Cardiac surgery made simple by eminent surgeons

by Samangie Wettimuny

[email protected]

World renowned consultant cardio thoracic surgeon, Dr. C. Sivathasan, of the Cardiovascular and Thoracic Surgery of The Heart Lung and Vascular Surgical Centre, Mount Elizabeth Hospital and Gleneagles Hospital, Singapore briefed the media on heart diseases and treatment at a recent discussion held at Mount Elizabeth Hospital, Singapore.

Excerpts:

The function of the normal heart (which is about the size of your fist) is to pump blood through about 96,000 km of blood vessels distributing blood from head to toe. Heart which beats about 60-120 per minute depending on one’s activities, pumps at a rate of about 5 liters a minute, while resting.

The right coronary artery distributes blood from the right side of the heart while the left coronary artery supplies the left side of the heart. The latter divides into two major branches, one supplies the front of the heart called LAD and the second branch called circumflex artery supplies the back of the heart.

Thus there are 3 major tributaries to the heart. From these arteries, branches arise like branches of a tree distributing blood to all parts of the heart.

The commonest heart disease that occurs in adults is resulting from narrowing or blockage of these arteries-It is called ischaemic heart disease or coronary artery disease. The narrowing of the arteries is brought about by deposition of cholesterol within the wall of the arteries.

The causes for coronary heart disease can be categorized into two, avoidable causes and unavoidable causes. The avoidable causes such as unhealthy diet, cholesterol level, obesity, smoking, high blood pressure, uncontrolled diabetes and physical inactivity are “life style” related and can be easily changed to prevent or minimise the progression of heart disease.

The unavoidable causes are those factors which cannot be modified. They are old age, males, females after menopause and family history.

The coronary artery disease manifests as angina, myocardial infarction or heart attack or as silent heart attack.

Angina Pectoris manifests as chest discomfort or tightness which may radiate to neck or down the left arm on exertion such as during brisk walking or walking uphill. The discomfort disappears on stopping the activity or on resting. Angina is caused by narrowing of the coronary artery. When we exert, the heart has to do more work to increase the blood flow according to the demand.

This in turn, will require increase in blood flow to the heart muscles. But the narrowed coronary artery compromises the blood flow resulting in inadequate blood flow to meet the demand made by the heart muscles, causing angina. On resting, the demand made by the heart muscles decrease and the blood flow in the coronary arteries become sufficient and the angina disappears.

Heart attack is caused by sudden blockage of the coronary artery often caused by rupture of a cholesterol plaque in the artery. This results in deprivation of the blood flow to the area of heart muscle supplied by that artery, resulting in damage to the heart muscles.

If the artery involved is a major artery then a large area of muscle is involved which may be fatal. If the artery involved is a tributary or end of a major coronary artery, the resulting damage will be minor resulting in a minor heart attack.

Immediate treatment of a heart attack is essential to save the heart muscles. If the blood flow is not restored within about six hours after a heart attack, the damage to the heart muscles becomes permanent resulting in diminution in the effective strength of the heart.

A patient does not always suffer from typical chest tightness when he sustains coronary heart disease. Patients, with diabetes often suffer from silent heart disease when they also have coronary heart disease.

The disease may manifest as progressive tiredness, or breathlessness or even indigestion. Burping after meals, heart burn especially after a heavy meal or on walking after a meal, may be mistaken for gastritis. The management of avoidable causes and healthy lifestyle changes play an important role in the treatment.

Appropriate investigations-blood tests, ECG, Treadmill Stress Test, and Echocardiogram should be done to determine the cause and extent of the disease. Based on these results further tests may be required such as nuclear perfusion scan and coronary angiogram.

Coronary angiogram is the ultimate gold standard which would reveal the exact road map of the coronary arteries, the distribution of cholesterol plaques and narrowing in the coronary arteries which would ultimately determine the necessity of invasive treatment.64 slice CT coronary scan is a new modality of assessing the status of coronary arteries.

It does not replace the requirement of a coronary angiogram. It should not be taken lightly as an easy screening tool for heart disease.

The investigation requires exposure to radiation, equivalent to more than 400 chest X-rays, during the process of scanning. Not all patients suffering from coronary heart disease require invasive management. About a third of patients can be managed by medical treatment requiring a combination of medicines. In others, coronary angiogram will be required

The risk of this procedure is less than 1%; it is free of pain and may require overnight stay in hospital. Depending on the site, extent and number of blocks assessed in the coronary angiogram, the treatment plan would be decided. If the lesions are suitable for balloon dilation and deployment of stents, such treatment will be advised.

In more extensive situations, coronary bypass surgery would be required. Nowadays, if your heart is not damaged and if you do not have any other significant disease such as impaired kidney function, lung disease, the risk of surgery is less than 1-2%. During bypass surgery, bridges to bypass the block on the affected coronary arteries are constructed.

Usually 3-4 bypasses are required. The heart surgeon would assess you and decide on the type of conduit required to carry out the bypass. Often the mammary artery which runs underneath the breast bone is used. Other bypass conduits may be taken from the forearm and legs. Removal of these arteries and veins do not cause any permanent harm.The surgery can be carried out with or without using a heart lung machine. Both methods have their own indications and advantages.

Heart transplant is also done in Singapore. It is done under very hygienic conditions. Donors of heart transplant are the ones who sustain brain injuries in accidents. Brain death is legally defined in Singapore where a person is pronounced dead when the brain stops functioning.

Talking of the Sri Lankan situation Dr. Sivathasan said that heart diseases are on the rise in Sri Lanka. One reason is diabetes. It is becoming more and more common now. Even younger people are suffering from diabetes.

It is one of the factors that contribute to heart diseases. Secondly changing food habits too make a great contribution. All the fast foods and super markets which have such food items in abundance have sprung up.

People are consuming those food stuff and the cholesterol level goes up. Next are lack of exercises and smoking, and stress. When asked how he compares Sri Lanka with Singapore, he being a Sri Lankan doctor graduated from Colombo Medical College who is now permanently based in Singapore, Dr. Sivathasan said technology-wise Sri Lanka is catching up very fast.

Though funding may be a problem in Sri Lanka with regard to highly complicated medical treatments, the country is rich with latest range of modern technologies with excellent doctors. What Dr. Sivathasan noted was that all the patients who approach for treatment get treated with respect.

Talking to patients and listening to them is very important. Keeping records is also equally important.

Records of patients can be easily traced as they are computerised.

In Singapore, a very high standard of doctor-patient relationship is maintained, Dr. Sivathasan pointed out.Prevention is always better than cure. Talking of preventive measures Dr. Sivathasan explained that it is necessary to avoid overeating and stop smoking. Engaging in regular exercises is a must. Smoking, engaging in regular exercises, try to lead a stress-free life as much as possible.

Dr. Sivathasan who is in constant touch with cardiologists in Sri Lanka will be here from November 27 to 29. During his visit he intends to give a health education talk on “You and your heart-Myths and facts” at Bonjean Memorial Hall, St. Joseph College, Colombo followed by a free medical consultation to members of the SJC Old Boys Union on November 28 from 5.00 p.m. to 8.00 p.m. Dr. Sivathasan who is known as one of the best cardio thoracic surgeons in his field is an Old Boy of St. Joseph’s College Colombo.