- surgical catheter based replacement was done for the aortic valve, which is the main valve connecting the left ventricle to the rest of the body. This valve usually degenerates after the age of 65 and and occasionally at younger age as well. Once the valve becomes narrow, the only way to replace the valve had been to cut open up the chest wall and put the patient on cardiopulmonary bypass to replace the valve. But at the age of 75 or 80, this method is fraught with numerous risks and 30-35 percent of patients can’t have it. However, if they don’t have the valve replaced they may die within a couple of years.
So, the science and experts like us tried to look for safer & better options as to how can we replace the valve without operation. We came up with was transcatheter cathcher arotic valve replacement. One of the first such cases in the world happened to take place in 2004 at Escorts Heart Institute.
After multiple trials, this technology has now become the mainstay of treatment for arotic valve disease. It allows us to treat patient of 85-90 years of age. We change the valve in cath lab through the non- surgical procedure of TAVR.
The patients go home in two-three days after their valve is replaced without any single opening in the chest. The next day people can’t even see the cut through where we passed the catheter and implanted the valve. Now, around 150,000 people have undergone TAVI worldwide. Because of ease of the procedure and less than one percent risk, the procedure is now moving to patients above age 60-years.
Another technique that has made a considerable progress is related to non-surgical treatment of the leaking of mitral valve, which is between two chambers of heart, and affects 10% patients who have heart diseases, had a bypass or suffered a heart attack. Some people are even born with leaking valve. It affects people from the age group of 40 to 60-70 years and causes breathlessness and enlargement of heart.
Pioneering innovations in cardiac care
Impella heart pump
A team of doctors led by Dr Ashok Seth, Chairman, Cardiovascular Sciences, performed India’s first “Protected Angioplasty and stenting procedure”on June 26 this year on a patient suffering from life threatening blockages with the support of Impella heart pump — the ‘world’s smallest heart pump’, which can support a failing heart for upto 7-days and occasionally longer. The hospital became the first in India to offer this new life saving treatment to patients suffering from high risk blockages and failing heart. This marked the beginning of the first “Heart Recovery Programme” in India, where the device can help the patient’s own diseased and weak heart to rest, recover and function on its own.
Mitra-Clip mitral valve repair without open heart surgery is one of the innovative scientific advancements of recent times. In another first in India, a team of doctors led by Dr Ashok Seth, supported by Professor Saibal Kar of Smidt Heart Institute, Cedars Sinai Medical Centre, Los Angeles,
successfully performed the catheter based procedure of MitraClip to repair a leaking heart valve without surgery in a 69-years old gentleman who was suffering from repeated heart failure and in whom open heart surgery was not possible. The gentleman recovered within days and has since gone home feeling rejuvenated after getting a new lease of life.
Transcatheter aortic valve replacement (TAVR )
Transcatheter aortic valve replacement (TAVR) is minimally invasive surgical procedure which repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place. Somewhat similar to a stent placed in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter. Once the new valve is expanded, it pushes the old valve leaflets out of the way and the tissue in the replacement valve takes over the job of regulating blood flow. A team of doctors led by Doctor Seth performed this surgery at Fortis Escorts for the first time in India.
Surgery in these patients sometimes becomes risky as the heart is weak, it is dilating, which makes repairing of the valves difficult.
This is where Mitra-Clip innovation becomes useful. It relates to non-surgical catheter based repair valves without opening up the heart in an angioplasty-based procedure in a cath lab. It has proven to be safe and effective in large trials. It also improves the survival of the patients and decreases the mortality nearly by 35 percent.
The first Mitra-Clip procedure in India was done by me at Fortis Escorts Heart Institute last week, though it was being done in United States and Europe for the last few years. People used to go outside the country to undergo this procedure.
There was a gentleman having a badly leaking valve. He had previously undergone a bypass surgery; he was breathless on minimal exertion; practically in bed; and his kidney function was gradually deteriorating. After our MitraClip procedure, he is well and was discharged 3-days later. One can’t detect any cuts on his body and he looks perfectly comfortable. The recovery was dramatic as the valve leakage was decreased immediately by 80-85 percent.
Science has progressed dramatically and we hope that techniques like this can help numerous patients in the country who would otherwise die or become candidate of heart transplantation. And as we know hearts are not easily available.
Q How these technological innovations can be made cost effective?
There are global companies who have developed the transcatheter valves and those have been tested extensively and brought to us. But we have also helped create our own TAVR valves in the country by supporting Indian company who want to create ‘Make in India’ valves. They have actually created the valves with input from us. The Indian TAVR valve is as good as their Western counterparts. After permissions from the Drug Controller General of India and put the valves into trial. After the successful trial and one year follow up, around a month ago it was approved by the Indian Government and DCGI to be used in the country for treatment of our patients.
The valve actually functions very well. Our valves are at par with the Western developed valves.
Good stents are also now being manufactured in India. New generation of stents are being researched, developed and manufactured in India. They are being implanted in patients giving good results.
I was closely involved with the development of bio-absorbable stents, which have many advantages over metal stents. Bio-absorbable stents are need of the hour as conventional stents are metallic and may remain in the body for life time after getting inserted. It may not matter to patients of 65-70 years of age but for younger patients it does matter as they have to live for another 40 years taking blood thinning medicines, which act as anticoagulants.
So we explored the potential of bio-absorbable stents which dissolves after two-three years. We developed that technology. Initially these too had some disadvantages. But an Indian company made the thinnest bio-absorbable stent; we tested it and did the trials and presented it to the regulatory authority. Such device is today available to 10 countries, and we are among one of them.
At one point in time, the American stents were available for Rs 2 lakh in the market, while this device was available to Indians at Rs 50,000. This is the way technology starts affecting people. Imagine, someone having stents in their arteries and it dissolved within two-three years and arteries regain their originality as if they never had anything inserted with. Technology can really help people.
A small pen-like motorised pump is another new innovation in cardiology that can support the heart attack patients to survive. This device can be inserted into heart the cavity to pump out blood from left ventricle to rest of the body and functions on a small motor. It supports patient with blocked arteries. This miniaturised submersible water pump like device is very fascinating. This is another technology and innovation which has been very useful to save lives. That is the spectrum of growth in technology.
Q Do we have such skilled manpower in the country to perform the intricate procedures using these advanced techniques?
The foremost priority should be to make these science and technology innovations available to the common man. This can be made possible if it can be made in India, which is very much the case now. But when it comes to skills, these are very specialised kind of techniques which require training and we take it as our responsibility to pass on this know-how and expertise to more doctors. Since these are advanced techniques, these will always be available only at few centres across the country where people can come and get the procedure done. It can never be available at the grassroots level. These are high-end technologies which are only safe & effective in experts’ hands, though there will be greater and greater no of doctors who would be able to perform this in coming years. But it will always be provided to limited number of people, thereby providing best outcomes.