Heart institute pioneers procedure to treat advanced cardiac failure

With around 20% of its 120 monthly patients in need of advanced therapy, the Caribbean Heart Institute (CHI) recently pioneered the first local cardiac resynchronisation therapy plus defibrillator implantation (CRT-D) procedure.

CRT-D is part of a standard treatment for advanced heart failure in North America but countries in the Caribbean have had to fly doctors in to conduct the expensive procedure. “It is something fairly novel to the Caribbean so we are very happy and pleased to provide this service for the first time in Guyana,” cardiologist Dr. Mahendra Carpen, who performed the procedure, told Stabroek News.

Carpen, who was trained in Boston, in the United States, has performed over 60 such procedures on patients in the US and in Trinidad.

He said it is important to select the right patients for advanced therapy. “Patients with heart failure, who have had regular medical therapy that has not worked and experience shortness of breath, swelling to the ankle, fatigue and have an ejection fraction of less than 35% on the echocardiogram are usually the ones for this procedure,” he said.

Carpen explained that an ejection fraction represents every time the heart pumps blood; it is supposed to send out at least 55% of the substance around the body but patients with advanced heart failure would usually send out less than 35%.

He said in some cases one part of the heart is contracting before another part of the heart and thus the blood is being moved from one end of the wall to another in the heart. He said, therefore, they would need to resynchronize the heart through CRT-D, which would see the muscles contract together so that blood is expelled in one direction.

During the procedure, an incision is made to the left shoulder to locate a vein. The cardiac resynchronisation therapy device is implanted under the shoulders and insulated wires are inserted into three regions of the heart. The wires carry signals from the heart to the heart device and also carry electrical impulses to the heart. “The most challenging part is finding the coronary sinus where another is inserted,” Carpen said.

The first procedure, which was performed on 70-year-old engineer Egbert Carter, lasted for four hours. Carpen was equipped with a team of nurses and technicians. A technician from Medtronic, a developer and manufacturer of advanced medical technology to treat chronic diseases, was flown into the country to ensure that the defibrillation device was properly inserted and working. “It was a special type of satisfaction to be able to conduct it in Guyana,” Carpen said, adding that the patient was in good spirits throughout the procedure. “He was chatting with us and cracking jokes,” he noted.

Carpen, who said all patients deserve the same level of care that is offered in other countries, noted that CHI was committed to offering the best heart healthcare in the country.

 

‘Frightening’

Carpen also expressed alarm that there are a lot of people between the ages of 25 and 45 living with heart disease. “What is very frightening to me is that I see so many patients under the age of forty-five. Those patients really scare me,” he said, noting that Guyana is a “very frightening place” for heart disease.

Twenty percent of patients visiting CHI every month are referred for further evaluation and advanced procedures, he stated. He added that people of South Asian descent are most likely to be susceptible to heart disease than any other race. “These are people with the highest incidence of heart disease,” he noted.

He stated most people with heart disease are unaware that they have it and sometimes visit the doctor only when the disease is advanced. He said he recently had a patient who went to CHI and said he was belching a lot and that he had an upset stomach. It turned out that that patient had had a heart attack and did not know.

“You can’t ignore pains. The commonest thing in this country is to think it’s gas and let me take a cup of hot tea. Seek help, don’t just think it’s gas because there are too many young people living with heart disease and they don’t know it. It is a very common thing to have a heart attack and don’t know…,” he said, before later adding that the heart disease mortality rate could be reduced with early screening and detection.

Noting that heart disease is the number one killer worldwide, he said persons should not ignore any “symptoms anywhere between your neck and your navel.”

He also urged that persons adopt sensible diets instead of drastic diets. He stated that the Guyanese diet should have more fruits, vegetables, greens and nuts rather than rice and roti. “I can’t be too harsh on these (roti and rice) because all of us kind of grow up on these. Changing diets is very difficult but it is important if you want to live,” he said.

Carpen said he hardly ever has patients who default from the clinic because in time “they always find their way back.” He added that their nurses are trained to the best to deal with patients. “We have some of the best nurses in the country here because we are dealing with lives here,” he said.

Heart specialist Dr. Rajiv Jauhar, who recently visited Guyana with a medical team from the Long Island Jewish Hospital in New York, had said 40 % of patients diagnosed with heart disease die within a year and that there has been an increase of the younger patients in heart clinics because of a breakdown in diet and lifestyle.

Last year, the World Health Organization (WHO) had reported that a third of all deaths are heart disease-related. Reports stated that after a heart attack, 30% to 45% of patients will progress to heart failure.

After a heart attack, cells in the heart die and the extracellular matrix (ECM) disintegrates. And the heart, having little regenerative capacity, causes the area damaged by the attack to be replaced by scar tissue. Pressure is then placed on the heart to pump the amount of blood the body needs.

Heart disease starts when cholesterol, fatty material and calcium pile up and clog the arteries, causing a narrowing of the arteries and thus a reduction of oxygen to the heart. The oxygen reduction to the heart causes chest pains. Some of the common risk factors for heart disease include: smoking, high blood pressure, high cholesterol, diabetes, family history of heart disease, peripheral artery disease and obesity.

Symptoms of heart disease usually occur during exercise or activity, when the heart experiences a demand for nutrients and oxygen that cannot be met because the coronary arteries are blocked. Some symptoms are chest pain, shortness of breath, jaw pain, back pain, especially on the left side and pains on the left shoulder.



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