Wednesday, September 18, 2013

From the Bottom of Heart

Another heart day is here to celebrate, evaluate, comprehend, apprehend, explore and innovate. On the occasion, Color Doppler talks to Dr. Murali P Vettath, who has created many firsts in the world of cardiology, in a bid to explore new horizons of cardiac inventions

 Dr. Murali P Vettath
Director, International Centre of Excellence in OPCAB Surgery,
Malabar Institute of Medical Sciences

Ria Lakshman. V, cd news

For many, he is God, who redeems their life. For the people, whose lives are exacerbated with severe pains of cardiovascular diseases, this man prophesies as savior and masters his art of recreating the realms of human heart on them. For many others, he is a mentor, philosopher and friend, who explores roads that are less taken. It is the story of Dr. Murali P. Vettath, the Director of International Centre of Excellence in OPCAB Surgery, Malabar Institute of Medical Sciences, Kozhikode, who has created many ‘firsts’ in the field of cardiac surgery.

The evidence of Dr. Vettath’s quest for innovation and his unwavering dedication to medical field is seen everywhere. In the journey that has taken him across the length and breadth of cardiovascular segment, he has performed more than 6000 open heart surgeries, with more than 3500 bypass surgeries performed on beating heart. His voyage began from Coimbatore Medical College in 1983 and carried on to take a DNB in General Surgery in 1987, followed by an MCh in Cardiothoracic and vascular surgery in 1991 from Government Medical College, Trivandrum.

With his specialized training from Australia in coronary bypass surgery for five years, Dr. Murali P Vettath established two cardiac centers under the Z H Sikder Cardiac Care & Research Centre, at the Z H Sikder Women’s Medical College and Hospital Pvt. Ltd., in Dhaka, Bangladesh. Besides giving training to numerous cardiac surgeons in Bangladesh, he performed the first beating heart surgery in the country in 1999. In 2002, with an intention to serve the people of his home town, Dr. Vettath relocated to Calicut and became the fortitude of Malabar Institute of Medical Sciences (MIMS).

Today, Dr. Murali P Vettath is one of the few surgeons worldwide performing 100 percent of all the Coronary Artery Bypass Grafting (CABG) on beating heart. He has authored numerous publications and research studies and invented surgical devices. His works are the bibles of cardiac surgery that he is now the mentor of many surgeons from all over the world. On the occasion of another World Heart Day, here, Dr. Vettath talks to Color Doppler.

You are the person who performed the first beating heart surgery in Bangladesh and you are still one of a few who continue to perform it. What was your motivation to begin?

Off Pump Coronary Artery Bypass (OPCAB) was a technique started by Buffalo and Bennetti in 1985. There was an enthusiasm among the surgeons in 1990s to begin OPCAB, which slowly reduced towards 2000, as many surgeons failed to find their comfort zone in OPCAB. The success of OPCAB lies in minor modifications in the techniques of anesthesia, surgery, viz; stabilizing and positioning of heart. This has to be mastered and in an experienced hand, the results obtained are worth the effort. In fact, we analyzed our 3000 patients who underwent off-pump over the past ten years, and found that results were worth the struggle.

It was probably the idea of mini-invasive direct coronary artery bypass graft (MIDCABG) introduced by Benetti in 1990s that explored the possibilities of not using CPB (cardiopulmonary bypass). The introduction of LIMA stitch was the next revolutionary step in development of OPCAB. This stitch allowed the grafting of posterior branches of the coronary arteries. Stabilizers further enhanced the process. But circumflex territory was still a danger zone. It was that time that the role of positioners became more important. So the process became even more seamless.

When you perform CABG on-pump with the help of heart lung machine, the heart is motionless or practically dead for the time. Instead, the heart lung machine performs the function of the heart. Beyond a time period, this is bad and it has a 2 percent inherent mortality in it. There is also a 2 percent stroke risk. This thought provoked me to change the technique to off-pump or performing surgery on beating heart.

In 10 years of OPCAB experience, where more than 3000 OPCABs were performed, we noticed that in the last 2000 OPCABs, we had only one conversion to the heart lung machine. The mortality rate has been drastically reduced CABG (Coronary Artery Bypass Grafting) surgery has come a long way - from Off pump in the 50s, CABG moved to On-pump after the heart lung machine was invented, and it is now back to Off-pump. It has come a long way. We had to re-engineer the OPCAB, because this procedure was not reproducible by lesser mortals like us.

Whatsoever, the ultimate aim of a surgeon is to deliver good results. The mindset of the team and their consistency is important to deliver this. Very few cardiac surgeons in the world actually do 100 percent off-pump surgeries. Surgeons try and perform OPCAB to a certain extent, but when it becomes risky then they change it to on-pump.

You are a researcher. There are innumerable inventions and publications in your name. Can you give an insight into your inventions that revolutionized cardiology?

When we sight a problem during surgery, they we try to find a solution to it. That is how inventions happen. To take the case of Vettath’s Anastamotic Obturator (VAO), I found a problem with the side clamp on the aorta, especially when a surgeons need to avoid it when a no-touch technique is required in case of diseased aorta. In patients with plaquey aortas, a saphenous vein top end needs to be connected. VAO can be used to make an anastomosis on a non plaque zone in aorta. The technique is to identify a soft spot on the aorta, and make two purse string sutures around the intended zone of anastamosis. A stab wound is made and an aortic punch is used to make a punch hole on the aorta. The VAO is then inserted into the hole and one of the purse strings is used to snare the bleeding around the VAO, if bleeding persists. The advantage is that this allows the surgeon to perform a hand sewn anastomosis on the vein graft. The instrument can be reused and could help in avoiding stroke in elderly patients. It is also a good tool to be used in redo CABG.

Similar is the technique of long mammary patch. This technique was devised to perform OPCAB for patients with diffusely diseased coronary arteries. In this technique, the distal perfusion tips of aortocoronary shunts are cut and inserted into the coronary artery. The bulb is inserted into the end from where the blood flows. The advantage of this technique is that the intima is left intact and no injury is made on it. We do not add any other medications than those used for the normal CABG patients. Also, the patient will remain stable during the surgery.

We also re-engineered the use of Intraaortic Balloon Pump (IABP) in OPCAB. Every patient undergoing OPCAB gets a femoral arterial line and this is used for monitoring, along with the radial arterial line. In this technique, the femoral arterial line is removed and a shealthless IABP is inserted. The IABP is maintained till the end and is removed only when the patient remains stable. It is very useful in avoiding conversions. With this, the conversion rates to heart lung machines have sharply declined. Then, once the grafting is complete, the IABP could be removed in the theatre itself. These are few of the modifications we did over years. By re-engineering the techniques, we are now able to perform OPCAB in any patient who needs CABG.

What do you predict are the future developments in cardiology?

Over the years, I have noticed that the life span of an Indian male or female has increased. And, the incidences of cardiovascular diseases too have gone up despite all the medicines, innovations and awareness that have increased. Especially, in Kerala, rate of awareness is high. If anything is announced in radio, television or internet, they immediately come to us. Coronary artery disease is mostly a sign of aging. We cannot stop aging. By performing CABG, all we do is, connect another pipe to bypass the block in the artery. But the disease process still goes on, we can only try and postpone the inevitable. It can be stopped only to an extent. I always say, what I do is a glorified plumping job. But, still we try to keep a man alive by doing this plumbing job on a beating heart.

What happens is over time, people develop diseases of the blood vessels, like diabetes, which affects kidneys, heart, eyes and every other organ. Nowadays, patients come with a lot of co-morbidities like renal problems, where they are on renal dialysis and also who need renal transplantation. In early days, people with all these never survive. Now they get dialysis, get a bypass surgery, and then they go and get transplant done. I have seen lot of patients who come here from Cochin to Kannur and different parts of the country, who are planning for a renal transplant. They come here, get the grafting done and go back for their renal transplants.

When I went to Tokyo, I visited a hospital where there was a floor of patients over 90 to 100 years of age. These are the patients, whose aortas are replaced. Aortic surgeries are done on the patients at 90 and 100 years of age. And, most of them are walking freely around. They have gone beyond what we are even thinking about. Here, over 80, we don’t want to do aortic surgery because we think that this fellow won’t survive. Do we really need that? It is very interesting. So with all these developments of heart disease surgery, renal surgery everything, what we are now looking at is Aortic surgeries.

Cardiac Transplantation will now remain the next procedure, Cardiac surgeons in our state are going to focus on, as the left ventricular assist devices in the market are prohibitively expensive and there are a huge number of heart failure patients waiting. Next would be the increase in number of Aortic stents that has come up. This is a procedure done in the catheterization lab. Its performed like an angioplasty, by make an opening in the femoral artery in the groin, through which he puts the stent into the aorta, opens the blocks or even narrows a section of the dilated aorta, in case of aortic aneurysm. These are done without doing surgery and I think there is a lot of future in that.

Over the last 10 years, which I noticed that, the most important thing that has happened in cardiac science is the treatment for acute MI or Acute Myocardial Infarction. This is called a Primary Angioplasty. That is, when one has severe chest pain or a heart attack, and if you reach the cath lab within the three hours. Then you can open up the block. These three hours is a golden period. You open up the block; perfusion of the artery is so good, that there is not much of damage happened to the heart. One could reach a cath lab within three hours (Golden hour) then the chances of recovery of that damaged myocardium or heart muscle is very high. That is the best thing that has happened.

Coronary artery or its branch gets blocked completely by a blood clot, then that area of muscle supplied by that artery suffers from loss of blood supply. But, since there are blood circulations coming from the other side, the area of damage gets smaller. If that block remains there for a long time, then he might succumb to it. The block happens when there is a sudden rupture from an inner layer of coronary artery (endothelium). Then, like volcano, some secretions come out. The blood will suddenly clot inside in that region. This formation is called a heart attack and this is called a Myocardial Infarction. Like the stroke in the brain, heart attack is the block in the coronary artery. So, there is no blood circulation in the area. So with Primary Angioplasty Interventional Cardiologist open the blocked artery and stent it, thereby saving the myocardial damage and saving precious lives.

Earlier what we do is to give injection that thins the blood. This does work in 75 percent of block and the 25 percent it does not. So still the block is there. So if you open it up, the block goes. We have performed more than 1500 Primary Angioplasties over the last 10 years. But for this we need a big cardiology team. Everyday there are more number of people coming up with this problem.

You were telling, Australia is still doing 99 percent surgeries on pump. So as of now, how do you evaluate the cardiovascular treatments in India?

We are in par with the best coronary surgery center in the world, in terms of quantity and quality performed by a single surgeon. In India, there are only a few Cardiac surgeons who perform OPCAB on all their CABGs. When I came from Australia, I found that equipment wise and manpower wise, we are better than or in par with the Australian centers in terms of Coronary surgery.

What are the new researches coming up in cardiology?

In stents, there are new biodegradable stents. In the usual drug eluting stents, the metal bit will remain and a covering comes over it. In this, after six months, the stent melts. It is already there in the market and there are companies that promote it. That will be the future of cardiology. In cardiac surgery, newer surgeries are coming up. One is Coronary bypass surgeries with robotics. The only thing is that it is time consuming and is costly. It is already there, in Delhi they do, and all over the world, like US, Germany, they have robotic surgeries. In India, surgery developments are low because the treatments are not insurance based. People need to spend their own money to do surgery. Only 25 percent of the patients in the country are insured. So, if the insurance becomes mandatory, more and more surgical developments would come to our place as well.

In India, do you see an increase in the number of people who come with cardiovascular diseases or is the number decreasing?

Oh. Yes! It is increasing. The awareness is high. But, the number is also going up. So the number of centers has also gone up. In fact, when we started here in MIMS, 10 years ago, there were only three or four, less than 10 cath labs in Kerala. Today, there are 70 odd cath labs in Kerala. There are 100 cardiac surgeons and 300 cardiologists in the State, which is a very big number. Japan has the highest number of cardiac surgeons — 3000 cardiac surgeons and 500 cardiac centers in such a small country. On an average, there a surgeon does only about 30 or 40 cases a year, whereas surgeons like us, do 400 surgeries a year.

You have made many inventions. How does it benefit the cardiac treatment in the country?

All my inventions are to supplement the surgeries. It is not made for commercial value. It is for the surgeons to have these devices as lifesaving equipment in their surgical set. I have patented many of these techniques. I patented because I feel good about it. You don’t make money out of it. The device what I have made will costs Rs. 500, whereas the device that comes from US and all costs 500 US dollars for one shot, which we can’t afford. That is why I made this. And, this is for life time. I have showed the device and anyone can make it. Most of the things what I have done is to help a surgeon to improve the technique of surgery and hence, to make the surgery successful.

CABG (Coronary Artery Bypass Grafting) surgery has come a long way from Off pump in the 50s, CABG moved to On-pump after the heart lung machine was invented and it is now back to Off-pump. It has come a long way. We had to re-engineer the OPCAB, because this procedure was not reproducible by lesser mortals like us.

What is your message for your colleagues or the other doctors in India?

Off Pump is a very good technique to do, but until you master it, there is a steep learning curve. Also, you have to do only what you can do. Don’t try to mimic something because somebody has done this. That is what I always say. I have videos and other things on net. But, unless you come and see me doing it, you can’t do it. Some come here, see it and go back. But they are not able to do it. Recently, a surgeon from Singapore came here. He was here for three months. He was assisting, he was so observant. He went back and after six weeks, he did his first Off pump. He mailed me only after he successfully did it. He was a professor in National University Hospital, Singapore. Beating heart surgery was not very successful there. His Boss was telling me that “This man will drive it forward.” I think there are still few more modifications to do. I am learning and I am changing. Change is the constant in Cardiac surgery too. I cannot say this is the ultimate thing. I don’t do things what I did 10 years ago.

In science, this change is very important. We have to move and change according to how it goes. And, prove on whatever we do. I am not even happy with this 0.4 percent mortality rate in OPCAB. Unless the physicians have an aim in life, he cannot grow. Otherwise, it is like a bank job. You sit there and do same things systematically forever.

This interview was taken for Color Doppler magazine, September 2013 issue -

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