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Bypass Surgery v/s Stent

Nov 22 | 3:30 PM

Cardiovascular diseases (CVDs) are the leading cause of death throughout the world. 85% of these deaths were caused by a heart attack or a stroke. According to the findings of the Global Burden of Disease study, India has an age-standardized CVD death rate of 272 per 100,000 population, which is significantly higher than the global average of 235. CVDs strike Indians a decade earlier than the rest of the world. Let us hear more on the management of Chronic Ischemic Heart Disease from Dr. Vivek Jawali, a well-known cardiologist from Bangalore.

good evening everyone i am dr naveda and on behalf of metflix i welcome you all to today's session um today we have with us dr robert jacka he's a consultant physician and an intensivist at craft hospitals and ar medical center coaching so hello everyone good evening uh welcome to another interactive lively session which we have with one of the top cardiothoracic surgeons of india so today we have the topic of bypass versus tense before starting with that when it comes to cardiothoracic surgeons in india there are only a few experts who have mastered the field throughout time dr vivek zavali is one of one of the best cardiac cardiothoracic surgeons who have pioneered the minimusly invasive heart surgery in india with a success record of over 18 000 cardiothoracic surgeries he beholds the prestigious stack of pioneering the minimally invasive heart surgery in india with his first surgery in the year 1992 on a beating heart he went on to perform india's first awake earth heart surgery in the year 1999. he has 29 index papers book chapters 11 national orations and countless national and national guest lectures and live surgery demos to his credit both in india and abroad with a rich experience of more than 39 years and over 30 000 surgeries under his belt doctor vivix early is unquestionably india's best cardiac surgeon with a near perfect success record currently he is working as the chairman of cardiac sciences and the executive council of fortis hospitals bangalore he's also an executive council member association of cardio cardiovascular thoracic surgeons of asia founder member of international society of minimally invasive cardiac surgeons former vice president of indian college of cardiology and such names and laurels are innumerable under his name the one of the key roles which he's ever played is the sri jai deva institute of cardiology at bangalore in founding it then founding the workout hospital's bangalore he was one of the board of directors of vocad limited and now the photos hospitals he is the first in india to perform an off-pump beating heart bypass surgery in 1991 minimally invasive bypass surgery in 1995 minimally invasive cardiac wall surgery in 1996 awake non-incubated cardiac surgeries in 1999 being the world pioneer in it it's a great pleasure to introduce dr vivek zawali who is also recognized as the recipient of the harvard medical international's lifetime achievement award for medical excellence in india we welcome you sir on behalf of netflix and we welcome you to a lively talk and we are most delighted to listen to your words over to you sir thank you good evening to everybody and thank you for being here it's quite chilly in bangalore wearing a sweater it's very pleasant here today my endeavor is to talk to you not about strength versus bypass surgery what is the place in the treatment of coronary artery disease the disease that gives heart attacks of medicines of strengths and of bypass surgery and what are the confusions that are going on what is the hype and what is the reality of in this confusions so let's go with the next slide you know coronary artery disease plaque formation happens due to multiple factors risk factors some of them avoidable some of them modifiable some of them not modifiable whatever it is the plaque starts like this and slowly grows when it grows much bigger and then it can rupture it can give rise to heart attack that can cause bad heart failures or can kill can spoil life and spoil longevity and that is why some treatment is required a prevention which is quite possible that's why we have world heart day and we treatment treatment mostly it was all medicines and it was very simple treatment but then came bypass surgeries in the early 60s and it transformed the field so much that we had something new that could guarantee us and it's widespread and millions underwent by pasadena then for anything disruptions come and came the angioplasty balloon dilatation as a disruption by android grunzik in zurich in 1977 in september and that caught everybody's imagination it was such a simplistic approach to this whole problem and then any disruption is not good enough it will just stay there stagnated we had wired phone then we had the mobile phones non-wired phones we had offset printing then we got digital printing disruption but unless the disruption is followed by many sustaining technologies then it will evolve so after the angioplasty was championed by andre guzia then came the different wires different balloons those days they used to do only plain balloon dilatation a lot of times things would go wrong they would suddenly close rupture i had to come to the hospital in the night almost three to four times in a week it was bad times but then rapidly newer technologies came then there came stents the stents came in the mid 80s and they transformed all trouble stopped i stopped coming for emergencies and then the stains he walked wires evolved catheters evolved then came lot of new monitoring and imaging techniques like the intra arterial ultrasound and then all kind of imagings and so it whole thing got ocd whole thing got very sophisticated today where we are any block can be drilled through can be dilated and open and we can stand everything but the question is which block that you have drilled or dilated and could stand will remain open and the stent will not go so only those blocks in whom the stent will stay patent for years and years should be subjected for standing those which will not do like that should be subjected for bypasses because at the same speed it also has been extremely sophisticated in our hands today the bypass surgery risk factor in a straightforward case has almost come nearer to zero or 1.5 percent and in complex cases it could be looking more and more but then on average it's all below five percent in bad cases because we have so much of gadgetry today to do it properly now when the strengthens came and then it became an industry and the industry became rich then rich and very very rich industry lot of money started flowing in this area and then started all kind of you know insulation manipulation manipulation of science manipulation of guidelines manipulation of practices so then guidelines were important at that time in the beginning three important studies were launched the coronary artery surgery study big study across the world veteran hospital study in america and one more study for diabetes called the bari study all the studies showed that the bypass surgery was doing better but then the technology changed and so newer and newer studies kept coming and then guidelines were required the problem started because the company started interfering and there was too much of money in that and this graph rain graphs internal memory graphs had no money behind them so the guidelines politics was if you see in this slide esc's european society of cardiology in that guideline committee there are 46 cardiologists and one surgeon so they will have overwhelmed opinionated kind of thing and the guidelines will be hassled american acca 23 cardiologists only two surgeons the bcs the british cardiology eight cardiologists one surgeon so the whole overall recommendations were vitiated and hence there are the potential bias and that led to so much of confusion that people were overstating and it was not uncommon that they were eight strengths and nine states and seven states were very common those days and they all failed precipitously and it created a lot of buy and all the money was going to only couple of countries so many countries were buying these tents so came lot of trials all these trials were done on technologies which got changed because something new came on the horizon and that was the drug eluting stent the drug-eluting strengths were supposed to be extremely sophisticated and it was felt that now the bypass surgery should be stopped these strengths will never get blocked because they have got some chemical inside and that will completely be a game changer so the companies boldly came forward putting a lot of money and launched some very good astute trials to check out where you should be done where the state should be put thinking that everything will be stands and they probably put money so what happened at that time in this conference going on people had cheek to even present such cases for a scientific journal as high journal as the american college of cardiology and the journals had a cheek to publish it this is a case report of a patient who had undergone 67 stents in 10 years can you imagine what would happen in this patient so this this all this confusion had to be stopped so new age trials were launched the trials were two one was syntax trial which was a comparison between surgery and drug-relating stents and freedom trial which was a tribe specifically for diabetic patients where there is a inflammatory change and the changes may gallop and hence it was felt by an older study called body study that bypassed was better was it really true it challenged and so freedom trial was launched they were all astute very scholarly new age studies where we could not point finger at them and both of them were expensive because the drug company the drug eluting stent companies were putting money on them for example the syntax study costed 1.2 billion dollars it spread across usa canada and multiple centers in europe and so all top people were you know participating this study so also was the freedom trial so this was supposed to throw us a light where all the controversies should stop a person who has got a straightforward single disease which is nice there is no controversy a person out of the three artists or two artillery disease which are again tight and short and nice there is no controversy these people will do damn well i have got relatives who have been stented in 90s and doing so well today then came another important indication that people who have got chest pain you take ecd and there is a heart attack starting and this heart attack guys are quickly taken nebulous the hospital and in the first three hours they are angiogram block is seen which arteries causing the heart attack is seen if that heart attack that that block is dilated and stented there is a miracle the whole damage to that heart muscle comes back and you you get a heart which is which is new like before so today this has come like a god's gift to mankind the emergency angioplasty instantly and those people who have any doubt in mind no this is the best that has happened to cardiology so we are coming back again to people who have got multiple artery disease or the left main there are three arteries left front left back right left anterior descending coronary artery circumflex artery left back and the right coronary artery the left two arteries arise as a single artery left main one and a half centimeter a block there can be very dangerous and it can cause instantaneous death so they have started this big mahabharata these big two studies were launched these studies before i talk about them you must know certain terms in medicine in research mess means major adverse cardiac events when you add another c to that mace is made major adverse cardiac events plus a stroke cerebral event repeat reversalization means i put a stand already bypass it failed and i have to do some other procedure again repeat revascularization if you have to do again and repeat investigation your first time procedure is not good and so you must straighten your indications whom should whom i should do what and also power of trial if somebody has done a trial and has presented that paper that trial should have a big size the end point should be still clear there are certain characters so that paper should be type a paper class one and other papers we should really human importance when we talk about the classes of recommendations guideline and we recommend by the government by a body by a scientific body by a hospital class one means evidence and or general agreement that given treatment or procedure is beneficial useful and effective no debate all other things are below that class two class three and all that that that class one or two can be class 1 a b c so what is class 1 a a means there is class 1 a means there is no debate no controversy it is an absolute guideline absolute directive this syntax trial did something very disruptive they brought in a scoring system previously we were not scoring and we were trying to like foolishly compare apple to oranges and all scientific outcomes were all you know dogmatic now syntax trial brought in a concept that you will see an angiogram and you will give you know points and scores for all clinical characteristics somebody's diabetes some of these facts something renal problem etc etc then how this block looks like and that also we are given points and the scoring when the when this trial was done they realized that anybody who has got a score of less than 22 angioplasty will do very good hands down those who had score of 22 to 33 we could debate anyway anybody who had a score of 33 and more there was no doubt they should be subjected to bypass surgery come to india come to japan come to china we are tiny guys small coronary arteries we have lots of diabetes lots of smoking we tend to have more diffused disease and there most of the time the syntax four is thirty three another this was the importance of syndra so after the syntax scoring was born any research any decision making it is syntax scoring so the now life is pre syntax scoring and post syntax scoring now when the syntax trial was done it was done under at many centers in a cooperative fashion at a large number of patients the first year showed that surgery for multiversal disease is one hands down so it came in new york times reader digest as a lay press news flash that whatever you are thinking is wrong the surgery is better for multivital disease and don't get carried away but hey this was only one year and in such a short time how can we make a decision like that after some time the graphs will go so we said the syntax trial said that wait for five years every year we publish results and at that five year we can have some dude panic so first year it was winning then came this was like a news flash in new york times then came the the third year the third year also the yellow line is the stents and the blue line is bypass surgery by passage was far better the problems happened much less problems happened much more and statistically there is a wide gap wide significance no but three years is not the case so i will i will pardon you from all that fourth year also the same story again surgery was winning so then a lot of grumbling started and the company started getting nervous because they had put so much of money and it was going against them so they said the syntax scoring is faulty then this journal landsat published another dramatic new concept corrected syntax scoring and it was called as syntax core two but the the the the the the funny paradox was actually syntax score showed that the in tax score one was showing low syntax scoring and what was 23 now it would be 28 in the syntax score so actually many more patients should have been for surgery then came the fifth year fifth years in tax score of intermediate 23 to 32 here also surgery was winning then the yellow line is the extents direct elite extents blue line is surgery then oh this is intermediate let us see what happens to the higher score higher was absolutely no debate hands down surgery was far better now this was a very astute study but then the problem is it doesn't suit a lot of people and the grumbling started all intelligent talking started we see all around us in politics all kind of internet talking same way in science so more and more studies were launched but anyway syntax trial whatever people talk the truth of the matter is this was an important study and surgery was shown to be far superior and a lot of doubts were created the physicians who are the first place where the patients go they must know about all these general practitioners must know about all this all this data is on the internet we shall not be talking today about a small time fly by night studies these are all class one studies class one guidelines these are all top unrefutable evidences we're not talking about anything that is not very important now freedom trial freedom trial was a strategy for multivessel revasculation in patients with diabetes is one happy journal called new england journal of medicine which is published from the harvard campus and it's a very respected journal with this journal is actually it is cynical towards surgeon but this journal published this paper this guideline this trial and the trial concluded that for patients with diabetes and advanced coronary disease bypass surgery was superior to angioplasties pci means for percutaneous interventions it was superior to the stems that it significantly reduced rates of death and peri-procedural heart attacks myocardial infarction means heart attacks now that was another blow then the the um journal of american college of cardiology it is one of the top journals in cardiology they the foundation of the journal launched the study they said no there's so much of dissatisfaction going on google stanches this study was called appropriateness criteria for coronary revascularization and was sponsored by american college of cardiology foundation and it assembled experts to create 180 different clinical units to represent a cross-section of contemporary practices as encountered by working cardiovascular surgeons for two three vessel diseases and then the shock in this was again if you look at by this side it is bypass surgery if you look at that side it is the stance green a is appropriate u yellow is uncertain and i read is inappropriate and if you look at different cohorts all the way you can see that it is favoring bypass surgery bigger than the european union which was really under recession the strengths were causing it's all social medicine there it's not like india where everybody puts their hand in pocket it's all private government washed his hands off no in europe everything is social medicine from germany italy everywhere and the governments were under a lot of pressure so they said let's have our own guidelines so joint european society of cardiology and european association of cardiothoracic surgery guidelines blow this guideline show this side surgery that side is strands and different cohorts if you eyeball the slides for favoring bypass surgery class 1 a one a one a one a m a all the way except that one vessel disease or two vessel disease where the left front artery proximally is not so much involved the left front artery supplies two third of the left ventricle so it can kill the left back artery supplies left ventricle but little bit and the right corner actually supplies the weaker right right heart look at this european guidelines now this was all based on syntax scoring okay so anybody who had more than 22 score the european union said that this is the recommendation now this was all very confusing most of the general practitioners most of the physicians like my friend here many of them don't get to see these slides because most of the time the talks are given not by surgeons but by physicians many many slides are actually prepared by the companies and given ready made so people save the trouble but then the fine print is many of the slides will be preferred by convenience but people are too intelligent and the presentations can be very ingenious so credo kyoto guidelines from japan japan at the total university putting at the center those different sports country the numbers are small whole japan will do bypass surgeries like my 140th hospital so august 2011 this many patients were enrolled in 26 centers of japan all the data was mined in the kyoto and the guidelines were churned out the guidelines were same as the european guidelines that i just now showed you but surprisingly it showed better outcomes with bypass surgery even in the lows in tax course less than 22 which was extremely surprising now another big then came the american college of cardiology and american heart association these two societies have globally a membership of 23 000 catalysts and surgeons these are our top cream of this world and every two three years to three years these people unanimously put a body called as the task force and the task force microphones the the contemporary literature scientific literature and gives certain guidelines which are sacrosanct and then as technology changed again after three years they would come up with newer guidelines and they are presented in annual conference i will spare you all these complicated scientific wordings but what is class 1a what is class 1 b or c but in this it is bald part in this diagram again green y is yes definitely and n is no and c is borderline now if you can look at why this side is coronary bypass surgery and the other side is drug eluting stents and then again if you look through it it is uh definitely leaning towards surgery now there were too many papers coming too many papers coming too many people challenging all these big papers big guidelines and in literature today i can defend anything even to a judge in the court so things have become very murky hard team and things synthetic scoring the problem is everything is pre-syntax coding after syntax scoring but if i get any any angiography report from anywhere in india even from the big astute uh institutions which are academic institutions where there are dime a dozen pieces running around enough manpower unlike a private hospital i hardly ever get to see that what is the syntax of that patient people will tell thousand reasons but i is difficult for me to buy that now is it is cumbersome it's time consuming all are too busy it's a it's a whole process no today there is a software on it what about institutional guidelines even they are not some big institutions there's a forties there is money there is nothing these people have got multiple hospitals across india they could put institutional guidelines and everybody should shut up and follow the guidance no we don't have those guidelines then what about teaching institutions with large number of pgs and residents you know heavy ones like pgi ames jaydeva vijams chitra we don't see syntax course in the reports then all that frost started people are not happy and people went on with their life like that and controversy is raging and everybody's unhappy the people who are sending cases referring cases are mostly physicians and gps they are harassed they are confused they don't know who's correct so they will prefer to take two opinions one from surgeon one from cardiologist then came another important study which shook everybody it was called as the excel trial an excel trial said that the leftman artery block because we know when a strength is put and the strength gets plotted there could be catastrophe but it's all right in small arteries people were strengthening left main after the syntax trial and syntax style was all very permanently misquoted there are clear-cut guidelines whom stents will do very well over years and years i have so many questions i see so many years 20 years good pattern strengths emergencies fantastic work but not for multivessel disease now this left main people started putting left and right strength even complex left-wing blocks an excel trial encouraged that and then there was a guy called david tagart david tagart is the chairman at oxford university hospital and he is a very scholarly guy very outspoken guy and that guy was so annoyed because everything was being manipulated and he walked out of the track and then walking out of the trial made a huge news on bbc and the bbc news came punch guardian everybody started making noise so escts european association of cardiothoracic surgeon because david made a noise the european association pulled out of this left main guideline of this excel trial cover after the bbc bombshell and the bbc report also raises the question of whether potential conflicts of interest in excel trial influenced how the study was reported in that the study was funded by abort vascular the company which making stands and that many of the trials have received funding from the stand manufacturers the other principal investigators also were questionable because they received funding from medtronic which is another big company making sense so excel trial was thrown into bin by the whole world then came a study called the noble study and it was it was had a nice five years of follow-up it gave a new data on this left-wing business and this paper adds product to the controversy dogging this excel trial and it said that excel trial was not right and the guidelines given by noble trial favored leftman cardinality disease this was 2019 then this year every year there is a conference that happens globally is the biggest trend conference it's called as a tcp the tct conference this year this presentation came up it was called as the fame three study and the frames three study was awaited badly like the syntax trial it was supposed to give because even the regulations then change they got more sophisticated everybody thought that the world post has now changed and now we will have some different news that all these multiversal diseases could be routinely four or five strains can be justified and then this cct it was presented and at the same time this new england journal of medicine is a heavy journal this study was published in this church and in patients with more complex that is multiple blocks in these three arteries severe blocks bypass surgery remained the treatment of choice conclude dr faram who is the professor of medicine and director of interventional cardiology at the stanford university and school of medicine at stanford and the chief of cadaver who was heading this study and even the famed free study this year came out with a term called double negative and so now this is kind of a verdict of 2021 but the problem is nobody is getting satisfied because there's so much of stakes for all the industry and too many people involved in that but these are all solid evidences i'm starting from the beginning of the history throughout all the changing workforce throughout all changing technologies to 2021. i'm showing you some angiograms those what doctors here would appreciate these are all angiograms of patients all of them are on average more than 12 to 13 years after surgery the first diagram you see here is a patient who has got a left and right internal memory y it looks like a normal angiogram of a normal patient no all original arteries are blocked stable and they are all bypassed by this double inter-memory artillery grafting and it is doing so well we all know in in cardiology cardiac surgery general medicine that once intra memory art is doing well for few years it is unlikely to get blocked forever and so graft like that is fantastically lumbaris it will go on patient has to be disciplined follow-up should be good doctor should be very careful to follow that guy's diabetes should be well managed blood pressure should be well managed he should have some discipline of his lifestyle the second the top one radial artery from the hand in the beginning the reality will abuse everybody no it's not good cheating no today now there's a lot of evidence and this is my case looks at smooth arterial graft this is 16 years posed by passage and it is this artery is bypassing two coronary arteries down below and the last one is a gastropar epilic artery from the abdomen from the stomach brought through the diaphragm to the right coronary artery again viable after 14 years these arterial grafts will never get blocked now a problem unlike stents where it's very mechanical in surgery there are too many variables but the worst variable is the surgeon himself a good surgeon not so good surgeon can be a variable so very difficult to pick up you know the astute studies like instantly there was this guy gersh he is the chair of myocardial cardiology in new england journal of medicine again i am including new engineers this is a very respectable journal that angioplasty treats isolated lesions in the proximal early vessel and bypass surgery bypasses that proximal vessel the early vessel and its by and the graft ends up in the later part of the vessel all the newer disease will happen in the early part of the basin so this advantage of bypass will never go then what are the indications then whom do we put stents at whom do we put bypasses american heart association and american college of cardiology recommendations can be better recommendations because they are a big body and also uh though their companies are all there but there is a task force of that country left wing which is this which is not discrete very early in the beginning of the body it can still be stented but later part of the body complex no it has to be surgery all the three arteries are blocked and the blocks are quite strong and also there has been a heart attack before and the left ventricle is not so good there is no question at all they have to be bypassed but even if the left ventricle is good and those blocks are bad everywhere no they should be bypassed if the diffu so for that there comes the controversy so if you do a syntax scoring the controversy will go then diffuse double muscle disease involving proximal left front artery and lv is little poor then again it must and should bypass surgery but again if the left ventricle is not that bad look at the syntax code and then there is a left front artery disease where a bipod where a heart attack can be killing an attack and it is not stained table then by passage now in our country what happens is hardly anybody is insured everybody is putting hand in their pocket most of the people are poor if they get a major expenditure because of a problem and they want doing the procedures again again in their life they will go into something called as a financial shock like a health check so we feel that there should be a lower trigger for doing biopsy rather than stenting for patients who are non-reimbursed this is the first time it's my sentence till now i was only talking about heavy weight evidences then so it is a good idea to do bypass surgery in multiversal coronary disease rather than putting multiple stems whether our patients like in karataka whether they're in bangalore or they're in a small place like biru large number of them pay out of pocket they are not insured repeated reimbursements are unlikely even in the reimbursed patients then their reimbursement bodies will start playing politics with them they who wants to bleed then in time effective primary angioplasty so people say that you will do one stand now we'll wait we'll see later on but suddenly happens then the correct treatment is to do an urgent emergency standard golden hour golden hour doesn't happen in big cities because of traffic and in smaller town because of facilities indecisiveness lack of finances then it may also this kind of thing we are unnecessarily putting stands can put the hospitals on back foot with the pairs like the the insurance companies corporates who are paying for their employees public sector companies are paying for like armies etc you know everybody will start raising so this is an embarrassing situation this editorial in important journal again new england journal of medicine said that publication is generally balanced the syntax trial publication was generally balanced and it calls for separating the diagnosis making the angiography and the treatment decision should be different and there should be a meeting of everybody it doesn't happen it's not realistic so most probably all the referring doctors should take two opinions surgeons and cardiologists and that is what the guidelines in social media countries like italy france are doing that there are government jio's that you better take the surgeon's opinion also and don't allow a self-referent then this editorial in uh another important journal the journal of thoracic and cardiac surgery is the most respected journal and this article summarized that despite of these findings it is apparent that their translation into practice is being heavily influenced by various stakeholders whose belief systems are unfulfilled by this staggering evidence the purpose of this editorial is to clarify the body of this evidence as it exists today so that all the stakeholders are held accountable to the primary stakeholder that is our patient the last this journal of thoracic and cardiac surgeon again this heavy journal another editorial written by david tagart who walked out of the excel trial who is the chair for the oxford university active hospital there are three points from that from that editorial a the cardiologist is the gatekeeper the physician and this may produce a conflict of interest in terms of self-reference which is not a very nice thing the disingenuous presentation and inappropriate application of results of randomized trials in highly select atypical groups to the whole population again can mislead you third the result of what happens when evidenced bids based medicine is challenged by a multi-billion dollar industry so that is all about the evidence that is all about in multiverse disease coronary artery surgery should be done however painful it may look however you don't want it you will end up there today we do a lot of bipolar surgeries in my 240s hospital bangalore most of the patients almost all i have got a block stand and then i'm doing a bypass surgery now there are papers after papers that if you are doing bypass surgery after multiple block stents the bypasses you will be more risky and it will not be the same viper surgery like a fresh backpack surgery now we will forget all that and i will just quickly educate you on some higher things in microsurgery that people are doing now now because of the multiple hypothesis tendings what patients we are getting now have got diffuse disease and our ongoing uh symptoms and they may they are threatened to get a heart attack so we have to do something so there is to be a procedure called as the [Music] segment from the inside the artery and then clear the artery and then put the graft people used to this the video operative video will show you how i am doing a coronary endarterectomy at the lateral aspect of the heart from an obtuse marginal branch of a circumflex artery i am doing this bypass surgery using a left and right internal memory y graft and a side to side anastomosis of the right inframammary artery while limb is going on the obtuse marginal branch of the circumference artery which is completely severely diseased and requires enough victim but whichever artery i might do an endotrichterm it will be very much the same the endotrichter me could be done like this as you see in this video which is common or it could be a complete opening that me where i lay open the entire artery and gently remove the whole plaque that's easier but closure grafting will take a very long time i prefer this as long as if it is possible percent time distally the plaque might break and i may have to make another incision and extract the rest of the plaque in the same manner important thing is note that i am not pulling the plug i am trying to just hold the platform and push the heart away from the block push the heart away from the block sometimes the block is stuck i might tease it holding the epicardium in the forsaken and and and and free that adhesion or sometimes i could pass a thin olive tipped probe and free it up thank you so there i was doing it y on the side of the heart the circumference obtuse marginal branch i was doing the inductive any artery we can do inductively long and these papers i'll show you two papers it shows this was a 101 patients endart rectum is done for diffuse coronary artery disease and it showed that there was excellent long-term result the problem about such procedure is the surgery should be well trained the another was all the patients were subjected to angiogram at the end of one year they were all studied and again is an excellent result so well done endotracheal otherwise this patient we have to say we can't do anything how long it lasts it lasts and we will treat you medically but that's not the issue there are things that we can do today then this our original article japanese article tells so that when we do that kind of pouring out whatever is left in the bottom of that of that artery inside will regenerate and form new smooth muscles and form a nice new inner lining within a very short time and a new lumen would be formed the surgeon has done a good job they then this controversy the problem over minimally invasive bypass surgery keyhole by pasta too many people are talking about it we were the pioneers in india in 1994 of september between the asian and australian continents we did the first minimally invasive bypass surgery in bangalore on the cunningham road and then since then uh we have come a long way at that time we were the monkeys with the hammer in the hand and everything looked like a nail we quickly did many many cases but then we realized that uh anyway i when we realized that no this was not for multivessel this is only for couple of front vessels and we stuck to that then came these two important papers which showed that if you can do minimalism surgery with less mobility less blood loss and internal mammary artery properly it can be superior to stenting that artery but that is debatable but there are these two solid papers that i am showing you one and two about 2014 and another paper was so there again there is a proof that properly done into the mammary artery can beat any stent and that is quite you know appealing to common sense so came metronic company and they brought certain devices by which we could graft multiple arteries through a minimally invasive bypass surgery now most of the bypasses in india we are doing beating heart without heartland machine i was the beginner i was the pioneer in 1990s uh in 1990 91 but then even today this debate goes on that can you do fantastic good anastomosis of the arteries by beating heart vapour surgery most of the western countries europe and the north america are challenging that and majority surgeons there should continue to stop the heart have the heart on by and hurtling machine cardioply just stop the heart and do the surgery in an ancient way we are doing it without all that on beating hard but then that is still being challenged when we do the same beating herself through a small keyhole and try to bypass grafts all around that doubt that debate that long-term result will be as good is yet to be proven so in our practice we are sticking to the front graphs which are easy which with which our hands are lubricated for minimally invasive about 25-30 patients and all other patients we will do properly with open synonymy you must understand whatever does outside whether like these are like this inside operation is same and inside what is important is your anastomosis joining should be excellent and the uh every vessel that is blocked should be covered should be grafted if that is not done through a cure surgery then you have done something wrong and also cosmetic is not the bottom line for women yes we will bend backwards for a man it's called a hairy chest so cosmesis is not the thing there's a guy called dr mcgee who is one of the top in this area i was having a conversation in bangalore when he had come to do a lecture with us i asked him that you went quite gung-ho on this and why were you so charmed by that but he was very frank he said i came to new york which where the quality of competition is so high and i had to do something one up and i started that but patient that's not a problem for patient that may be problem for us surgeons so this area is still to have a lot of froth to yet settle down there are people who have been doing half sternum cut and calling it meets many minimally invasive surgery know that we are not amused by that because blood loss would be the same pain may be little more because the bone is cut in a crooked fashion so it may look good to look at but for a man it's all hairs and for women it will go inside even a bikini so we have been doing this called abdominal bypass surgery where we go behind the surname and i will not waste your time on that i will not waste time on all this then another thing is about robotic bypass surgery the robot came da vinci from texas for cardiac surgery and we quickly realized it was not useful the learning curve was too steep it was dangerous for the patient apart from the cost so but then the other speciality is very quick to understand its potential urology onco surgery gynecology today in my hospital bananagata road fortis hospital almost every day in my next theater robotic theater at least three robotic surgeries happen but they are not cardiac cardia we can do but it's going to be me too we still today don't know the asd closure oh it can be done properly but then we can also do all my all my colleagues do it with such a small incident we can take down the internal memory arteries and then make a smaller incision and do the minimal energy bypass theory but that we can do with a simple endoscope so mitral wall repair or that could be potential because here you get a 3d vision and the depth perception is very nice but the learning curve is very steep that is why this in this whole huge india which has got few thousand surgeons who are advanced who are well accomplished hardly couple of them are doing routinely robotic surgery robotic surgery could be a magnificent branding and marketing tool for the hospital it is yet to establish itself as a good tool alternative to off-pump full synonymy surgery or even the minimally invasive surgery and tell with surety that we will give you graft quality in long term as good as this no that is a very fat question mark then we have the next group and next set yes so we talked about evidence strength versus bypass surgery for multiversal disease it has to be bypass surgery now look at this video can we have this video in this video i'm showing you what happens if there is a heart attack how the scarred tissue we go on dilating you show the video please [Music] [Music] so this video showed that when there is a scar of a heart attack the muscle tissue is dead and scarred the pressure inside will keep on dilating that and over a bit of time the heart will become large it will become dumbbell shaped its shape will be lost its size will be big and the output will reduce and the people will go into heart failure a sluggish area will develop a clot the clot pieces can go to the brain and cause a major paralysis the the heart valves will get dilated displaced and distorted and the leak will start if the viral leak starts then more volume overload and the heart will become a bigger football so if a patient comes after a heart attack and if his size and is distorted valve is leaking just doing bypass surgery also is not enough so the referring doctor must see on the echo in his town is there a significant miter bar leak then he must ask the surgeon to repair the leak if the the heart is unreasonable in one side he should ask the surgeon to do repair of that i okay now can we show these videos oh yes sir you can see pre-operative and post operative how i repair the heart what we were seeing in that that first video was completely distorted dumbbell shaped lost his size lost its shape and in the second video i showed there a wire scene i showed that post openly how nice it became spindle shaped blade shape size and shape had come back all those things can be done not a very high hanging fruit and it's done quite often by us so that has to be done then this shows you studies which shows that it is very effective there were some papers which challenged that but then this study showed that it was those papers were really half baked they could not do a good job and the people who are experienced they could actually show such different results so that stays no need of video i am just talking to them about it and the valve is leaking then it is very easy to repair that leak we divide the leak as mild moderate or severe and you can see it on the echo very easily within couple of minutes if the leak is severe this patient will have limited lifespan later on he will keep on coming back with heart failure spend a lot of money die bad so after doing bypass surgeries we must repair that valve it's very easy we have what de formed reformed geometrically designed means we measure that valve put the ring inside and once the ring is put all the the leak will go junior most person in my team can actually do this repair so this also the referring doctor must remember then this so this study shows you that after a particular red line if you allow this mitral leak to be there then death will come faster heart failures will start badly many people will have blockages like the coronary artery into the carotid artery which supplies the blood to the brain any patient who has got triple vessel disease he has a 33 percent chance of having a block in the coronary arteries diagnosis is very simple no money all we do is put a stethoscope put it on the neck and you will hear a very harsh arrogant murmuring sound there and then we get a study done of scan and the scan will show how tight is the block how is the block at satisfied the block is tied patiently getting symptoms and we drew a bypassing because there are blocks then they will get stroke and they will get paralysis so for this kind of patients we do the bypass surgery and the carotid endotherectomy clearing that the block together there are a lot of studies which show that you better do surgery and not stand there and that there is absolutely no much debate on that so this picture shows you that after removing the block i take the vein from the leg and a small piece of that and i put it on that that area where i incised and make the artery bigger and then this will be a long lasting solution for that this paper shows you that endar treatment operation is far superior any which way you look at even the cost wise it is almost three times less than the stenting the paper shows the operation is better today we can do all kinds of things look at this this this is a scan this guy i won't tell his name he's the chairman now he's a minister you are the chairman of the team nigerian tv now he's a minister he came with a bad heart with a after a heart attack required five grafts he would require introverted brain pump because the heart was poor we did screening pre-operatively and we found there was a tumor in the liver we did a neural biopsy this was a cancer we did a pet scan there were no secondaries anywhere we did bypass surgery with the same incision going like a l and also did the tumor removal partial hepatectomy in the same city seventh day he was discharged he did extremely well we do this kind of thing very often and he is still doing very well and he has climbed in his career this you can see a huge incision and all that so we have come a long way you can stand anything you can bypass anything but then there has to be very clear-cut indications and create clear-cut guidelines so thank you very much for attending this session and then we could now get back to dr rohit and open this session for discussion and questions etc thank you thank you so much sir it was really a very wonderful session and uh very enlightening videos uh it actually gave a good idea good outlook because the thing is when we practice uh as patients come to our clinic with just an mi or something we usually have just one plan referred to a cardiologist we never knew that there were so many sides to the same story so uh it today information is at the click of a button and that's why everybody should keep abreast and that's why yeah that's really nice so uh we'll just take up the questions what is the best time for non-cardiac surgery so somebody has got a police technique to be done somebody has gotta have very senior physician of bangalore today who is in renal failure on dialysis he has to go to coaching because that is where he's enrolled back for transplant i would say anywhere between one to two months but surgeries like thyroid gallbladder stones or any surgeries we could actually do simultaneously under the same anesthesia why because a the patient require only once suffer only once money spent will be less relatives will suffer only once so many of them we do in the same city but if they have to be spread spread it over after month so there's one question uh what's your opinion about edta chelation therapy for coronary artery disease whether it can be ruled as ruled used as an adjunct or alternative to capture stenting or is there any much on that i will answer in a very simple way that there are top hospitals in bangalore bombay cochin which hospital is offering chiles and therapy and if the children therapy is done in dingy flats in smaller towns that summarizes the answer next question so what is the role of a ct coronary calcium score in assessing coronary attributes excellent question see today was death lot of young celebrity death has raised the question that how do you diagnose early pune had a tremendous family history his eldest brother raghvendra came to us when he was just 23 years old with an anterior or heart attack clean cut guy no habits daily huge dance practice a lot of yoga father was a very disciplined he had instilled fantastic discipline in his children but 23 years old and heart attack then after him came dr raj kumar the father and he was operation for long many years but he was extremely extraordinarily disciplined person he survived very well died of some other cause had this problem or not surprising so if somebody has a family history you should wake up 35 parties over little discipline of food etcetera etcetera but then start doing annual checks at least three years tmt treadmill test shows any doubtful problems or symptoms strong family history but normal treadmill don't respect the training and then you must get invasive further just because you have no huge evidence to do a uh do an angiogram do a calcium if calcium scoring is significant then you must proceed further and that calcium scoring is very silly very simple most of the cardiologists can do it very far for you so and also look at other risk factors your low density lipids which are the bad they should be nice your amount your apple lipoprotein i mean lipoprotein a if it is not normal again that is a bad thing homosystem for young people all these are indicators you are your inflammatory markers all these are indicators so this is how you look at it holistically not just take one parameter but the bottom line is if you are having family history if there are any other risk factors then you go checking once in at least a couple of years yeah that's true so actually in mumbai also there was one famous doctor called dr rakesh sinha so he was the holding the guineas world record for removing the largest uterine fibroid and he went for a marathon and he collapsed and he expired immediately so see sudden cardiac death also people should understand it can be due to so many things brain hemorrhages probes these that and the heart the communist is you know arrhythmias there's a thing called wpw syndrome will focus on white syndrome very common in young people can use sudden death many times the coroners have abnormality there could be a bad tense muscular bridge on the left hand sleep on the artery that should be diagnosed sometimes the left anterior decision coronary artery could arise from the pulmonary artery and all hypertrophic cardiomyopathy there are many other rare diseases however stenosis so these people will fall on a football ground get a symbol in the er people should have high suspicion and most of the cardiologists are knowing this you know there is a set pattern and the cardinals will just pick them up like that but the important thing is to consult right uh sir next question uh please elucidate in total arterial graft capg is it superior to conventional svg can a patient go for total total arterial graft and reduce abg see the total article that word has created a lot of fancy in bombay i had some seniors who kept on doing any patient comes bilateral memory whether it's a usually independent diabetes is a fat guy he's got a asthma doesn't matter because the whole thing was branded so high just like these multiple stents and no in mch cardiac surgery which is a post doctoral post graduation for cardiac surgery we give a full essay question called conduit selection in bypass surgery five patients are not the same like five fingers every patient has got different characteristics somebody's but usually diabetes insulin depend diabetes somebody got bad lungs somebody got real failure somebody's chaka check no problem at all young so we customize so bilateral into memory artery can be a very good operation in a selected subgroup radial artery graph which was thought to be bad now it has been shown by the newer studies the arts trial that no it's a fantastic graph next only to an internal mammary artery and then veins once upon a time we treated veins very badly and they blocked very fast then came the awareness that we should do them with love and properly we are doing it now and then came a joker on the horizon the statins when we started treating all byprocessing patients with statins suddenly the vein grafts are doing so well and look at the social media everybody thinks that charities are banned cities are bad no that's wrong don't learn medicine from social media for god's sake because someday it will kill you and so uh conduit strategy for everybody bilateral i will be total artillery revasculation that is not true today for example the senior physician who's so famous in bangalore i operate in the morning i gave him one internal memory and all veins because a one side has got av fistula for the dialysis the start analysis we suck the blood all the intermembrane artery from the left side the blood will go to the diaphragm to the dialysis and he will have a skinnier then so no internal mammogram so i took into memory acting from the opposite side then his radial artery the cartilage have done twice angiogram the radial artery has been damaged so on the other side other side there is a fistula so i can't take leader artery so we put an endoscope because the veins and we gave him veins so in each patient it will be different so leave it to the surgeon is the correct answer to your question because highly technical things and in that what happens when the patient comes for surgery he has brought so much of knowledge from so many people telling him who have no idea about surgery and there are a lot of times cardiologists will tell that this patient is inoperable no we can do an endothecal we can do lots of things so for god's sake these decisions which are highly technical leave it to the experienced cardiac surgeon so then there's another question what's your take difficult to discuss to a non-cardiac surgeon yeah so uh next question what's your take on eecp as an alternative to cbt it's a good palliative thing hospitals are having it it's for a very selected subgroup of patients and that has to be decided between cardiologists cardiac surgeon by group meeting those are little fine decisions but for a certain subgroup of patient it's a good preparation and it's a good uh therapy but not as a for everybody you know all kind of things i see on whatsapp bypass the bypass bypass the strength do ecp no you are over selling you are some they're all sitting there don't do like that this there's a lot of science in this area if i take out all the books periodicals scientific literature published on coronaries artery disease medicine and on all the areas you know almost 10 000 volumes of books will be there in that library and then today we forgot to talk about medicine today fantastic new medicines have come so all the people on the angiogram who have disease which is not tight and there is something called ffr and ffr we can measure exactly how much flow is going that artery structural understanding by angiogram functional understanding by ffv the catalysts are very big experts in that the same study showed by angiography and ffr if you apply that then the bypass is very far superior so by that many patients actually majority of the patients are candidates for tight lifestyle and only medicines and some patients about 25 will be between strengths and byprocedurally and that i already discussed so you are saying something wrong i'm sorry yeah uh no so i was just going through the next question uh yeah is holder monitoring done in run-up cardiac surgery routinely any place where there is a cardiology uh unit and a cardiac unit they all will do halter monitoring holder monitoring is done as a 24 hours or more ecg to know whether there are arrhythmias what are the therapies etcetera etcetera and then the there is a specialist cardiologist called electrophysiologist these are the some of the smartest guys in my my world of cardiac sciences and these guys will then take it forward and do all kind of tests and pinpoint the diagnosis and treat that patient the arrhythmias either by medicines or by catheter ablation of those points or some hybrid management between surgeons and these cardiologists uh so can coronary plaques get reversed by statins and lifestyle changes is there any evidence for this can be arrested not reversed the norwich came with such a big hungama and now dean arnish is forgotten next right uh sir then one final question and a personal one what made you choose cardiac surgery oh anybody who goes to a bad branch like cardiac surgery where life is so difficult uh it's only passion not as a i didn't get anything i have been to currency will never do that general practice is evergreen it will never die it will always be young and i i was doing vascular surgery as my choice after my ms and then next to my theater in bombay hospital was dr nemisha who used to do a lot of cardiac surgery only guy in private that time and so i have a charm by looking at that and but i half-heartedly uh changed and got a seat in the best that time the km and km very early in my life i was too young impressionable uh i was given to do an independent open heart surgery first time by my chief dr purukhar and that was the turning point because i fell in love and i was so emotional when i saw i could stop the heart and restart and do all that so it's exactly like falling in love and once that happens with a genuine fashion not you are cheating yourself it's true love it never goes off so it's there so for all the medical students here post graduation do for passion and don't go to all the western countries general practice is the backbone of medicine india we screwed up but we will come back it will all come back there the whole cycle will complete yes so it was great to have you to learn very advanced view to know all the basics as well and to realize as what physicians and what general practitioners should know while referring a patient ahead so thank you so much for joining us for uh clearing all our doubts too sir thank you thank you very much yes thank you so much for coming on to netflix uh so we did have the polls if you would like to run them now uh we can run them so we have two poles for the audience you can put in your words based on what y'all just uh heard throughout the talk what would your take be oh you have to just you know click on that and click yes for your choice click on submit okay uh so for the first word will you refer a patient for significant triple vessel coronary artery stenosis um we had most of them going 98 go in for bypass surgery they would prefer a refer a patient for a bypass surgery uh running the second pole the second one was will you refer patients with significant left main coronary arteries to nurses uh 66 would refer them for a bypass surgery that was the result for the work anyway thank you it was an interesting session innovative good luck to netflix come with nice topics like this and all the best thank you so much and we hope to have you again on the platform as well excellent good night thank you good night everyone good night

BEING ATTENDED BY

Dr. Darius Justus & 1341 others

SPEAKERS

dr. Vivek Jawali

Dr. Vivek Jawali

Chief Cardiothoracic & Vascular Surgeon, Chairman Dept of Cardiovascular Sciences. Chairman Medical Advisory Council, Fortis Hospital, Bangalore

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft Hospital & AR Medical Center, Kodungallur, Cochin | General Physician MIT Mission Hospital, Kodungallur, Cochin Senior Resident at Dept of Medicine, Al Azha...

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dr. Vivek Jawali

Dr. Vivek Jawali

Chief Cardiothoracic & Vascular Surgeon, Chai...

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft H...

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