Interview

Interview with Cardiothoracic surgeon Dr Satish Kini, M.B.BS, MS, M.Ch.,
By Ravi K and Dr Soumya Kudva on 6th Mar 2009
Dr. Satish Kini completed his MBBS and MS from Pune and M.Ch., CVTS from Mumbai. He was Associate Professor in St. John's Hospital before joining Vivus as Chief Cardiothoracic Surgeon. Dr. Kini has obtained extensive experience in UK as a part of overseas training in his field . He worked for three years with pioneer heart surgeon Dr Denton Cooley at the TEXAS Heart Institute, Houston, Texas where he also worked on heart transplant surgeries. He has also worked at Royal Prince Alfred Hospital, Sydney, Australia . He has the distinction of presenting several papers in national and international conferences and is a member of several Medical Councils.
imedguru :	Researchers have determined that those of Indian and Pakistani descent have the highest rates of heart disease in the world, to the extent of 3 times to those of American and Europeans. What is the reason for such high occurrences of heart related problems in the Indian sub continent?
Dr. Satish :	The people in the subcontinent have anatomically smaller arteries and Sri Lankans have the smallest of all as compared to rest of the population of the world. There are various types of heart problems .The blockage of arteries is governed by multiple factors such as smoking, diet, diabetes, genetic, lack of physical exercise, stress. There is general lack of awareness about risk factors in the people of the subcontinent. So the exposure to risk factors and smaller arteries combined together put us Asians at higher chances of having heart problems.
IMG :	Do you think our eating habits, spicy food contribute to the occurrences of heart ailments in India more than others. What diet is good for heart?
SK:	Spicy food does not have any effect on heart however in India we consume lots of oil, ghee, coconut oil in our daily food intake and this excessive fats keeps getting deposited in the arteries and restricts the flow of blood. It the blocked arteries because of bad cholesterol which leads to a heart attack. Diet that contains less oil and fat and more protein and vegetables is good for heart and body as a whole. One should minimize oil intake as the body stores excess fat in the form of lipids. Coconut oil, dalda, ghee etc should be replaced with oils such as mustard oil, Safola oil, olive oil etc. Non-vegetarians should reduce their intake of red meat such as beef, mutton etc and instead replace it with chicken ( skin out) and sea fish. Fishes found in the seas such as Mackerel, Salmon and sardine are extremely good for the heart as it contains an oil called Omega-3 which is very good for heart . Nuts such as badaam , pista etc is also good for heart. One should avoid shrimps, lobsters, red meat etc as they contain lots of cholesterols and is extremely dangerous for heart.
IMG :	What is the effect of alcohol on the heart?
SK:	Small dose say 30 ml of alcohol is okay for the heart as it dilates the blood vessels. Red wine has anti- oxidant properties and helps in cleaning up our system . However for this reason alone alcohol should not be consumed as lemon and orange juice also contain anti- oxidant properties and works good for the human body.
IMG :	What is the most common age at which people are likely to suffer from heart related problems?
SK:	Mostly heart attacks are more common after 50 years however there are no set rules regarding the same and generally heart attacks during the younger age is due to genetic reason. With the changing lifestyle so called Fast life we are seeing young people with the heart problem.
IMG :	What are the visible signs of heart attack and how can patients differentiate between chest pains due to gastro problem from a real heart attack?
SK:	Any pain in the left side of the chest, generally should be taken as heart attack unless proved otherwise. The pain due to heart attacks comes from exertion or after a big meal and can vary from slight discomfort to shooting radiating pain going from left side of the chest to left arm. Sometimes the pain can look like the pain arising out of acidity, or pain in the throat or back and these types of symptoms are difficult to pick up. We all need to be observant about the pain. Typically pains due to heart attacks do not subside when analgesic such as crocin or any other pain killer is taken unlike other pains.
IMG :	There are few cases where the heart attacks signs are not so visible and patient die despite having no previous attacks. How does this happen?
SK:	In less than 10 % of the cases people have something called “Left Main Disease” where the left artery is naturally blocked and in such cases when a heart attacks is triggered the patients have nothing to fall back upon and therefore collapse immediately. Another form of attack where the signs are not much visible is called “Silent Attack” which occurs in patients having a history of diabetes say from 10-15 years . For people suffering from long term diabetes the nerve endings/terminals gets affected and become numb and less insensitive due to which the severity of pain felt or perceived by the patient may be less or may go unnoticed.
IMG :	People with “left main disease” how do they really detect or prevent such attacks?
SK:	This problem can be detected only through a Tread Mill Test (TMT) that is why it is recommended that after a certain age one say 40 years one should go for regular investigations especially tread mill test.
IMG :	What are the routine test that is helpful in early detection of hear related risks?
SK:	After the age of 40 years it is important for all to go for regular checks on diabetes, cholesterol and TMT test. If the results are normal and one does not have family history of heart attacks then in 2 years the tests can be repeated. However if one is diabetic and the results are not negative then he needs to test more frequently and all such investigations should be done with the consultation of a doctor.
IMG :	What approach do you recommend to people to prevent heart related ailments?
SK:	Regular exercise such as brisk walking, well balance diet, weight reduction ,regular health checks, giving up smoking and drinking will be helpful in preventing onset of heart attacks. Even people who are genetically prone to heart problems will be able to prolong and improve their quality of life through a well balanced regimen.
IMG :	What are the first aid steps to be taken in case of heart attack and can a person help himself during a heart attack?
SK:	There are no first aid steps in case of heart attack and the patients should call for an ambulance and reach hospital at the earliest. At most a person can do is put a sorbitarate tablet under his tongue. These tablets dilate the arteries and reduce the immediate risk . However most of the people are not patients when they get their first heart attack and therefore they may not have such tablets with them. Other recommendation is a to have a aspirin tablet if a heart attack is suspected. In any case the patient should reach the hospital within 6 hours of an attack in order to prevent any permanent damage to the heart .There are several treatment options available to the patient such as Streptokinase injection, stents etc which can quickly restore the blood circulation and prevent damage to the heart.
IMG :	There have been email circulating in which it is said that in case of heart attack one should deliberately cough in order to prevent oneself from collapsing. How far is this true ?
SK:	This is not true and on the contrary the patient should not exert at all. Deliberately coughing is only going to put more stress on the heart which is already stressed out. In all cases of heart attacks patients should reach the hospital at the earliest.
IMG :	How does smoking affect the heart ?
SK:	Smoking effects each and every cell of the human body right from the head to toe and it affects all the organs of the body . When a person smokes in addition to nicotine he also inhales toxic gases such as carbon dioxide , carbon monoxide as result all the blood vessels and organs such as pancreas, stomach, kidney and heart, brain etc gets affected. The blood vessels have an inside coating called endothelium that gets inflamed because of nicotine and causes spasms and constriction of the vessel and thereby leading to a situation of less blood supply to the heart.
IMG :	What are the occurrences of congenital heart diseases in India?
SK:	The prevalence of congenital heart disease in the normal population all around the world is just about 0.8 percent and is uniformly spread unlike the other heart problems. The effect of this disease can range from having little or no effect on one’s life to the tune of affecting the life severely from the day one and may need correction in the childhood.
IMG :	How can parents detect congenital heart diseases during early stages ?
SK:	If the child is not growing normally as comparable to children of same ages group. General symptoms are failure to grow, breathing difficulty, more chest infections, sometimes the child becomes blue .
IMG :	what treatments options are available to patients suffering from heart problems and at what stages are they applied ?
SK:	The treatment of heart attack ranges from giving blood thinners or enzymes to diffuse the clot , inserting of stents to establish blood circulation to full-fledged Bypass surgery . Inserting a stent involves a small invasive procedure where an artery is punctured in the groin area and the catheter is inserted to check the blocked arteries in the heart .Stents work like a pen refill that sits in the artery and expands it to restore blood circulation. These procedures are expensive and can help in quickly restoring blood circulation to the heart. Putting a stent is not an alternative to bypass surgery as commonly misunderstood and is only a way to prolong surgery. With stents there is lots of limitation in terms of periodical checkups as the stents can get blocked any time and there is no guarantee as to how long it will last. This also brings in use of expensive medication and changing your lifestyle drastically to suit your condition. The bottom line is that these procedures are not a solution for a patient to lead a completely normal life..However in cases where surgery cannot be performed a patient has no option but to use this procedure as a life saving means. Surgery depends on the various factors such as number of blockages, other diseases in the patient such as diabetes, renal problems etc .For patients with a single blockage a stent placed inside may not require any surgery however patients with multiple blockages should undergo bypass surgery at the earliest. Bypass surgery is like creating a diversion to a blocked artery and providing an alternative channel for the blood to reach the heart. The recovery from a bypass surgery usually takes about 6 weeks after which the patient can resume normal activities and lead a normal life. Provided the patient takes care of his health, he can lead a quality life, free of any heart problems for the next 15 years or more.
IMG :	we have been hearing a lot about beating heart surgery of late. What exactly is a beating heart surgery and what are the benefits of it ?
SK:	Heart surgeries have evolved over many years and the first bypass surgery was done in 1964 .Earlier on during the bypass surgery the patient was put on a heart lung machine and the heart was completely stopped and bypass graft carried out .Currently most of the bypass surgeries almost 95% are done on beating heart without the need to stop the heart. In the beating heart surgery a device called “octopus” is used to stabilise a part of the heart where the surgeons can perform the grafting. The entire surgery is carried out in a sequential manner without stopping the heart and without the need to use the heart lung machine. However during the surgery the heart lung machine is kept as standby as a security measure. Beating heart surgery is cheaper as compared to the normal bypass surgery as expensive heart lung machine not being used . In addition to the cost beating heart surgery is physiologically advantageous to the patient’s recovery.
IMG :	what is heart remodelling surgery ?
SK:	In the case of heart attack, a part of the heart may become damaged and becomes like a balloon. This is called aneurysm and causes heart failure. In the remodelling surgery, the balloon part of the heart is removed surgically and the heart is remodelled to its original geometric size.
IMG :	What is a minimally invasive surgery ? is robotic surgery is form of minimal invasive surgery ? are there any cases of it being performed in India ?
SK:	Robotic surgery and minimal invasive surgery are slightly different. In a robotic surgery the surgeon sits in small room and works on a computer system which in turns manipulates the robot . Since the robot’s hands are smaller and can move 360 degrees as compared to human hand it can perform surgery without completely opening the chest . However such types of surgery takes 12-15 hours and are very expensive. Minimal invasive surgeries are performed by surgeons directly on the patient by making multiple smaller incisions instead of opening a large area. This surgery is also time consuming and very expensive due to the use of specialised instruments involved in the surgery. The recovery time in this case is generally less as compared to conventional operations.
IMG :	What are the latest techniques in performing heart surgery and how does it help the patients?
SK:	With respect to the surgery techniques we are at par with the western world. the new technology making news in the west are Left Ventricular Assistive Devices (VAD) and total artificial heart.VAD is a mechanical device that is used to partially or completely replace the function of a failing heart. Some VADs are intended for short term use, typically for patients recovering from heart attacks or heart surgery, while others are intended for long term use, typically for patients suffering from congestive heart failure. VADs are designed to assist either the right (RVAD) or left (LVAD) ventricle, or both at once (BiVAD) and are attached to the heart and in case of heart failure it takes over the function of heart and thereby prevent heart attack. Artificial hearts are designed to completely take over cardiac function and generally require the removal of the patient's heart. Artificial heart is still under clinical trial. There is also a lot of research being carried out in Stem Cells therapy and currently under clinical trials.
IMG :	What is heart transplant? is it being done in India ? Who can donate heart? Is age an important criterion in organ donation?
SK:	In the case of heart transplant , the patient’s heart is replaced with a healthy heart from a donor . Cases of heart transplants are more found in Western countries as compared to India . In India the cases of transplants are rare due to the low awareness levels amongst the people and high cost of surgery. In India there is a long waiting list however in the absence of donors it becomes difficult to manage. The cost of such a surgery is also very high and costs almost to the tune of Rs 20-25 lakh . Moreover this too is not a permanent solution and it can last 5- 10 years. Any brain dead person can donate his heart. Generally younger hearts are preferred and hearts from people over 50 years age is not accepted.
IMG :	How can we bring down the cost of heart surgeries in India?
SK:	The cost of surgery in India is the lowest in the world and is in the range of Rs 70,000/- to a little over one lakh. The cost is because of consumable items, medication, ICU costs, and equipment costs. In the case of poor people , yashasvini scheme (in Karnataka) is already helping them a lot where government bears the cost of surgery and pays about Rs 70,000/- to the hospital which is just enough to absorb the cost of the surgery and treatment. Patient awareness is the key to reduce the cost of surgery. For patients having multiple arterial blocks it is important for them to undergo bypass surgery at the earliest instead of prolonging the surgery through procedures that use stents. Such procedures are only temporary solution and cost very high as compared to surgery because of the high cost of stents and costly medications involved.
IMG :	What approach should the patients take towards care in the post surgery period?
SK:	Patients after 6 weeks from surgery become absolutely normal and they can resume normal activities. One should carry out all normal activities and exercise in moderation and increase the activity level. Post surgeries medicines are given to control blood pressure and sugar levels and blood thinners such as aspirins are taken for life.
IMG :	What message would you like to give to our readers towards maintaining a good heart?
SK:	Regular exercise such as brisk walking and moderate well balanced diet.