Tuesday, June 25, 2013

Back on his feet, living angina-free

Mass General interventional cardiologists finding ways to avoid coronary artery bypass surgery

Farouc Jaffer, MD, PhD

Chester Roskey embraces the “Florida lifestyle.” Sunny days and warm temperatures bring the 76-year-old and his wife, who recently celebrated their 55th wedding anniversary, a lot of happiness. Roskey takes advantage of the nice weather by going for regular one to two-mile walks and hits the gym four to five days a week. He’s physically fit and has maintained a healthy diet for years. Health wise, the one negative is he smoked cigarettes for about five years roughly 30 years ago; smoking is a risk factor for many cardiovascular diseases. The one-time marathon runner isn’t ready to slow down. When his doctor in Florida told him in January he had a serious heart condition, he understandably started to worry about his long-term health.

The early symptoms, diagnosis and treatment

In December 2012, Roskey started to experience lower jaw and angina (chest) pain during his daily walks. Not too long after talking with his doctor about the pain, and then taking pain medications, Roskey found himself with small pads called electrodes hooked to his upper body: his doctor had ordered a common stress test. The test, which required him to walk on a treadmill for 10 minutes, helps monitor the heartbeat and blood pressure. The goal was to raise his heart rate to determine if blood flow was being reduced in the arteries that supply blood to the heart. Shortly after starting the test, Roskey knew something was wrong.

“After about three minutes on the treadmill, they stopped me,” says Roskey.

His doctor ended up performing a cardiac catherization procedure and discovered Roskey had a 100 percent blockage, or total occlusion, in his right coronary artery. His artery’s ability to deliver blood to the heart muscle had been restricted and was in danger of reducing the flow of oxygen and nutrients to the heart. Left untreated, this blockage would continue to cause him the debilitating chest discomfort he was experiencing on a near daily basis despite taking multiple medications. The procedure to clear the blockage in Florida, however, was unsuccessful, meaning Roskey was in need of further treatment.

His doctor suggested that he’d need coronary artery bypass surgery, an invasive surgery in which a bypass is created by connecting a piece of vein above and below the blocked area of a coronary artery. Roskey also had a history of mitral valve prolapse, a congenital heart condition which can lead to mitral regurgitation (blood leaking backward from the left ventricle to the left atrium). Most cases of mitral valve prolapse don’t require treatment, but in cases where mitral regurgitation is severe, surgery may be necessary. Since he had both conditions, his doctor recommended he seek treatment at a larger medical center.

Getting a second opinion at Mass General

There wasn’t much doubt where Roskey was heading for treatment.

“I thought of going to MGH right away,” Roskey says. Originally from the Bay State, he knew about Mass General’s excellent reputation for performing routine procedures to more complex ones. Choosing Mass General was also a great excuse to spend time with a couple of his adult children who live in Massachusetts.

When he arrived at the hospital, Roskey figured he’d be receiving the standard course of treatment since the catherization hadn’t worked before. “What I expected was having my chest cracked open and being taken care of by bypass graft and having my mitral valve repaired,” says Roskey.

He was all too familiar with the long recoveries residents in his Florida retirement community undergo after having coronary bypass surgery.

“I fully expected six to eight weeks and a day or two in the ICU.”

What he didn’t expect was his Mass General interventional cardiologist to offer a different, less invasive treatment that offered a much quicker recovery.

Advanced treatment options

Roskey’s cardiologist at Mass General, Farouc Jaffer, MD, PhD, who is part of the Institute for Heart, Vascular and Stroke Care, wanted to give as many options to his new patient as possible.

Jaffer, who has led the effort in creating total chronic occlusion treatment options in the Corrigan Minehan Heart Center Coronary Artery Disease Program along with his colleague Robert Yeh, MD, MSc, says coronary artery patients are accustomed to receiving bypass surgery but stresses in some cases there are other treatments that are as effective and less invasive.

Jaffer and Yeh have steadily increased the number of procedures they perform using what they call “advanced techniques” during catherization. Since 2012, they have treated 40 to 50 patients with stable to severe angina. In Roskey’s case, he had severe and debilitating angina, which cardiologist’s refer to as “Class III to IV angina."

The classic symptoms for patients with angina include discomfort, pressure, pain and heaviness in the chest while engaging in activities. Some patients experience pain during events like stressful arguments and at rest. Other symptoms include fatigue, nodding off early at night and an overall lack of energy.

Jaffer says total chronic occlusions are significantly harder to open and close, because the operator cannot see the other side of the blockage. The advanced techniques help solve that issue.

“Traditionally, when we’ve approached blocked arteries we’ve always thought we needed to stay right inside the middle of the vessel to get one open. We’d have a 90 percent blockage and there would be a 10 percent space for us to get through, says his colleague Yeh. “We’d get through that area right in the middle and open it up with things like balloons and stents, but with 100 percent blockages, you don’t have that 10 percent little pathway to go through.

Working together, Drs. Jaffer and Yeh have found ways to get around the 100 percent blockage issue.

Mr. Roskey’s treatment

After undergoing a thorough examination and ultrasound at Mass General in April, Dr. Jaffer confirmed that the mitral valve prolapse was not causing the valve to leak significantly. He identified the complete blockage in Roskey’s artery and determined Roskey was a good candidate for the advanced techniques catherization. Roskey underwent the procedure the next month in May.

“With Mr. Roskey, rather than going through the blockage, we were able to drill around the blockage, come back in and then reopen the entire channel,” say Jaffer.

Roskey recalls the procedure lasted several hours, but the process was painless. “I felt no pain, no discomfort – I just had to really pee after six hours,” laughs Roskey.

Jaffer says the procedure went well and he and his team were able to successfully clear the blockage.

Successful recovery

Roskey recently returned to Mass General in June for a follow-up exam and received good news from his cardiologist.

“I’m delighted to report that he is angina-free,” says Jaffer. “He no longer has symptoms walking his traditional mile and is continuing to increase his productivity on walks and his ability to simply enjoy life.”

Since Jaffer was able to completely open Roskey’s coronary artery, the heart healed itself and will receive more adequate blood flow which in turn fixed the mitral valve issue.

In addition to Roskey having angina relief, another symptom he had prior to the procedure, getting extremely warm in bed at night, which affected his sleep, also is gone. Roskey is feeling well and is optimistic about his long-term health.

“Things are going absolutely fantastic,” Roskey says.

Positive outlook for other CTO patients

Jaffer emphasizes there is hope for other patients with coronary artery heart disease. Medical therapy which includes taking antiplatelet medications (decreases ability of platelets in blood to stick together and cause clots), anticoagulants (blood thinners), antihyperlipidemics (lowers lipids in [fat] in the blood) and antihypertensives (used to lower blood pressure) work for the majority of patients.

“The vast majority of patients who have this type (100 percent occluded artery) are told that they really don’t have options beyond medical therapy. Medical therapy is critical and it’s very important to make patients both angina-free and to prevent new blockages,” says Jaffer.

Medical therapy is fully utilized in their treatment approach. The problem is, for many patients, it's not enough to give the heart enough blood and enough efficiency to keep patients from having limiting symptoms. That’s when minimally invasive and bypass surgery come into the picture.

Risks and comparison to coronary artery bypass surgery

Stringent guidelines are followed when choosing patients to be treated with the advanced techniques.

“We’re very particular about the patients that we choose to do these types of procedures on, because they are a little bit more invasive,” Jaffer says.

Increased bleeding can take place in the legs, groins or in the heart can happen in some cases where the blockage is particularly hard and tough to drill through, and they also use two IVs, instead of one.

Jaffer says that traditional bypass can be a good therapy for relief of angina. He says, there are many cases, however, when using advanced techniques is a better treatment option. He cites faster recovery time (often only a few days) and a reduction in acute risks when using advanced techniques over bypass surgery. Patients who have had previous bypass surgery but still are having angina are also often excellent candidates for these techniques, which can avoid a second bypass operation.

One new advanced approach Jaffer and Yeh will be performing more frequently at Mass General is called a retrograde procedure. Yeh says the research and clinical experience his team has acquired over the years fixing chronic total occlusions has prepared them for using this new technique.

“Completely blocked arteries often get blood supply from “collaterals” says Yeh. “We can actually use these collaterals to go backards through the blockage we’re trying to fix. By merging a forward and backward approach – and connecting the dots in the middle – we can open arteries we never thought could be opened before.”

Clinical implications of using advanced techniques

Both Jaffer and Yeh see the use of these advanced approaches as examples of how treatments are getting better and more successful for patients.

“It’s really the best of technological innovation meeting clinical practice,” says Yeh. While there’s an important and necessary focus on the prevention of cardiovascular disease in the United States, he says there are still plenty of patients who are older, sicker and have more complicated forms of coronary disease.

Jaffer says the techniques his team is using will only get better in the future. The aim is for procedures to be quicker, less invasive, decrease patient recovery times and have the best outcomes possible.

“It’s very demoralizing to be told to live with angina when it is truly limiting,” says Jaffer. “We are thrilled that our technology has really matured to allow us to tackle this very complex subset of coronary blockages.”

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