Open Heart or Pinhole?

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Novel therapies in the treatment of heart disease offer excellent options to open heart surgery. Dr. S. Manoj, Cardiologist, explains.
The only solution to heart disease need not always be the dreaded open heart surgery, with its accompanying pain, long scars, possibilities of infection, prolonged recuperation and so on. Radical progress in medicine now allows us to perform some of these procedures through a puncture the size of a pinhole.

Take Hypertrophic Cardiomyopathy (HCM) - HCM is a peculiar heart disease, where the muscles that form the heart chambers start thickening for no reason. This is a condition that appears in athletes or is seen to run in families. In a certain type of HCM, the muscle thickens so much that it obstructs the pumping of blood by the ventricle, by encroaching on the outlet space within the heart chamber.

Safer solution
Conventionally, patients with this type of HCM who have symptoms of repeated loss of consciousness, breathlessness etc., were subjected to Open Heart Surgery, where the Heart Surgeon slices off the extra thickness of the muscle (as seen in the picture) allowing the outlet space to be restored. This is a major heart surgery with considerable risk.

Now it is possible to achieve the same results without Open Heart Surgery. Through a ‘pinhole’ approach from the hand or leg, we use a 2mm balloon and inject < 1ml of absolute alcohol in a controlled manner. This chemical ablation dissolves the muscle thickness and restores the outflow space, relieving the symptoms. This is done under local anesthesia in a conscious patient with no stitches.

Pacing Therapy and Implantable Defibrillators in Heart Failure
The pinhole approach can also prevent the need for open heart surgery when it comes to heart implants like pacemakers and defibrillators. Miniaturization of these devices allow treatment to be delivered through a tiny incision. Now patients are happy to undergo these most advanced therapies with just local anaesthesia.

Keeping Pace
During heart failure, there is poor pumping efficiency of the ventricles – both in most cases, and also incoordinated contraction of the right and left ventricle, described as dyssynchrony. A Pacemaker – Biventricular (pacing both the ventricles) – or Heart failure device – is put in to remove this dyssynchrony and improve the pumping efficiency of the heart. This relieves symptoms of heart failure, improves physical activity and reduces requirement of medications.

Preventing Sudden Death
Another important cause of death in patients with heart failure is abnormal rhythm disorder of heart – ventricular tachycardia/ fibrillation. This could lead to sudden cardiac death. To prevent it we implant a device - Automatic Implantable Cardioverter / Defibrillator – AICD – that tracks each heartbeat and corrects abnormal rhythm by delivering shock therapy inside the heart. AICD has saved millions of lives and together with pacing therapy has helped buy time for patients awaiting heart transplants. Now, through the pinhole approach, both the Pacemaker and AICD are implanted under the skin below the left collarbone, and the electrical leads are introduced through the veins to be positioned inside the heart chambers.

Dr. S. Manoj, MD.DIP. NB., (GUMED) D.M., DIP. NB., (Cardio) MNAMS
Senior Consultant Cardiologist