Doctors in operation theater

The term coronary angioplasty is used to describe a technique wherein a balloon is used to crush blockages in the blood vessels [coronary arteries] supplying the heart, thereby restoring good flow of blood. These procedures are invariably followed by insertion of a metal scaffolding called a stent which prevents recoil and reduces re-blockage at the ballooned site, which is called a stenting procedure.

The process

Balloon angioplasties and stenting techniques have become a very routine day-to-day procedure performed in most tertiary care hospital across the country. Primary angioplasty, however, is a term used to describe an angioplasty done as a life-saving emergency procedure in a patient with an on-going heart attack [PAMI – Primary Angioplasty in acute Myocardial Infarction]. Heart attacks occur due to sudden total occlusion of a pre-existing partial block, thereby completely cutting off the blood supply to a portion of a heart muscle.

These 100 per cent blockages need to be removed within 3-6 hours from the onset of heart attack; else the muscle of the heart gets damaged permanently. Doing angioplasty in a critical patient of heart attack is in itself challenging and doing so in the critical window period of this 3-6 hours further adds to the challenge. Recently, we did an audit of our door to balloon time [that is the time at which the patient reaches the hospital with ongoing heart attack to the time actually the balloon opens the block and restores the blood flow to the muscles of the heart] was 42.5 minutes. The international accepted time is within 90 minutes. Therefore our response time was indeed encouraging. Can you imagine the impact of a short door to balloon intervention, on a patient who often comes crashing with a massive acute myocardial Infarction? A few hours later, we are wondering why he is still in the hospital.

The only other option available for the treatment of heart attack other than the primary angioplasty is use of specific intravenous medications called “thrombolytic agents”. These agents are thrombus [clot] busting medications, and when administered in patients, dissolve the clot in 60-65 per cent of cases. The remaining 35-40 per cent of cases either die due to failed thrombolysis [failure of drug to lyse the clot], or even if they survive the attack, go home with a very weak heart due to a large portion of the heart muscle being permanently damaged. These patients who do survive with weak hearts go on to live with either heart failure, valve leaks, ruptures in the portion of the heart or rhythm problems [electrical disturbances] and have a very morbid and unproductive life, with abundant economical, social and psychological burden.

Difficulties faced during the procedure

We have millions of such patients in our country with this morbidity, which ultimately is a large burden to the state. On the other hand, success rate of primary angioplasty is more than 95 per cent when performed by experienced doctors. Mind you, several procedures are not easy during primary angioplasty. Identification of culprit lesion may require a thorough evaluation; vessel access can be challenging; lesion morphology can be tricky; thrombus burden can be truly “burdensome”; hemodynamics critical and worsening by the minute; or no re-flow may be stubborn to usual treatment. Or, simply, a combination of these variables and darned, bad luck! This requires not only specialised training in interventional cardiology, more importantly a dedicated team of nurses, and cath lab technician who can react quickly to an emergency call.

The day-to-day angioplasty and stenting procedures have become routine and boring in some ways. However, this primary angioplasty is a new challenge in life, something which calls for a little personal sacrifice. Anybody can do a short door to balloon intervention! Most skilled interventional cardiologists in Mumbai and across the country can do an exceptionally good job with short procedure times and a door to balloon time of less than 90 minutes, when it is on routine hours. To do it regularly, day-to-day, and during off hours in a community hospital, in a fairly standardised methodology, does call for a lot more dedication and commitment. PAMI is not rocket science. I cannot overemphasise the urgency that exists in achieving the mandatory short door to balloon time guidelines.

PAMI reminds of a relay race in a 400 meters race. Like these relays, I am the final person with the baton and I must make up time for the delays of late presentation to the emergency room [ER], at times patient presents late to the ER, the clock is ticking and time to alarm at 90 minutes. If the ER/transportation doesn’t get its act together, the clock continues to tick; if patient’s/relative’s decision is delayed, it is still ticking, and always, yes always, I am expected to get it right and finish within 90 minutes. My 27/7 commitment means I am immediately available. I have to see the patient and I have to set the process rolling. In most cases, I try to lead from the front. I scrub in along with them, so I am even able to help them prepare a patient. It disseminates a feeling of urgency and team work. It lets the message resonate that each moment is precious. My availability has been an absolute personal decision, and a calling in life, sparked by a fierce determination to get it exactly right. Remember, the procedure is just one part. Some patients need an extremely close follow-up post procedure; especially those with cardiogenic shock [Cardiogenic shock is based upon an inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively]. Not every patient has a perfect result and often requires additional care. At times, physically it is very exhausting, though mentally it is extremely rewarding.

Hopefully, I will have the good health and the support of the hospital and the staff to continue doing it for many more years to come.

AV Ganesh Kumar
Dr AV Ganesh Kumar MD, DNB [med], DM [cardiology], DNB [cardiology] FACC is Head, Dept of Cardiology at Dr LH Hiranandani Hospital.



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