Hope for those awaiting bypass surgery

Pass by a bypass

By Uthpala Gunethilake 

"We carry out such less complicated and cost-effective measures to treat certain heart conditions though not many are aware of it," said Cardiologist Dr. Vajira Senaratne of the Colombo National Hospital. He explained that Balloon Mitral Valvuloplasty (on which he presented the Prof. P. B. Fernando oration at the opening of the annual academic sessions of the Ceylon College of Physicians recently) and Angioplasty are two such methods. 

According to Dr. Senaratne, Balloon Mitral Valvuloplasty allows cardiologists to side-step a major surgery which would otherwise be necessary to correct a heart condition caused by rheumatic fever, termed 'mitral stenosis'. This is common among the five-to-15 age group, especially among girls. "Rheumatic fever, which is the result of a bacterial infection in the throat, called tonsilitis, can affect some patients' hearts, mainly heart valves. 

The commonest valve that gets blocked, is the mitral valve. Since valves control blood flow within the heart, when the mitral valve narrows, the flow is restricted and the patient finds that he can't breathe and perform tasks - like walking or climbing stairs. If the valve is too narrow the patient can even die," said Dr. Senaratne. 

He explained that since mitral stenosis is a mechanical obstruction in the mitral valve it cannot be corrected by medication. "Therefore from the time cardiac surgery started in Sri Lanka, this was repaired by an operation which involved opening the chest through an incision, with the patient under anaesthesia. It was a major surgery, the patient had to be in Intensive Care for a couple of days and for about 10 to 14 days in the hospital," he explained. 

But the new procedure introduced in 1997 brought a total change. Dr. Senaratne said that it is carried out with the help of a balloon, by passing a catheter through the groin into the heart. "It goes into the right side of the heart, then enters the left side through the punctured septum, which is the wall which separates the heart into chambers, and crosses the mitral valve with a balloon. The balloon is dumb-bell shaped. Once you cross the valve, you inflate part of the balloon, and then you pull it back and inflate the rest. When the balloon 'balloons' out, it clears up the narrowed valve." 

Dr. Senaratne pointed out that this procedure has many advantages over treating mitral stenosis surgically. "This takes only about half an hour, and the patient is conscious, being only under local anaesthesia - and has fewer complications. It also leaves no scar, and the patient can go home in one or two days' time. It's also much more economical, though of course the balloon, which is a little expensive, is re-sterilized and used about 3-10 times. Since young people - schoolchildren or those doing jobs, basically the active part of our population- are more prone to it, it is an advantage that this method allows them to get back in shape quickly." He also reminded that where children are concerned, the risk of complications during surgery is high, and that the same goes for pregnant mothers who are also prone to mitral stenosis. "In such cases and where the patient has already had a cardiac surgery, this procedure is certainly better," he said. 

Angioplasty (Percutaneous Transluminal Coronary Angioplasty) is also performed with the help of a catheter and a balloon, for patients who otherwise would have to undergo bypass surgery. "Middle-aged people are affected by this condition where vessels carrying blood to the heart gradually become blocked, resulting in a stroke. Again, it's a mechanical block and you have the option of Angioplasty or bypass surgery," Dr. Senaratne said. He pointed out that since bypass is also a major surgery, when it's only one or two vessels that are blocked, angioplasty is an excellent option. "In Angioplasty also, you pass a catheter through the groin, and with the help of a wire and a balloon clear the block in the vessel. Then to maintain it you insert a 'stent', which is a stainless steel device to prevent the vessel from getting blocked again. 

He explained that this also has advantages like fewer complications, local anaesthesia, shorter duration and shorter time of recovery, stressing however, that in certain cases it cannot replace bypass surgery. "There are cases where you must do the bypass, but there are people who go for bypass even when they can do with Angioplasty. That is unfair to the patients who really need by-pass surgery. Also people don't know that Angioplasty can be done here; they go to India to get it done." He pointed out that both Angioplasty and Balloon Mitral Valvuloplasty help clear up the surgical backlog in the cardiac sector. "The waiting period for bypass surgery is very long. There are only a handful of cardiac surgeons for the whole country. We are tackling mitral stenosis effectively and successfully with Balloon Mitral Valvuloplasty, and we have cleared up about 300 cases from the list of patients who were awaiting surgery. This allows the surgeons to handle serious cases like bypass or hole in the heart, sooner. It's the same with Angioplasty," he said. 

Dr. Senaratne says however that prevention is most important where both these cardiac conditions are concerned. "Mitral stenosis," he explained, "prevails in developing countries due to problems like lack of medical attention towards the first stage of it, which is tonsilitis, and lack of proper ventilation in houses. And the other common reasons for heart diseases are smoking, lack of exercise, too much cholesterol, stress, blood pressure diabetes etc. - which can all be prevented. What we do here is the final measure." 

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