NMC Health : What’s new in cardiac treatment?

Technology has opened up new options with better outcomes for treating cardiovascular disease

Cardiovascular disease is the number-one killer in the UAE, affecting people as young as 45 years on average, as opposed to 60 in the US, and hospitals in the country have their job cut out. The emphasis is on providing cutting-edge technology and sophisticated therapies even as experts stress preventive measures.

'There has been a remarkable increase and advancement in providing cardiovascular health in the UAE over the past decade,' says Dr Sanjay Rajdev, Consultant in Interventional Cardiology at NMC Speciality Hospital in Abu Dhabi. 'Several new hospitals equipped with the latest technology and specialists from all across the world have sprung up.'

GN Focus lists the latest advances in cardiac care.

Valve within a valve

'For long the only treatment for aortic valve stenosis [the narrowing of the valve opening] was open-heart surgery and the replacement of the diseased valve with an artificial one until the introduction of a novel concept of placing the new valve inside the diseased valve without open-heart surgery,' says Dr Rajdev.

Transcatheter aortic valve implantation (TAVI)has revolutionised how aortic stenosis patients with intermediate or high risk of open-heart surgery are treated, he says, prolonging their lives. The new procedure uses a catheter to carry a collapsed replacement valve to the site, which is then expanded so it can start regulating blood flow.

Robotic repairs

Coronary robotic surgery has been successfully performed worldwide for over 15 years, but using robots for mitral valve repair only took off over the past six years. In the procedure, surgeons operate on the heart using a robot with surgical instruments and HD cameras on its arms.

'This year alone, we have performed nine robotic mitral valve repairs, 16 robotic totally endoscopic coronary bypass surgeries and one robotic atrial septal defect closure,' says Dr Rakesh M. Suri, Chief of Staff and Thoracic and Cardiovascular Surgery at Cleveland Clinic Abu Dhabi. The clinic's Heart & Valve Institute (HVI) uses robotic procedures to treat mitral valve regurgitation.

Besides being minimally invasive, robot-assisted surgery offers greater precision, faster recovery times and is a viable alternative for older and sicker patients not previously eligible for major surgery.

A drug called ARNi

A new drug, angiotensin receptor-neprilysin inhibitor (ARNi) is helping heart failure patients - after decades of waiting by the medical fraternity. It is far more effective than existing options, says Dr Rajdev. 'The updated American College of Cardiology, American Heart Association, and Heart Failure Society of America guidelines for heart failure have made ARNi (sacubitril/valsartan) the go-to drug over angiotensin-converting enzyme inhibitors and angiotensin receptor blockers.'

Dr Shoaib Yakoob, Specialist Cardiologist at Medcare, says sacubitril/valsartan has had a major impact in managing the disease, reducing cardiovascular death and hospital admissions by almost 20 per cent. 'It remains to be seen if this magic drug can help delay people from getting a heart transplant or other implantable device for the condition.'

Cholesterol control

Patients with high cardiovascular risk who don't meet their target levels of cholesterol as well as those who have certain genetic types of elevated cholesterol disorder are now being treated by proprotein convertase subtilisin-kexin type 9 inhibitors. These drugs control LDL cholesterol (the bad kind), potentially reducing it by 50-60 per cent.

'This new drug class further reduces the risk of major cardiac events over and above the established standard of statin therapy,' says Dr Rajdev. The new medicine is to be injected once or twice a month.

Remote monitoring

Swedish market research firm Berg Insight forecasts that 19 million people worldwide will use remote patient monitoring by next year, with the GCC earmarked as one of the biggest regions for growth.

HVI runs a remote heart monitoring programme in the UAE. Launched in August 2016, it covers 150 patients who are monitored through implanted cardiac devices such as pacemakers and defibrillators. 'Implanted heart devices are able to communicate with the patient's doctor and technicians in Cleveland Clinic Abu Dhabi's remote centre,' says Dr Suri. 'If there is an abnormality and the patient receives a shock to their heart, for instance, we can react instantly and get them to hospital quickly for treatment.'

The benefits of remote heart monitoring include reducing instances of hospitalisation and improving a patient's chances of survival by decreasing the incidence of strokes and heart failure.

3D printing in the UAE

Today, 3D printing is used in assisting complex heart surgeries and catheter-based interventions, with 3D organ replicas helping in procedural planning. '[In complex surgeries,] the technology includes the separation of cardiac and vascular structures from the surrounding tissue, giving the physician clear sight of any target region and what to expect in the operating room,' says Dr Suri. They are also used as a visual aid during surgery and for quality assurance post surgery to find out the cause of any adverse outcomes.

But what's most promising is its future use. 'Although 3D printing can only be used for specific types of heart surgeries and dedicated percutaneous interventions, such as valve and device implants and surgery for congenital heart diseases, its future application is in creating custom organ implants for specific patients,' says Dr Suri.

Two advances that haven't reached the UAE

Cardiac transplants

Indicated in severe heart failure conditions, a heart transplant requires an extensive network for success, involving government, insurance companies, trained healthcare staff and adequate funding, says Dr Rajdev. It has layers of complexity, including ethical issues, donor availability and a system for identification and safe transport, besides being extremely expensive.

Canakinumab

This antibody aims to reduce levels of inflammation in the body. It's been shown to improve outcomes in atherosclerotic heart disease patients. It could see promising results in the UAE, says Dr Rajdev.