Healthy Honorary Editor : Dr. Urmil Shah From the desk of Editor: Newer technology and research is the key to field of medicine including cardiology. In this issue of Healthy two topics covered are classic example of how newer innovation is helping doctors to manage their patient in a better way day by day. When I was doing my DM residency absolute indication of CABG was patient with left main disease but in 2014 with availability of newer hardware and technology the whole concept of managing left main disease is changed. Patient with stable coronary artery disease where anatomical information about coronary artery blockage which is obtained by conventional coronary angiography with known limitation of physiological imaging techniques; interventional management in this subset of patients does create many doubts and discrepancy. A simple diagnostic technique with name of Fractional Flow eserve (FF) and Intravascular Ultrasound (IVUS) is very useful in decision making regarding intervention in many patients. - Dr. Urmil Shah urmil.shah@cims.me Price : ` 5/- Management of Left Main Coronary Artery Disease The third case of Angioplasty in the world done by Dr. Andreas Gruentzig in 1977 was left main stenting. Patient died after 4 month of procedure a time of No Drug Eluting Stent, No Antiplatelets, No IVUS. CASS(Coronary Artery Surgery Study) study shown significant better outcome of CABG compare to medical arm. Since then for many years, CABG has been main stay for treatment of left main disease. Due to improvement in technology and availability of new generation drug eluting stent many of the patients with left main disease can be managed with good midterm outcome compared to CABG. Patients with left main disease who have already undergone CABG with one graft patent (Protected Left Main) is always m a n a g e d w i t h i n t e r v e n t i o n. Management of unprotected left main disease (without previous CABG) will be discussed in this article. Left main disease can be classified into isolated left main disease (approximately 15%), left main with 1 vessel, 2 vessel and 3 vessel disease. Left main disease can also be classified according to location of lesion to ostial, mid and distal left main disease. There is great limitation of conventional angiography for diagnosis and managing left main disease. Intra Vascular Ultra Sound (IVUS) and Fractional Flow eserve (FF) are very important in deciding Figure 1 Cardiologists Cardiothoracic & Vascular Surgeons Cardiac Anaesthetists Dr. Ajay Naik (M) +91-98250 82666 Dr. Milan Chag (M) +91-98240 22107 Dr. Dhiren Shah (M) +91-98255 75933 Dr. Niren Bhavsar (M) +91-98795 71917 Dr. Satya Gupta (M) +91-99250 45780 Dr. Urmil Shah (M) +91-98250 66939 Dr. Dhaval Naik (M) +91-90991 11133 Dr. Hiren Dholakia (M) +91-95863 75818 Dr. Chintan Sheth (M) +91-91732 04454 Dr. Vineet Sankhla (M) +91-99250 15056 Dr. Hemang Baxi (M) +91-98250 30111 Dr. Saurabh Jaiswal (M) +91-95867 25827 Neonatologist and Pediatric Intensivist Dr. Gunvant Patel (M) +91-98240 61266 Dr. Anish Chandarana (M) +91-98250 96922 Pediatric & Structural Surgeons Dr. Amit Chitaliya (M) +91-90999 87400 Dr. Shaunak Shah (M) +91-98250 44502 Dr. Keyur Parikh (M) +91-98250 26999 Cardiac Electrophysiologist Pediatric Cardiologists Vascular & Endovascular Surgeon Dr. Ajay Naik (M) +91-98250 82666 Dr. Kashyap Sheth (M) +91-99246 12288 Dr. Milan Chag (M) +91-98240 22107 Dr. Srujal Shah (M) +91-91377 88088 Dr. Vineet Sankhla (M) +91-99250 15056 1 www.indianheart.com
Healthy severity of lesion. IVUS is mandatory pre and post to decide stent size and post stents opposition to vessel wall. The aim of any intervention including left main intervention should be good immediate success with acceptable risk as well as good long term outcome. Many factors are important both clinical and anatomical like presentation, age of the patients, LV function, risk of bleeding, long term out come data,cost, patients preference, availability of skilled operator and well equipped center to recommend line of management. For choosing CABG and angioplasty, syntax score based on Angiography is very helpful. With syntax score less then 33 mid term outcome (5 to 6 years) for CABG and stenting with first generation drug eluting stent is same as shown in syntax study and also in meta-analysis, so angioplasty should be offered. For >33 syntax score, CABG is better than angioplasty and should be offered (Figure - 1). Clinical syntax score and global risk score which includes clinical and biochemical parameters can be of additional value in deciding line of management. New ongoing trial EXCEL study with new third generation DES (Xience) with syntax score <33 may give better guidance for choosing between CABG Vs. Angioplasty. Figure 2. Distal Left Main Lesion Management Ostial or mid left main disease is manged with single drug eluting stents of main vessel with provisional stenting of other branch, where as distal bifurcation lesion is managed with two stents using either mini CUSH or CULOTTE(Figure - 2). Plasty is done through femoral route and pre and post angioplasty IVUS by experience person is pre requisite in left main intervention. European guide line published in 2013 as shown in figure below will give a clear idea for managing stable left main disease (Figure - 3). It is advocated to discuss all left main cases with multi vessel disease with heart surgical team and surgical risk should also be taken into account before recommending patient with left main disease. In conclusion, my current opinion in decision making would be CABG for left main disease with syntax score >33 if CABG is not contraindicated or predicted risk of CABG <10 %. With syntax score <33 Angioplasty with drug eluting stent with IVUS is recommended except technically difficult lesion CF, diabetes. Figure - 3 2 www.indianheart.com
Healthy FF & IVUS - Diagnostic Techniques (Useful Adjuvant to Coronary Angiography) Though coronary angiography (CAG) is considered to be gold standard for diagnosis and management of Coronary Artery Disease over years, there are several definite limitations. In patients with acute coronary syndrome, coronary angiography still can give definitive line of management as far as intervention is concerned with help of clinical parameter, ECG and bio marker. But in stable angina patient there are many doubts, controversies and discrepancies regarding definitive interventional management with help of only coronary angiography as it gives more of a anatomical information and not physiological information. Non invasive test like thallium scan, stress test, stress echo done to know evidence of ischemia in patient with stable angina especially with left main disease, multi vessel disease, lesion of intermediate severity (50 to 70 %), LBBB, with LV dysfunction has several limitations. One has to be reasonably sure leaving this kind of patient on medical management; at the same time one should not be not doing intervention on patients which is not g o i n g t o b e n e f i t t h e p a t i e n t. Physiological assessment of lesion especially of intermediate severity and left main with the help of FF (simple pressure wire which measures pressure difference across the lesion with maximum hyperemia with adenosin) has been found to be very helpful in decision Figure-1 : FF is a technique to assess the functional significance of a coronary stenosis. FF is independent of changes in heart rate, blood pressure or prior infraction, and takes into account the amount of viable myocardium and the contribution of collateral blood flow. making along with coronary angiography inside Cath Lab. DEFFE study showed that deferring angioplasty in a patient with insignificant lesion (FF more than 0.8) has same incidence of MI and death at the end of 5 years and so can be considered safe in the long run. Deferring angioplasty helps to reduce the cost to the patient and reducing extra risk of the intervention. FAME-1 (FF v s. A n g i o g r a p h y i n Multivessel Evaluation) study of 1000 patient with multi vessel disease was conducted for FF guided (with FF < 0.8) angioplasty over only angiography guided angioplasty were studied. FF guided intervention was associated with 39 % less incidence of death MI and repeat procedure with less need of stent, hardware, dye. Thus FF guided therapy was not only cost effective but cost saving. ecently published FAME-2 study clearly demonstrated that patient with FF < 0.8 (physiologically significant lesion) doing (Figure-2) www.indianheart.com 3
Healthy angioplasty is better than medical arm in long run as it reduces the future urgent need of revascularization. Thus FF avoids needs of intervention resources and cost to the patient at the same time improves quality of life and improves outcome in the long run. If one includes extra cost of urgent revascularization and outcome one can say that using FF along with angiography in patient with stable angina is not safe but cost effective also. In patient with multi vessel disease decision regarding which vessel should be stented is best done with FF which is lesion specific where stress thallium and stress echo is of limited value. This is the reason why FF is class-iia indication according to AHA/ACC 2011 guideline in patient with intermediate lesion (50 to 70 %) unstable angina not having symptom and positive non invasive imaging. European PCI guideline 2013 classified FF as class-i A indication for detection of ischemia related to lesion where objective evidence of ischemia is not available. 4 (Figure-3) Intravascular ultrasound (IVUS) as it gives more precise information regarding vessel size and composition of plaque is very much essential while doing complex interventions like left main disease, bifurcation disease, calcific disease. The reason for early stent thrombosis a potentially dangerous complication is partly because of under expansion of stent where IVUS has an important role. www.indianheart.com (Figure-5) (Figure-6) Mata-analysis of various CTs of IVUS Guided vs Angio Guided BMS and drug eluting stents implantation clearly showed better outcome in form of overall MACE (Major Adverse Cardiac Events), angiography restenosis less stent thrombosis with IVUS guided Angioplasty. Thus FF is very useful adjuvant to conventional agniography and is considered as gold standard in dealing with stable angina patient with inter mediate lesion (50 to 70 % lesion) and in patient with multi vessel disease as it improves MACE. Whereas IVUS is essential to improve outcome and reduce complication in complex coronary intervention. (Figure-4) (Figure-7)
Healthy Hospital, Ahmedabad In Association with Gujarat Cardiothoracic Surgeons Club JIC 2014 Joint International Conference Ahmedabad Aortic Conclave (AAC) Around 200 Cardiac Surgeons & Anaesthetists attended the conference First of its kind live workshop on Aortic valve repair in India First of its kind Cardiac conference in India to be live webcasted all over the world First of its kind of conference to have wetlab for new and aspiring cardiac surgeons who get guidance from expert from the field of Aortic Surgery Video Launch of a very new techologically advanced Aortic sutureless valve in India Cardiothoracic & Vascular Surgeons Dr. Dhiren Shah +91-98255 75933 Dr. Dhaval Naik +91-90991 11133 Dr. Saurabh Jaiswal +91-95867 25827 Pediatric & Structural Surgeon Dr. Shaunak Shah +91-98250 44502 Vascular & Endovascular Surgeon Dr. Srujal Shah +91-91377 88088 Cardiac Anaesthetists Dr. Niren Bhavsar +91-98795 71917 Dr. Hiren Dholakia +91-95863 75818 Dr. Chintan Sheth +91-91732 04454 Thoracic & Thoracoscopic Surgeon Dr. Pranav Modi +91-99240 84700 Congratulations to Dr. Hemang Baxi and Dr. Vineet Sankhla for receiving the prestigious FESC (Fellowship of European Society of Cardiology) Award HOSPITAL CONGATULATES D. KEYU PAIKH AAPI GLOBAL LEADESHIP AWAD AT THE HANDS OF HONOABLE CHIEF MINISTE Hon ble Shri NAENDA MODI Dr. Hemang Baxi Dr. Vineet Sankhla www.indianheart.com 5
Healthy We bring in among the first in World adiotherapy Versa-HD (Elekta) in Asia Pacific Dr. Devang C. Bhavsar MD (M) +91-98253 74411 Consultant adiation Oncologist at Cancer Center. Associate Professor and post graduate teacher at Gujarat Cancer & esearch Center. One of the pioneers of Image Guided adiotherapy technique in India. Special interest in Neuro Oncology, Prostate Cancers & SS. Very active in social activities like cancer awareness camps. Linear Accelerator, Versa HD To complete its offer of a super multispecialty hospital, is proud to offer a new service, by introducing adiation Oncology Center. This upcoming set up is all geared up to be open to service by end of March 2014. Uniqueness of adiation Centre n First Versa HD Linear Accelerator by Elekta in Asia n Agility- High focus 160 leaf MLC, newly launched by Elekta n APEX DMLC - A High definition 2.5mm leaf width for brain tumors n First FFF mode treatment in Asia by Elekta n 3 times higher dose rate than any other normal Linac dose rate n Hexapod-6 dimensional motion correction by robotic couch n Minimize the treatment setup error by correcting 3 rotational & 3 transverse motions during the treatment. n Active Breathing Coordinator System q Exactly track the position of moving target like lung tumor because of breathing motion & reduce the dose to normal tissue. n 4D SYMMETY q SymmetryTM provides acquisition and in line reconstruction of 4D volumetric data, utilizing unique patented technology for sorting each projection image into a phase based bin. This sorting occurs by reviewing the moving anatomy within the projection images and calculating a respiratory trace directly from the internal anatomy Dr. Kinjal. Jani MD (M) +91-98255 76533 Consultant adiation Oncologist at Cancer Center. Gold medalist for subject ENT in MBBS. eceived the first rank award from Gujarat Cancer Society in 2005. One of the highest experience of Image Guided adiotherapy in India. Special interests in Head & Neck Oncology, Prostate Cancers & Breast Cancers. Very active in social activities like cancer awareness talks and camps. Equipped with the latest state-of-the art equipment and supported by highly qualified and dedicated oncologists, Care Institute of Medical Sciences is all set to become one of the desired destinations of cancer patients from across the country and specifically catering to the population of Western India. 6 www.indianheart.com
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