What is coronary angiogram (also known as cardiac catheterization)?

A coronary angiogram, also known as cardiac Cath or cardiac catheterisation, is a minimally invasive diagnostic procedure that is widely used for invest igating heart disease, a common medical problem in India. It enables the interventional cardiologist to visualise the functioning of the heart. A catheter - a narrow, flexible tube- is inserted into a blood vessel, normally at the groin or at the wrist, and guided to the heart. The cardiologist is able to see the movement of the catheter as it is threaded towards the heart, by sharp images which are projected by a series of x-rays that are being continuously taken. The procedure yields very clear images of the heart valves, the coronary arteries and the chambers of the heart.

What are the advantages in getting coronary angiogram done at heart hospitals in India?

• Indian doctors have great expertise in performing coronary angiograms


• Cardiac Centres in India have state of the art equipment for performing coronary angiograms and angioplasties


• Cost savings: A coronary angiogram which costs approximately US $ 4000 in the USA. would cost approximately US $ 600 to 700, just 15% of the American cost, with savings of up to 85%.
  

What can you expect from a coronary angiogram in India?

The coronary angiogram is the gold standard investigation for several heart related diseases. It helps to confirm or rule out disorders relating to the coronary arteries. If there is a problem, it indicates a clear treatment path (angioplasty? Open heart surgery?)

Is the cardiac catheterisation procedure an investigative tool only?

Cardiac Cath Procedure commences as an investigative procedure. In the event of findings which indicate the need for minimally invasive intervention, such as a balloon angioplasty or the placement of stents, such intervention can be carried out as part of the same procedure. Thus, the cardiac diagnostic procedure is transformed into a therapeutic or a curative procedure too. Once the procedure becomes therapeutic in nature it is described as an angioplasty.
Some examples of interventional procedures: placement of stents, balloon angioplasty, cutting balloon, rotoablation, etc

Do hospitals in India have the latest equipment for carrying out procedures like coronary angiograms?

Leading cardiac hospitals in India are as good as the best cardiac centres in other parts of the world. This is attributable not just to the skill of Indian cardiologists to also to the high-tech equipment that is available at hospitals in India today. For example, heart centres in India have the latest cardiac catheterisation labs made by global players like Siemens, Phillips, GE, etc.

How is a coronary angiogram done?

In a coronary angiogram, the interventional cardiologist inserts a catheter -a narrow flexible tube -into an artery, normally at the groin or in the arm. The point of entry is numbed so that you do not feel any pain or discomfort during the procedure which can take about half an hour.
A sheath is first inserted, followed by a guide wire and then the catheter. The catheter is guided through the heart to the arteries in the heart region. A special contrast dye is injected in order to provide clear images of the blood flow from the coronary arteries to the heart muscles. The images are a series of x-ray pictures and provide a very clear picture of both the exact location and the extent of blockages in the coronary arteries. This information guides the interventional cardiologist about whether or not to perform a coronary angioplasty.
Throughout the procedure, the internal and intra-arterial blood pressures are measured through the catheter to make sure that the catheter is not blocking the blood vessel, although by design the catheter thickness (approximately 2 mm) will always be smaller than the lumen of the blood vessel.

How experienced are Interventional Cardiologists in India at coronary angiograms?

Heart disease is very widely prevalent in India and doctors in India are perhaps the world's most experienced in heart diseases. The cardiologists on our panel have -each- performed at least 10,000 coronary angiograms...in addition to which they have performed a large number of coronary angioplasties too. These numbers represent a great amount of experience in handling a wide range of cardiac disorders. Practice, as they say, makes perfect. The skill of the Interventional Cardiologist lies in obtaining clear images with the least possible injection of contrast dye and the least possible radiation exposure to the patient.

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What Is Coronary Angioplasty?

A coronary angioplasty is a widely performed procedure that is used to treat heart problems caused by blocked or narrowed coronary arteries (blood vessels that supply blood to the heart muscle). This procedure is performed highly successfully by interventional cardiologists at heart hospitals in India. The coronary angioplasty, which normally takes between one to two hours, aims to remove or reduce blockages in the coronary arteries and restore blood flow to the heart muscle. The coronary angioplasty procedure is performed in a Cardiac Catheterisation Lab (see image below). All cardiac speciality hospitals in India as well as most of multi-speciality hospitals in India are equipped with Cath Labs

Why is a Coronary Angioplasty done?

The arteries supplying blood to the heart muscle are vital as inadequate blood supply can lead to angina (pain originating in the heart muscles) or a heart attack. Over a period of time blood vessels anywhere in the body can become lined with a fatty deposit called plaque, which eventually can cause a significant narrowing down or even a complete blockage of the blood vessel. This condition, called atherosclerosis, results in inadequate or no blood supply to the muscles served by the artery concerned, leading to possible muscle death. Thus, the coronary angioplasty is done to:

1. Treat patients suffering from angina and shortness of breath
2. Treat patients who have had a heart attack. A heart attack happens when there is a total cut off of blood supply on account of blocked arteries.

An angioplasty done very soon after a heart attack can open up the blocked arteries and minimise the damage to heart muscle.

What are the advantages in getting coronary angioplasty done at heart hospitals in India?

• Indian doctors have great expertise in performing coronary angioplasties, given the large number of patients with coronary heart disease in India


• Cardiac Centres in India, and multi-speciality hospitals too, have state-of-the-art equipment and cardiologists with great expertise in performing coronary angiograms and angioplasties


• In view of the large number of angioplasties performed on a regular basis by Cardiac Hospitals in India, the centres of excellence in treatment of heart diseases in Indian cities are able to operate at great levels of efficiency and economy, which translate into low-cost heart procedures without any compromise on quality.


• There is absolutely no wait list at hospitals in India to undergo this procedure. Treatment can commence immediately on your arrival at the hospital.

How Is Coronary Angioplasty Done ?

The coronary angioplasty is a corrective procedure. This is preceded by a diagnostic procedure called the Coronary Angiogram.

In a coronary angiogram, the interventional cardiologist inserts a catheter -a narrow flexible tube -into an artery, normally at the groin or in the arm. The catheter is guided to the arteries in the heart region. A special contrast dye is injected in order to provide clear images of the blood flow to the heart muscles. The images are a series of x-ray pictures that provide a very clear picture of both the location and the extent of blockages in the coronary arteries. This information guides the interventional cardiologist about whether or not to perform a coronary angioplasty.

Having decided that the patient will benefit from this interventional cardiology procedure, the specialist can immediately move on from diagnosis to treatment. Another catheter, with a special balloon at the tip, is inserted and guided to the artery blocks. Once the catheter is exactly positioned, the balloon is inflated and the plaque which is blocking the artery is compressed against the inner wall of the artery. If the specialist, based on training and experience, believes that the compression of the plaque is sufficiently curative he will conclude the procedure. On the other hand, he may also decide that a stent may need to be inserted.

A stent is a wire mesh tube made of special material that is placed at the location of the artery blockage. It is an expandable device which is stretched out against the inner artery wall after inflating the catheter balloon. The expanded stent is fixed against the inner wall of the artery and helps in keeping the artery open, thus restoring the blood flow to the heart muscle. Stents are also available with a special coating of drugs which reduces the possibility of plaque forming once again in the same spot. These stents are called drug eluting stents.

In case the patient is suffering from more than one block, the treatment is replicated for the other blocks. If there are multiple blocks, the patient may be advised to go in for a heart bypass procedure rather than an angioplasty.

The cardiologist determines the need for a coronary angiogram based on other primary cardiac investigations such as ECG, blood tests, 2-D Echo, stress test, etc. He will discuss these reports with you and advise you why he believes there is a need for a coronary angiogram. He will also explain to you that in the course of the angiogram, he may find blockages that definitely call for treatment by way of balloon angioplasty, placement of stents, etc. He will ask you whether you would want to proceed with the angioplasty if that is the requirement following the angiogram, or whether you would want to review the results of the angiogram and return later for the angioplasty. This is a decision for the patient and the family to take.

The advantage with a having the treatment, if necessary, along with the diagnostic procedure is that both the diagnosis and treatment are completed as part of the same procedure. This will reduce the overall cost - and will also reduce the amount of radiation exposure that will be received by the patient.

In either case, the cardiologist will advise you about:

• dietary restrictions (you may be asked to stop eating several hours before the scheduled procedure)
• restrictions on the medicines that you are taking
• the duration of the procedure, normally one to two hours

During the coronary angioplasty :

A coronary angioplasty is performed in a high-tech cardiac catheterisation laboratory in the hospital. You would be asked to lie flat on your back and will receive intravenous fluids and medicines to keep you comfortable throughout the procedure. You will be conscious but drowsy. You will also receive strong anti-clotting medicines to prevent the formation of blood clots during the procedure

• a small incision is made in an artery normally in the groin region and in a step by step procedure, a guide wire, a sheath and a guiding catheter will be threaded into the opening of the coronary arteries
• a dye is injected at this stage to enhance the quality of the images
• a balloon catheter is introduced to compress the plaque in the blocked arteries
• a cutting balloon may be required in some cases
• hard plaque may need the use of a rotablator
• in some cases a stent may also need to be inserted
• after compression of the plaque, either by balloon angioplasty alone or in combination with placement of stents, the guide wires and catheter is removed.

After the coronary angioplasty procedure in India:

You will be placed under observation for a few hours and made to lie flat on your back without any movement of the limb where the incision was made, in order to allow it to seal completely.  Discharge from the hospital is normally made a day or two after completion of the angioplasty procedure.  Your doctor will advise you on restrictions immediately following the procedure.  Normally, you would be able to resume work gradually one week after the completion of the procedure. 

Your doctor will also advise you on lifestyle changes that you need to make, because while the coronary angioplasty procedure will be able to remove existing blocks in the coronary arteries, it will not help in preventing the formation of fresh blocks.  This can only be achieved by a combination of lifestyle changes and possibly, medication as well.

How experienced are heart specialists in India at doing coronary angioplasties?

As a category, interventional cardiologists from India perhaps have the greatest level and variety of experience in handling various cardiology related diseases, including coronary angiograms and angioplasties. This is quite simply a function of the large number of patients who need this cardiac procedure in India. Today, patients from all over the world come to India seeking the expertise of heart specialists at Indian hospitals in the areas of balloon angioplasty, cutting balloons, placement of stents, etc.

What kinds of stents are used by cardiac centres in India?

Our associate hospitals use the highest quality of cardiac implants and devices. In the case of stents, they use top of the line products from leading manufacturers like Boston Scientific, Medtronics, etc

What are my likely cost savings by getting the coronary angioplasty done at an Indian cardiac centre?

A coronary angioplasty with a stent costs approximately US dollars 16000 at a good cardiac centre in the USA. The same procedure at an equally good cardiac centre in India would cost approximately US dollars 6000, with savings of up to $ 10,000.

What is Coronary Artery Bypass Graft (CABG) surgery?

Coronary Artery Bypass Graft (CABG) surgery, commonly referred to as Bypass Surgery, is a widely accepted procedure for the treatment of blocked coronary arteries that supply blood to the heart muscles.  The surgery is now one of the two front-line treatment modalities for patients at risk of heart attacks, the other being coronary angioplasty.

The Coronary Artery Bypass Graft Surgery is performed by a cardiac surgeon with the objective of bypassing a block in one of the arteries leading to the heart muscles.  The portion of the affected artery which contains the block is cut away or bypassed.   A graft ( a new section of artery or vein) harvested from  the chest (thoracic), leg (saphenous) or arm (radial) is then attached to the affected artery in order to create a new loop through which the blood can flow without any obstruction. 

A traditional bypass surgery follows the open chest method, where the chest is opened up to expose the heart.  This technique also requires the “stoppage” of the heart and use of a heart-lung machine to which the blood is routed during the surgery.  Newer techniques for bypass surgery have emerged: typically, the beating heart bypass surgery in which the heart beats, although at a slower rate, and continues to pump blood to heart muscle during the procedure.  This innovative procedure, performed regularly by our heart surgeons in India, eliminates the risks associated with stopping the beating of the heart for the purpose of carrying out the surgery.

Is Coronary Artery Bypass Graft (CABG) surgery done at hospitals in India

Yes, Coronary Artery Bypass Graft (CABG) surgeries are done with great professionalism in India.  This is not surprising, considering that India has perhaps the world's largest number of people with coronary artery disease.  Genetically, Indians are prone to coronary artery disease and a large number of Indians regularly seek treatment, including heart bypass surgeries and coronary angioplasties at multi-speciality and cardiac speciality hospitals in India.

What are the advantages in getting Coronary Artery Bypass Graft (CABG) surgery done at heart hospitals in India?

• Highly qualified and experienced cardiac surgeons
• Success Rate of 98 to 99%
• World-Class Operation Theatres
• Absolutely no wait list even for complex cardiac surgeries
• Savings of up to 80%, compared to costs in the USA

What happens during the Heart Bypass Surgery

You will be under general anaesthesia. The surgeon will use a clean section of artery or vein from your body, typically from the leg, the chest or the arm.  This section, which is called a graft, is attached so that it connects the aorta with the coronary artery below the blocked section.  Another way is to detach one end of an artery in the chest and reattach it to the coronary artery beyond the blocked a section This new section, or the new routing, provides a block free alternate path for the blood to flow.

After Coronary Artery Bypass Graft (CABG) Surgery

After surgery, the heart-lung machine will be turned off and the heart will resume beating. Immediately after surgery, your condition may seem worse to you than it was prior to the procedure.  This is not on account of the surgery not having gone well, it has more to do with the stress and trauma related to the operation itself.

Your heart, BP, oxygen and other body vitals will be actively monitored for about two days in ICU. You will probably spend another five days in the hospital before your discharge.  Full recovery can take up to two months, although your doctor may allow you to begin driving in about four weeks after surgery.

In either case, the cardiologist will advise you about:

What are the success rates at cardiac centres in India for Coronary Artery Bypass Graft (CABG) surgeries?

India has the largest concentration of heart patients in the world.  Consequently, Indian doctors acquire a great deal of experience in treating heart diseases over a very short period of time.  The success rate at our associate hospitals in India for Coronary Artery Bypass Graft Surgeries is over 98%, in line with global benchmarks.

What are my likely cost savings by getting the Coronary Artery Bypass Graft (CABG) surgery done at an Indian cardiac centre?

A Coronary Artery Bypass Graft (CABG) surgery costs approximately US dollars 30,000 at a good cardiac centre in the USA.  The same procedure at an equally good cardiac centre in India would cost approximately US dollars 7000, just a quarter of the American cost, with savings of up to $ 23,000.

Function of the Mitral Valve

The mitral valve regulates the flow of oxygen-rich blood from the left atrium (upper chamber) of the heart to the left ventricle (lower chamber) of the heart. It is from the left ventricle that blood is pumped out through the aorta to the body.

Medical conditions necessitating Mitral Valve Surgery

The mitral valve can, broadly speaking, have two main problems:

• Mitral valve stenosis, where the valve has become narrow and does not open fully. This leads to insufficient flow of oxygenated blood to the body
• Insufficiency or regurgitation in which the valve does not close completely. This condition leads to the flow of blood back to the lungs, causing shortness of breath.

Mitral Valve Repair Vs Mitral Valve Replacement

Mitral valve diseases were treated in the initial days by the replacement of the mitral valve. However, mitral valve repair is clearly the preferred option over valve replacement for a number of reasons:

• Mitral valve repairs have a success rate of 98 to 99% as against 92 to 94% for mitral valve replacements
• Infection rate and the risk of stroke is much lower for mitral valve repairs
• Mitral valve repairs are long-lasting. Approximately 95% of patients will have their mitral valve in good condition even 20 years after the procedure.
• Long-term survival rate is higher with mitral valve repair
• Blood thinners are not required after mitral valve repair

Is Mitral Valve Repair/Replacement surgery done at hospitals in India?

Yes, Mitral Valve Repair/Replacement surgeries are done with great professionalism in India. This is not surprising, considering that India has perhaps the world's largest number of people with heart disease. Genetically, Indians are prone to coronary disease and a large number of Indians regularly seek treatment, including mitral valve repairs and replacements at multi-speciality and cardiac speciality hospitals in India.

Advantages in getting Mitral Valve Repair / Replacement surgery done at heart hospitals in India

• Experienced cardiac surgeons
• State of the art operating theatres
• World Class success rates ( 98-99%)
• Zero waiting list
• Low-Cost ( with no compromise on quality), savings of up to 75%

What are the kinds of Surgery for Mitral Valve Repair in India?

Mitral valve repairs can be repaired either by:

• Open-Heart Surgery, or by
• Minimally Invasive Surgery

Mitral valve Repair by open-heart surgery in India:
Repair by open-heart surgery involves a chest incision, general anaesthesia and surgery which can take between three to five hours. As this is an invasive procedure, risk factors tend to be higher than with the minimally invasive option. For many candidates with other health conditions, open-heart surgery may not be the ideal option.

Mitral valve repair by minimally invasive heart surgery in India:

This procedure is fast becoming the norm for mitral valve repair by leading cardiac surgeons in India. This procedure is far less traumatic for the patient as only a 2-4 inch incision is required. Consequently, there are several possible advantages the minimally invasive mitral valve repairs:

• Reduced blood loss, lesser pain and lower risk of infection
• Hospital stay is reduced
• Faster recovery

Do hospitals offer Surgery for Mitral Valve Replacement in India?

Yes they do offer mitral valve replacements in India. However, as discussed above, mitral valve repair is very much the preferred option in comparison with the mitral valve replacement. However, some patients are not good candidates for mitral valve repair. For these patients mitral valve replacement surgery may be the only option.
Artificial mitral valves are available in two types:

• A metallic valve, which will last a lifetime, with the downside that the patient has to also take blood thinners lifelong.
• A tissue valve, which has a life of only 10 to 15 years, with the advantage that blood thinners will not be needed to be taken by the patient.

What are my likely cost savings by getting the Mitral Valve Repair/Replacement surgery done at an Indian cardiac centre?

A Mitral Valve Repair/Replacement surgery in India will cost approximately a quarter of the prevailing cost in the USA. Savings would thus be up to 75% of the cost payable in the US. Further, there is no wait list for Mitral Valve Repair/Replacement surgeries in India.

What is a pacemaker?

A pacemaker is an electrical device that is used to regulate and normalise the rhythm at which the heart works. The rate at which the heart works and the rhythm at which it works are triggered by electrical impulses generated from within the heart. Abnormalities in these electrical impulses result in arrhythmia, where the heart rhythms are too slow, too fast or irregular.

A pacemaker has two components to it: the electric leads which are connected to the heart and a pulse generator/computer which detects abnormality in the heart's rhythm and delivers an electrical impulse to the heart to normalise the rhythm. The pulse generator is powered by a battery which should last between 5-15 years, depending on the amount of power drawn from it. The pacemaker can have 1, 2 or 3 leads depending upon the kind of device.

The pacemaker, securely sealed in a titanium case, is implanted by a surgical procedure in the chest region below the skin. Heart specialists in India normally perform this as a minimally invasive procedure requiring the patient to stay in the hospital for just a day.

How does a pacemaker work?

The leads from the pacemaker which are implanted in the heart provide constant feedback to the pulse generator about the rate, and the synchronisation, of the heart beat. The intelligent chip in the pulse generator determines if, and when, correction is required. The leads also carry these corrective electrical impulses from the pulse generator back to the heart. This function of correcting the pace at which the heart works is called pacing..

Pacemakers can be programmed in two different ways:.

The first way is called demand pacing, in which the generator is programmed to send an electrical impulse to the heart once the heartbeat falls below a certain programmed rate, which is determined by your cardiologist..

The second method is called rate-responsive pacing, where the pulse generator assesses the body's demand for oxygen by measuring either the beating rate of the heart or the movement of the body. Once it determines that there is a need for a higher level of oxygen, the pulse generator automatically paces up the heartbeat to correspond to the perceived level of activity.

Which heart diseases require implantation of a pacemaker?

A pacemaker is vital for patients suffering from arrhythmia. It is also considered for implantation in patients suffering from congestive heart failure, fainting spells (syncope) and hypertrophic cardiomyopathy.

What is Cardiac Resynchronisation Therapy?

Cardiac Resynchronisation Therapy, CRT in short, is the procedure by which the two lower chambers of the heart, the ventricles, are made to function in synchronisation with each other. The performance of the heart is greatly dependent on the way in which the chambers work in relation to each other. Sometimes on account of irregular electrical impulses, the synchronisation is impaired.

In cardiac resynchronisation therapy, a pacemaker is implanted with leads running to both the left and right ventricles. Responding to the signals received through the lead wires, the pacemaker sends back corrective impulses which ensure that both the ventricles pump in coordination with each other. This dramatically increases the effectiveness of the pumping mechanism, raising the survival rate of the patient.

As this therapy involves placing of both the ventricles, it is also referred to as Biventricular Pacing

What are the various kinds of pacemakers offered in India?

Based on the number of leads, and the placement of the leads, pacemakers can be categorised as follows:

Single chamber Pacemaker in India: This type involves the implant of one lead in the atrium (upper chamber) or the ventricle (lower chamber) of the heart

Dual Chamber Pacemaker in India: This type involves the implant of two leads, one in the atrium and one in the ventricle

Biventricular Pacemaker in India: This type of pacemaker is used in Cardiac Resynchronisation Therapy and requires the use of three leads. The first lead is placed in the right atrium, while the other two leads are placed one each in the right ventricle and the left ventricle.

How is the pacemaker implanted?

The pacemaker is implanted, normally in the upper chest, as part of a surgical procedure performed under local anaesthesia.

The electrophysiologist / cardiologist assisted by fluoroscopy imaging, implants the leads at the designated locations within the heart, by threading them through veins leading to the heart. The other end of the leads is connected to the pulse generator unit which is implanted in the chest region. This procedure will take upwards of one hour and can sometimes take several hours.

Once the leads are attached to the heart as well as the pacemaker, the cardiologist would test the device to make sure that electrical impulses are flowing from the pacemaker to the heart and that the heart rate and rhythm are being read accurately by the pacemaker.

What are the advantages in getting Heart Pacemaker Implantation / Cardiac Resynchronisation Therapy (CRT) done at heart hospitals in India?

• Great expertise of our interventional cardiologists
• Ultra-modern imaging and interventional equipment
• Low-cost ( just 1/3 of costs in USA)
• Outstanding success rates.
• No wait list

Are the success rates at cardiac centres in India as good as those at leading hospitals in the West?

India has the largest concentration of heart patients in the world. Consequently, Indian doctors acquire a great deal of experience in treating heart diseases over a very short period of time. The success rate at our associate hospitals in India for Heart Pacemaker Implantation / Cardiac Resynchronisation Therapy (CRT) is very much in line with global benchmarks.

What are my likely cost savings by getting the Heart Pacemaker Implantation / Cardiac Resynchronisation Therapy (CRT) done at an Indian cardiac centre?

Heart Pacemaker Implantation / Cardiac Resynchronisation Therapy (CRT)in India will cost approximately 30% of the prevailing cost in the USA. Savings would thus be up to 70% of the cost payable in the US. Further, there is no wait list for Heart Pacemaker Implantation / Cardiac Resynchronisation Therapy (CRT) in India.