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Structural Heart Interventions – The new frontier in Interventional Cardiology

Structural Heart Interventions – The new frontier in Interventional Cardiology

Over the past few decades, major strides have been made in Interventional Cardiology. Coronary angiography, Balloon angioplasty and drug eluting stents were treatments offered for patients who would otherwise be treated with either medications or open-heart surgery. These therapies for patients with critical coronary artery disease and acute myocardial infarction were able to improve not just mortality but also led to improvement in the quality of life for the patients.

Over the past few years strides have been made in the field of structural heart intervention not just in the refinement of techniques but also novel devices. An example is transcatheter aortic valve replacement that has evolved from an innovative experimental approach for valve disease to a valuable therapeutical option patients with all risk profiles of patients with severe aortic stenosis.

Structural heart interventions can be broadly divided into valve replacements and valve repairs.

Transcatheter Aortic valve replacements/implantation (TAVR/TAVI)

Transcatheter Aortic valve replacements/implantation (TAVR/TAVI) has been the poster child of percutaneous structural heart interventions. Alan Cribier in France did the first balloon expandable valve for severe Aortic stenosis. In 2006, the first in man Self Expanding CoreValve was performed in our institution, Metro Hospital & Heart Institute. Since then this therapy has been used to treat thousands of patients across the world and is now considered to be the standard of care. The pivotal Partners B trial compared TAVR to medical therapy in inoperable extremely high-risk patients with Aortic Stenosis. TAVR demonstrated a 20% absolute risk reduction in those who received the transcatheter valve compared to medical therapy. This magnitude of mortality benefit rivals those of primary angioplasty in acute myocardial infarction.

Since then multiple trials have demonstrated benefit of the therapy across risk profiles including high risk, moderate risk and most recently low risk patients who would otherwise receive open surgical valve replacement. There has been considerable improvement in the device and procedure technique as well and now it is performed with a 14-16F sheath in the femoral artery that has resulted in significant reduction in procedural complications. Heart block requiring permanent pacemakers is another known complication, but with improvement in device design and implantation techniques this risk has also reduced significantly.

Most centers now do the procedure under conscious sedation and uncommonly use general anesthesia. A 14-16F sheath is placed in the right femoral artery. After predilation of the aortic valve, the prosthetic valve is advanced via this access site and deployed across the aortic valve(Fig 1a). The patient is observed in the CCU and discharged home in a few days.

Transcatheter Aortic valves can broadly be divided into Balloon expandable (picture 1b) and Self Expandable valves (Pic 1c). Both these valves are equally efficacious, and most procedures can be done with either types of valves. This therapy is also coming as a savior for patients with prosthetic valve stenosis, the treatment for which was a second open heart surgery. These subsets of patients are also being treated with TAVR with good outcome.

Mitral Clipping

Another landmark treatment has been in the space of mitral valve. Severe mitral regurgitation(MR) even in asymptomatic patients typically progresses to left ventricular dilatation, left ventricular failure, worsening MR, and eventual symptom onset and surgical therapy has traditionally been advocated to break this cycle. Surgical mitral valve repair has primarily been reserved for patients with suitable anatomy and performed in very few institutions. This is where catheter-based therapies have evolved.

Different transcatheter mitral valve repair techniques have been developed over the past few years addressing the leaflets, the mitral annulus, or the left ventricle. These techniques usually mimic well-known surgical techniques. The MitraClip (Picture 2) is the most commonly used catheter-based mitral valve repair technique. It mimics the surgical edge-to edge technique first described by Alfieri (pic 2b) and coworkers and creates a double orifice mitral valve.

EVEREST II trial, demonstrated in extremely high-risk patients, although MV surgery is superior to transcatheter MV repair using Mitraclip in reducing severity of MR, the clip reduces symptoms, produces durable reduction in MR, and promotes favorable reverse remodeling of the LV. Patient admissions were heart failure were also reduced because of this therapy. These clips are also used to treat tricuspid regurgitation. Newer and more novel devices including specialized mitral valves are being developed to treat mitral regurgitation.

In some cases of mitral stenosis specially with mitral annular calcification (MAC) who are ineligible for balloon valvuloplasty are not being treated with TAVR valve implanted. Small studies have shown encouraging results in these subsets of patients.

Left Atrial Appendage Occlusion

Atrial fibrillation is one of the most common arrythmia’s with its incidence increasing with age. This abnormal heart rhythm increases the risk of thromboembolism and strokes. To reduce this risk, patients require lifelong anticoagulation with warfarin or any of the newer anticoagulants. However, many patients either do not want to take anticoagulation or are unable to tolerate the same secondary to side effects like bleeding.

There are now devices that are used to plug the left atrial appendage (the most common site for thrombus formation in atrial fibrillation) and absolve the patient from taking lifelong anticoagulation. This has been widely accepted as an alternative for anticoagulation in patient who either do not wish or are unable to take the medication. One of the commonly used is “the watchman device”. This is a parachute-shaped, self-expanding device that closes the LAA (Fig 3a). A similar device is the “Amplatzer Plug device” that has a similar mechanism of action. These have been tested in several studies that showed the devices are a good alternative treatment for patients who cannot tolerate treatment with blood thinners.The procedure is done via the right femoral vein and after a trans-septal puncture into the left atrium, the device is deployed into the left atrial appendage.

Percutaneous interventions in structural heart diseases are emerging rapidly. There has been considerable innovation in this space and now able to offer treatment for diseases that otherwise had only medications. With advancement structural heart disease interventions it has emerged as an independent specialty catering to patients with various valvular and other structural conditions.

By,

Dr. Sameer Gupta , FACC, FSCAI

Consultant, Interventional Cardiology & Peripheral Intervention

Director, Cardiac Cath Lab, Metro Group of Hospitals,

(Limb Disease Specialist)

Diplomate, American Board of Internal Medicine
Diplomate, American Board of Cardiology
Diplomate, American Board of Interventional Cardiology
Diplomate, National Board of Echocardiography, USA
Diplomate, American Board of Vascular Medicine Endovascular Medicine



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We’ve got the best Anaesthetics and Critical Care experts coupled with latest anesthesia machines ensuring adequate gas mixture delivery to the patient, Anesthetic gas monitors who ensure extreme economy and negligible theatre pollution. The department has long experience of giving successful anaesthesia in various thoracic, vascular and congenital heart disease cases.

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Our Blood Bank is committed to provide high quality services by assuring the supply of safe and quality blood and its products to the patients. The blood bank adopts most modern technology and equipment. We’ve fully automatic ELISA processor, blood grouping and cross matching and blood component equipments. All the records and standard operative procedures (SOPs) are maintained and followed as per National and International standards.

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Department of Cardiology is headed by Padma Vibhushan & Dr. B C Roy National Awardee Dr. Purshotam Lal, a pioneer in Interventional Cardiology consisting of a team of highly qualified and skilled interventional Cardiologists. Under his leadership, the centre has grown into the most specialized centre for angiography and angioplasty.

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Metro Dental And Implant Centre has delivered millions of smiles over the years. The centre offers state-of-the-art dental services both through general out-patient and private OPD.

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The centre provides a holistic, scientific and a technologically advanced approach for all dermatological and cosmetic conditions. Consultations with our experienced dermatologists ensure that the patients get the best advice, be it for skin diseases or cosmetic interventions. Our specialized services include- Pimples / Acne – Pigmentation Treatment, Cosmetic Peels, Non-surgical removal of warts, Laser treatment, as more.

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Department of Endocrinology and Diabetes is a full-fledged facility involved in evaluating and treating patients for diabetes, Obesity, Sexual disorders, Hirsutism, PCOD, Osteoporosis, Adrenal disorders, other endocrine disorders. We offer a wide range of treatment options for endocrine and metabolic diseases. Our specialists are the most experienced one having a long track record of successful treatment of the patients.

ENT & Cochlear Implant

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We provide the complete diagnostic and treatment of disease and conditions associated with the ear, nose and throat. We are well experienced in treating everything from a basic disease to doing a complicated surgery involving Otolaryngologists, Audiologists, Speech-language pathologists and other medical professionals. Services include Endoscopic Sinus Surgery, Micro-Surgery of Ear, Cochlear Implant, Rhinoplasty, Head & Neck Surgeries, and more.

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Metro Centre for Liver & Digestive Diseases (Gastroenterology & GI Surgery) has combined medical and surgical department. The team of doctors has received super speciality training in their respective field which ensures high quality of care. The combined setup of Gastroenterology and GI Surgery allows quick assessment and treatment of the patient. Our surgical services include the performance of specialized and complex GI surgical procedures for the management of diseases of various parts of the GI tract.

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Clinical Haematology unit headed by very senior clinical haematologist . To support this, Metro Path Labs are well equipped and advanced labs to handle relevant investigations related to blood, lymphnode and spleen disorders like Leukemia, Thalassemia, multiple myeloma, etc. Routine procedures done here are Bone Marrow Aspiration, Bone Marrow Biopsy, Peripheral Smear Study, Reticulocyte count.

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The department aims at healing the person completely - body, mind, spirit, and emotions aimed at optimal health and wellness. This is achieved with the help of specialists and by gaining proper balance in life. Our specialists use all forms of healthcare ranging from conventional medication to alternative therapies, to treat a patient. Our doctors use the combinations of drugs and lifestyle modifications to address any condition.

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We bring you the convenience of getting quality homeopathic treatment for all your chronic and long standing illnesses. We are committed to provide you the best of the information and constitutional homeopathic treatment. Diseases Treated by Homoeopathy are Infectious Diseases, Viral Diseases, Diseases of Infancy and Childhood & Allergic Disorder.

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The Department of Internal Medicine is a full-fledged facility offering comprehensive care for general and preventive medicine for all ages. The Department has the support and back-up of all super-specialities in the hospital providing end to end services varying from diagnosis, prevention, treatment, wellness, preventive health checks, rehabilitation services and management of various medical conditions.

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A sub-speciality of Radiology is a subspecialty of radiology, providing minimally invasive treatments performed under guidance of x-ray fluoroscopy, ultrasound or computed tomography (CT Scan). In simple terms interventional radiologists “Not Just Diagnose But Treat too” with minimal invasive techniques. The advanced technology in Radiology provides a strong platform for efficient Interventional Radiological Procedures.

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Metro Centre for IVF is at the forefront of delivering quality services in the field of Assisted Reproductive Techniques like IVF-IUI, ICSI, Surrogacy, etc.

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A highly skilled team of medical professionals including physicians, medical technologists, medical technicians, lab assistants, biologists, chemist, microbiologists, geneticists, and other specialists work collaboratively to provide advanced diagnosis and laboratory services. Fully automated Robotic Arm, State-of-the-art BacT / Alert 3D Microbial Detection System etc. are among our top of the line technologies available.

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Metro Hospitals and Heart Institute is well equipped with latest technological advancements in general and laparoscopic surgery and the centre is boasted to an advanced centre for general and laparoscopic surgeries.

Nephrology & Renal Transplant

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Our department of nephrology and renal transplant is a well equipped unit with a dedicated team of skilled consultants and paramedical staff which offers patient the advantages of a multidisciplinary approach. Our center deals in treating children and adolescents with congenital and acquired kidney diseases. We accept patients at any stage of kidney disease. The services include Medical Management of Kidney Diseases, Dialysis and Renal Transplant.

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The Department of Neurosciences has extremely talented and very well trained doctors who collaboratively work towards creating new paradigms for knowing the human brain condition and caring for it. Facilities include NCV, EMG, EEG, Video EEG, Botox Therapy for migraine and movement disorders (dystonia), Dedicated Stroke ICU, Neuro Rehabilitation Advanced facilities for Surgical Neurology.

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A balanced diet provides complete balanced nutrition which is essential for a healthy life, enhancing the immunity of the person. The department consisting of expert dieticians provides Diet counseling according to the diagnosis of the patients, Diet counseling for different types of diseases like Diabetes, Liver diseases, Renal diseases, Diet related to pregnancy and lactation, Cardiac diseases, Weight management and many more.

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Metro Centre For Obstetrics And Gynaecology is determined to unite their exceptional medical competence, advanced technology and novelty to offer the best treatments to the patients. Our broad spectrum of services include painless deliveries, management of high risk pregnancies/late pregnancies, gynae laparoscopic procedures, gynae onco services, pre and post natal care, amongst others.

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We strive to create the best in class infrastructure, comprehensive facilities and render care and support by handholding every cancer patient in their journey. The management plan for each cancer is chalked out once the cancer is identified and staged. Treatment plan may include surgery, radiation and/or cancer medicine therapy. The team of Oncology Comprises of expert Medical Oncologists, Surgeons and Radiation Oncologists.

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The team of highly experienced Ophthalmologists in a modern set-up perform various services like Phacoemulsification (Sutureless Cataract Surgery), YAG laser (for after cataract and glaucoma), Green laser (for diabetic and retinal eye diseases), Automated Perimetry, (For Glaucoma and Neurological visual Field), Applanation Tonometry for Glaucoma, Glaucoma surgery, Squint Surgery, etc. The results of all procedures match the international standards.

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Metro Centre for Orthopaedics and Joint Replacements offers a wide range of treatment and comprehensive care for all kinds of musculo-skeletal conditions such as joint pain, spine pain, trauma, sports and other injuries. The Centre is well recognized for joint replacement surgeries of hip, knee and shoulder. The department is led by highly trained Orthopaedicians along with wide array of advanced technology. The Centre is specialized in providing services such as minimally invasive surgery, joint replacements, Orthopaedic Rehabilitation.

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Metro Centre for Paediatrics & Neonatology is a top-notch centre for childcare which provides comprehensive paediatric, surgical, and immunization services to children up. We follow a holistic approach to treatment with our Neonatal Intensive Care Unit, Paediatric Intensive Care Unit, Paediatric and Neonatal Emergency, etc.

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The services in Physiotherapy & Rehabilitation include Consultation, Diagnostic: examination, S D curve, muscle testing, ADL testing, Manual therapy: active/assisted/passive/resisted/graded resisted exercise etc., physiotherapeutic interventional procedures, (home care) etc., Obstetric, gynecological clinic: antenatal and post natal care, and other management, Geriatric clinic: help in ADL activity, pain free activity, Fitness clinic, Posture correction clinic, Ergonomics clinic, etc.

Plastic, Cosmetic & Reconstructive Surgery

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The department has highly experienced specialists in cosmetic and plastic surgery, state-of -the-art infrastructure ensuring world class medical attention and care. It is an acknowledgement center of excellence providing advanced and intricate treatment. The center also offers the world superior quality cosmetic treatment at costs that are highly affordable, with results comparable to those at the best centers across the globe.

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With the mission of spreading mental health awareness, we provide a variety of services ranging from awareness programmes to rehabilitations. The services provided are Pharmacotherapy, Electroconvulsive Therapy, Narcoanalysis, Biofeedback, Detoxification and Rehabilitation Programmes, Deaddiction Counseling, Stress Management, Couples/ Marital Counseling and many more.

Psychology

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We have a long experience in addressing the mental health conditions. Our experienced psychologists analyze the reasons behavioral disorder, emotional problem or psychiatric disease, and suggest and implement a valid solution to the problems customized to individual needs. The privacy of the patient is taken seriously during the total course of treatment.

Pulmonology & Sleep Medicine

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World-renowned specialists and comprehensive advanced setup helps treat disorders related to the lungs, breathing and sleep with high success rate. The services include treatment of Asthma, COPD, Chronic Respiratory Failure, Sleep Disorders, Interstitial Lung Diseses, Tumours and Cancers of the Lung and Chest, Allergic Disorders, Laparoscopic Assisted Thoracic Surgeries.

Radiology

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A highly skilled team of experience Radiologists and Technicians comprises our Radiology Team. The highly advanced technology combined with high expertise ensures 100% accurate results which helps build right diagnosis. The facilities include: CT Scan (500 Slice), Advanced MRI (1.5 Tesla), 4D Ultrasound, Digital X-Ray, Bone Densitometry, Colour Doppler.

Rheumatology

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Immensely qualified team of experts is always available to accord the diseases of musculoskeletal system. The service include the treatment of various auto immune diseases like Rheumatoid Arthritis, SLE, Ankylosing spondylosis, gout and other immunological diseases, New Biological Treatments. We do have 24*7 physiotherapy department which deal with musculoskeletal problems with special emphasis on the correction of joint deformity.

Stem Cell Therapy

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coming soon

Urology

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The Centre for Uro-Sciences boasts of experienced and renowned Urologists having thorough exposure to all urological disorders including complicated conditions. It is has good track record for high success rates. The treatment includes Laser prostatic surgery, Urologic Cancer Surgeries, Laparoscopic Urological Surgeries, Percutaneous Renal Surgery, Urethral Reconstructive Surgery, etc. and the facilities include ESWL (Extra corporeal shock wave Lithotripsy), Uroflowmetry, Uro Radio diagnosis, etc.

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