A recent conference in Dublin gave a rare glimpse into the skilled world of unblocking arteries from within, writes CLAIRE O'CONNELL
WHEN I was invited to a conference showing live broadcasts of the latest in heart procedures I have to admit I squirmed. As one who peeks at the bloodier scenes in the TV series ER from behind my hands, I wasn’t sure my feeble stomach could take it.
So on the day, I sat in the back row of the darkened lecture theatre in St James’s Hospital, just in case I had to beat a hasty retreat.
I needn’t have worried. There was little gore or trauma. Instead it turned out to be a fascinating glimpse into the skilled world of unblocking arteries from within.
The live satellite link to an operation at Columbia University Medical Centre in New York allowed an international panel of cardiologists sitting in Dublin to watch, discuss choices and share opinions on a complex case of a 76-year-old woman being treated for narrowing of the coronary arteries around her heart.
Such conference broadcasts are “extremely helpful” for doctors who want to find out about new techniques and technologies in minimally-invasive cardiac procedures, according to Dr Niall Mulvihill, a consultant cardiologist at St James’s Hospital.
He was one of several cardiologists who performed procedures for the cameras over two days at the sixth annual live course on complex percutaneous cardiac intervention (PCI) at St James’s earlier this month.
The PCI approach accesses blocked arteries around the heart not by opening the chest, but by feeding equipment in through blood vessels, then widening the narrowed segments from within and leaving in place a supportive “stent” device to help maintain good blood flow.
It’s a far less invasive procedure than the traditional bypass, where blood vessels from the leg or chest are grafted on to reroute blood around the blocked stretch of artery, says Mulvihill.
“When you are having a bypass you have to be asleep and paralysed. They saw open your chest and they stop your heart in order to stitch the bypasses on,” he explains. “And while your heart is stopped they use a bypass machine to make sure there is oxygen getting to your brain, but your body is completely dependent on that machine.”
After about an hour, the team restarts the patient’s heart and closes up, and the surgery usually means a week-long stay in hospital and a recovery time of at least six to eight weeks, says Mulvihill. “It’s a very invasive and physically gruesome procedure.”
Stenting, on the other hand, is less of an ordeal. “Recent directly comparative studies show there’s no difference in mortality whether you have surgery or stenting, and if you have stenting, you are usually out of hospital 24 to 48 hours later and can be back to normal in about five days,” he says, adding that the patient can be fully awake, or sedated if wished.
The downside is that stenting covers less ground, and a patient may need a later procedure if there is further narrowing. But for most that’s not a deal-breaker, explains Mulvihill, who notes that around 8,000 stenting procedures will be carried out in Ireland this year.
“You can offer patients the scenario that we will give you a bypass today and you will have a 1.5 or 2 per cent risk of mortality and you will have to go through the open-heart surgery, or else we will put in three stents in two arteries but you will be a little more likely to come back for a second procedure in the next five years. If you ask which would you want, 99 out of 100 will pick stenting.”
Step one in the procedure is to introduce a “wire” or catheter into an artery in the arm or leg and advance it towards the heart. Using real-time X-ray, the team can monitor the wire’s progress and inject radio-opaque dye to test how well the blood is flowing through the vessels ahead.
Rigid arteries with internal calcium deposits can be particularly tricky, and in the Columbia case the team wheeled in magnets to help navigate the wire through tortuous bends. Their strategy ignited much interest in the Dublin-based audience, which was chaired by consultant cardiologist Dr Peter Crean.
“I knew that the technology was available, but I hadn’t seen it used,” says Mulvihill.“Its application in treating coronary disease is very new. I’m pretty sure that Columbia would be the first centre in the world to receive that.”
The New York-based doctors led by Dr Jeff Moses then inserted equipment through the wire to drill away some of the calcified plaques and widen out the arterial passageway with a balloon before inserting a stent.
A quick X-ray check revealed much improved blood flow, and a camera sweep within the artery highlighted the now smoother terrain. The woman who had been initially billed as a “really tough, high-risk case” was off to recovery.
Yet while it might be described as minimally invasive for the patient, the best strategy is to try avoid the procedure altogether, and Mulvihill’s bottom line on keeping your blood vessels healthy is to give cigarettes a wide berth.
“The number one thing to do is not smoke,” he says. “Beyond that, in consultation with the GP, have a cardiovascular assessment – the simple things are getting your cholesterol checked and getting fasting blood-sugar levels checked to look for evidence of diabetes.
“There’s no harm in having a check at 40 and if you are healthy and well you can have it done again at 45 or 50.”