Unlike old, demonetised notes that we left behind in 2016, some problems followed us into the New Year. Cardiovascular diseases (CVDs) continue to be a major source of death or impaired quality of life.
The World Health Organization estimates that CVDs account for a quarter of all adult deaths from non-communicable diseases in India.
The good news is that medical technology is striving to make interventions safer, simpler, and more convenient. From avoiding surgical incisions, to diagnosing tricky heart conditions and expanding the reach of life-saving interventions, here's a glimpse of a few potentially path-breaking technologies in heart health to watch out for in 2017.
THE PILL-SIZED PACEMAKER
For decades now, doctors have used pacemakers that simulate the heart's natural electrical pulsing process to correct slow or irregular heartbeats.
Conventional pacemakers have two main components: a "pulse generator" about as large as a tea bag stitched into a surgically-created "pocket" under the skin in the chest wall, and "leads" or wires that deliver the pulses, placed in the heart through an artery.
In an example of radical miniaturization, the new generation of pacemaker is less than 10 per cent of the size of the traditional one; imagine a large pill. It is compact, and integrated - yes, no leads. The doctor places it directly into the heart via a catheter (a straw-like tube) inserted through a vein in the groin area. (Think stents). Ergo: no incisions or scars. Launched globally in 2016, it is also available in India.
Studies have found that long-term lead and pocket-related complications occur in 8 per cent and 11 per cent respectively of traditional pacemaker implants within five years. The new pacemakers' leadless, integrated design addresses major causes of post-implant complications such as fractured/dislodged leads, and infections of the pocket. In global clinical trials of one brand, 95 per cent of patients had zero dislodgements and no systemic infections six months on.
Procedures are shorter, less painful and recovery quicker. It eliminates a key post-op discomfort for patients - keeping the left arm immobilized. There are no visible signs of an implant like the slight bulge at the pocket in case of the conventional pacemaker. The battery lasts 10-12 years, as long as a conventional pacemaker. They are also Magnetic Resonance Imaging (MRI)-compatible.
Leadless pacemakers are currently designed to pace only one heart chamber or 'ventricle.' They cannot be used on certain groups of patients (such as the morbidly obese), or patients who have an existing implanted cardiac device providing active cardiac therapy that may interfere with the sensing performance. Doctors used to conventional pacemakers will need to retrain in this procedure. And while they have cleared extensive clinical trials, their safety and performance has to be closely followed in surgical practice over several years.
AORTIC VALVE REPLACEMENT WITHOUT SURGERY
Any malfunction of the aorta, the human body's largest artery, can lead to life-threatening conditions. One such is aortic stenosis which results from excessive wear and tear of the aortic valve. This valve - located at the top of the heart's muscular pumping chamber - is meant to open and close to allow the uni-directional flow of blood from the heart to the body.
However, with age, disease, or calcium build-up, the valve stiffens or narrows and has trouble doing this. The heart has to work overtime and is gradually weakened. Symptoms such as breathlessness, dizziness, chest pain, fainting etc may result but not always in a pronounced way until the disease has progressed. Estimates suggest that half of those with severe symptoms may die within a year, if left untreated.
The solution for severe aortic stenosis is major open heart surgery. Doctors put the patient on a heart-lung bypass machine, cut the rib cage or breast bone to expose the heart and stitch on a new mechanical or tissue valve. This method effectively rules out those who are unable to withstand or recover from surgery such as seniors, those with an earlier bypass surgery, those considered high risk for open heart surgery etc. That's about 4.5 lakh or 30 per cent of the estimated 15 lakh severe aortic stenosis sufferers in India.
Such patients now have an option known as Transcatheter Aortic Valve Replacement (TAVR). Using a catheter, the doctor inserts a tiny, metal valve into the heart through a blood vessel. It expands and sits on top of the diseased valve and performs its function. Where open heart surgery would leave an eight to ten inch scar on the chest, in TAVR the catheter is inserted into a small incision in the leg, upper chest or shoulder. While the procedure is well-known, a more refined valve and delivery catheter for greater accuracy of placement and more effective functioning is now available here.
TAVR is only for those who are at high or extreme risk from open heart surgery. While conventional valves used in open heart surgery last an average of 12-15 years, more evidence on the long-term durability of TAVR will emerge going forward.
INSERTABLE CARDIAC MONITOR
Imagine a device that's one-third the size of AAA battery sitting near your heart and warning your doctor that it skipped several beats. Earlier, I described the world's smallest pacemaker. But how do you know when you need one at all? Doctors have a number of effective diagnosis tools at their disposal to diagnose irregular heartbeats known as arrhythmia. But there are times when arrhythmias are infrequent and evade capture. They go undiagnosed until they turn into something far worse, like stroke.
To pin down elusive arrhythmias, doctors implant a portable loop recorder also known as the insertable cardiac monitor (ICM) non-invasively into the heart. Conventional monitors are used to monitor arrhythmia on the spot in a clinic or over 24 to 48 hours. The ICM has a battery life of over 2 years allowing extended monitoring over several weeks and months.
While ICMs have been used for several years, the world's smallest one, measuring just one cubic centimetre, has recently become available. It is inserted under the skin and above the heart with an incision of less than one centimetre and wirelessly communicates with a patient monitor. This can be a potent preventive and early diagnosis tool. In the West, efforts are on to take the procedure out of the hospital and into a doctor's chamber to improve convenience and cut costs.
There's a lot more to look forward to in the coming years, from Bluetooth-enabled cardiac monitors, to drug-filled stents. More on that, some other day.
The World Health Organization estimates that CVDs account for a quarter of all adult deaths from non-communicable diseases in India.
The good news is that medical technology is striving to make interventions safer, simpler, and more convenient. From avoiding surgical incisions, to diagnosing tricky heart conditions and expanding the reach of life-saving interventions, here's a glimpse of a few potentially path-breaking technologies in heart health to watch out for in 2017.
THE PILL-SIZED PACEMAKER
For decades now, doctors have used pacemakers that simulate the heart's natural electrical pulsing process to correct slow or irregular heartbeats.
Conventional pacemakers have two main components: a "pulse generator" about as large as a tea bag stitched into a surgically-created "pocket" under the skin in the chest wall, and "leads" or wires that deliver the pulses, placed in the heart through an artery.
In an example of radical miniaturization, the new generation of pacemaker is less than 10 per cent of the size of the traditional one; imagine a large pill. It is compact, and integrated - yes, no leads. The doctor places it directly into the heart via a catheter (a straw-like tube) inserted through a vein in the groin area. (Think stents). Ergo: no incisions or scars. Launched globally in 2016, it is also available in India.
Studies have found that long-term lead and pocket-related complications occur in 8 per cent and 11 per cent respectively of traditional pacemaker implants within five years. The new pacemakers' leadless, integrated design addresses major causes of post-implant complications such as fractured/dislodged leads, and infections of the pocket. In global clinical trials of one brand, 95 per cent of patients had zero dislodgements and no systemic infections six months on.
Procedures are shorter, less painful and recovery quicker. It eliminates a key post-op discomfort for patients - keeping the left arm immobilized. There are no visible signs of an implant like the slight bulge at the pocket in case of the conventional pacemaker. The battery lasts 10-12 years, as long as a conventional pacemaker. They are also Magnetic Resonance Imaging (MRI)-compatible.
Leadless pacemakers are currently designed to pace only one heart chamber or 'ventricle.' They cannot be used on certain groups of patients (such as the morbidly obese), or patients who have an existing implanted cardiac device providing active cardiac therapy that may interfere with the sensing performance. Doctors used to conventional pacemakers will need to retrain in this procedure. And while they have cleared extensive clinical trials, their safety and performance has to be closely followed in surgical practice over several years.
AORTIC VALVE REPLACEMENT WITHOUT SURGERY
Any malfunction of the aorta, the human body's largest artery, can lead to life-threatening conditions. One such is aortic stenosis which results from excessive wear and tear of the aortic valve. This valve - located at the top of the heart's muscular pumping chamber - is meant to open and close to allow the uni-directional flow of blood from the heart to the body.
However, with age, disease, or calcium build-up, the valve stiffens or narrows and has trouble doing this. The heart has to work overtime and is gradually weakened. Symptoms such as breathlessness, dizziness, chest pain, fainting etc may result but not always in a pronounced way until the disease has progressed. Estimates suggest that half of those with severe symptoms may die within a year, if left untreated.
The solution for severe aortic stenosis is major open heart surgery. Doctors put the patient on a heart-lung bypass machine, cut the rib cage or breast bone to expose the heart and stitch on a new mechanical or tissue valve. This method effectively rules out those who are unable to withstand or recover from surgery such as seniors, those with an earlier bypass surgery, those considered high risk for open heart surgery etc. That's about 4.5 lakh or 30 per cent of the estimated 15 lakh severe aortic stenosis sufferers in India.
Such patients now have an option known as Transcatheter Aortic Valve Replacement (TAVR). Using a catheter, the doctor inserts a tiny, metal valve into the heart through a blood vessel. It expands and sits on top of the diseased valve and performs its function. Where open heart surgery would leave an eight to ten inch scar on the chest, in TAVR the catheter is inserted into a small incision in the leg, upper chest or shoulder. While the procedure is well-known, a more refined valve and delivery catheter for greater accuracy of placement and more effective functioning is now available here.
TAVR is only for those who are at high or extreme risk from open heart surgery. While conventional valves used in open heart surgery last an average of 12-15 years, more evidence on the long-term durability of TAVR will emerge going forward.
INSERTABLE CARDIAC MONITOR
Imagine a device that's one-third the size of AAA battery sitting near your heart and warning your doctor that it skipped several beats. Earlier, I described the world's smallest pacemaker. But how do you know when you need one at all? Doctors have a number of effective diagnosis tools at their disposal to diagnose irregular heartbeats known as arrhythmia. But there are times when arrhythmias are infrequent and evade capture. They go undiagnosed until they turn into something far worse, like stroke.
To pin down elusive arrhythmias, doctors implant a portable loop recorder also known as the insertable cardiac monitor (ICM) non-invasively into the heart. Conventional monitors are used to monitor arrhythmia on the spot in a clinic or over 24 to 48 hours. The ICM has a battery life of over 2 years allowing extended monitoring over several weeks and months.
While ICMs have been used for several years, the world's smallest one, measuring just one cubic centimetre, has recently become available. It is inserted under the skin and above the heart with an incision of less than one centimetre and wirelessly communicates with a patient monitor. This can be a potent preventive and early diagnosis tool. In the West, efforts are on to take the procedure out of the hospital and into a doctor's chamber to improve convenience and cut costs.
There's a lot more to look forward to in the coming years, from Bluetooth-enabled cardiac monitors, to drug-filled stents. More on that, some other day.