DR. S. A. MERCHANTSenior Interventional Cardiologist

DM (Cardiology), MD (Med), DNB (Cardiology)Fellow of the American Society ofCardiac Angiography & Intervention www.drmerchant.in

A Guide to Todays Heart Treatment

23232323

23

22

2

ACHIEVEMENTS OF DR. S. A. MERCHANT

DR. S. A. MERCHANT IS A CONSULTANT INTERVENTIONAL CARDIOLOGIST FOR THREE DECADES AT MUMBAI, INDIA

2

Dr S .A Merchant 1978 batch Gold Medalist allumini from prestigous KEM Hospital.

Over a span of 14 academic years accomplished DM cardiology, MD Medicine, DNB

cardiology & Left KEM hospital as lecturer in cardiology in 1992

Trained in interventional cardiology between 1989 & 1993 at world renowned

University of Rouen in France and Mass Gen Hosp & Havard Medical School. USA

First Consultant & founder member of prestigous Lilavati Hospital & Research Centre in Mumbai. Has been in practice in interventional cardiology for 20 yrs at lilavati hospital till today25 years of practise in interventional cardiology at state of the art superspeciality hospitals NABH & JCI Lilavati, Saifee, Hinduja khar hospitalsCredit of performing more than 10,000 procedures in cath lab successfully and mastered the art of treating most complex heart disease with soluble scaffolds, medicated stents, peripheral stents, device implants for heart failure patients & other interventionsFirst in the world to implant Soluble stents below knee in Diabetic foot

23232323

23

22

2

3

First few in the World who pioneered soluble stent technology for complex coronary artery disease.

One of the first innovators of the TAVI valve in the world along with Legion of Honour Prof Alain Cribier

Large Experience of whole body angiography in diabetics and treating carotids, renals, lower extrimity & below knee blockages with stents

Recipient of the prestigious Fellowship of the American Society of Cardiac Angiography & Intervention

First few in India to start the Heart Failure Program with Innovative Devices & published a pilot study on follow up on 75 heart failure patient.

First few in India to master complex cath lab procedures for multivessel coronary artery disease who were referred for bypass surgery. A pilot

study on 100 patient with stents replacing bypass surgery in the pipeline.

First cardiologist in Mumbai to start The Interventional Diabetes & Hypertension Multiorgan Cardio Vascular Assessment Program”

successfully at Lilavati Hospital Cath lab with whole body angiography & DSA (Digital Subtraction Angiography)

A Teacher & Academician par excellence invited as Faculty delivered more than 500 CME lecture to doctors on innovations in cath lab.

A Thinker & Innovator in Interventional Cardiology started for the first time a Cardiac Rehab Program ‐ Full Life to Heart Patients at Lilavati &

Saifee Hospitals.

Published a book on “Journey & Experience of 25 years of Dr. S A Merchant in the field of the cardiology (stents & Innovative Devices) in 2014

Delivered more than 300 Health Talks on “Secrets of Healthy Heart” to corporates, communities, General public, NGO, Government Agencies

as A Community Social Awareness Programs

23232323

23

22

2

Saifee Hospital | Mumbai

Consultant Cardiologist

Visiting Faculty in CardiologyRaheja Fortis | Mumbai

Cardiologist

KEM Hospital | Mumbai

Cardiologist 1978 - 1990

Lilavati Hospital | Mumbai

Consultant Cardiologist

Hinduja Healthcare | Mumbai

Consultant

4

Dr. S. A. Merchant�s Professional Qualification & Fellowship :

1978 MBBS from Seth G S Medical College & KEM Hospital, Mumbai

1984 M.D. Int. Medicine, Seth G S Medical,& KEM Hospital, Mumbai

1989 Diplomat National Boards of Cardiology, KEM Hospital, Mumbai

1990 DM Cardiology, KEM Hospital, Mumbai

1991 Lecturer in Cardiology, KEM Hospital, Mumbai

1992 Fellowship in Interventional Cardiology, University of Rouen, France

1993Fellowship in Interventional Cardiology, MGH & Harvard Medical School, USA

1995 Consultant Cardiology, Liavati Hospital & Research Center Mumbai Till Date

1996 Fellow of American Society Of Cardiac Angiography & Intervention.

2002 Consultant Cardiologist at Saifee, Raheja Fortis Hinduja Hospitals in Mumbai Till Date

23232323

23

22

2

HYPERLIPIDAEMIA

MODIFIABLE RISK FACTORS

STRESS OBESITYPHYSICALINACTIVITY

DIET HYPERTENSION

DIABETES SMOKING CONTENTS

5

What is coronary artery disease? (pg 6)

What is Angina, Heart Attacks & Test to detect Blockages ? (pg 7)

What is Angiography? (pg 8)

When will your doctor recommend Angiography? (pg 9)

What are the procedures to relieve coronary artery disease? (pg 10)

What is Angioplasty ? (pg 11)

How will doctor know that you require Angioplasty or Bypass surgery? (pg 12)

How is Angioplasty different from bypass surgery? (pg 13)

What are the types of Angioplasties and how does your doctor recommend which one is best for you? (pg 14)

What are the Medicated ‘Stents' and why are Stents so important for your treatment? (pg 14‐15)

What is soluble stent & How it Benefits you ? (pg 16)

Will I need another Angioplasty? (pg 18)

Life after Angioplasty? (pg 19)

What are the newer life saving Intervention in the cath lab? (pg 20)

Can one reduce the progress of blockages & Heart Disease? (pg 22)

Secrets of a Healthy Heart. (pg 23)

23232323

23

22

2

WHAT IS CORONARY ARTERY DISEASE?

Coronary artery disease (CAD) affects millions of people around the world.

WHY YOUNG INDIANS ARE MORE PRONE TO HEART ATTACKS.

1) Life style

2) Stress

3) Diet more greasy with refined sugar

4) Chemicals in food

5) Lack of Outdoor Physical Activities

6) Tendency to Diabetes

7) Indian Metabolic Syndrome ‐Waist Obesity , Pre‐Diabetes, Low HDL

8) Habits ‐ Smoking Tobacco

9) Indian Genes & Hereditary 6

Fig. 1. Coronary Arteries

Left CoronaryArtery

CircumflexBranch

DiagonalBranch

Left AnteriorDescending(lad)

PosteriorDescendingArtery (pda)

AcuteMarginalBranch

Right CoronaryArtery

Coronary artery disease (CAD) affects the coronary arteries that supply blood to the heart muscle (Fig. 1).The most common cause of CAD is artherosclerosis, commonly called hardening of arteries.Risk Factors : Lifestyle, Stress, Diet of Refined Sugars & Fats, Diabetes, Hypertension, Smoking, High Cholesterol, Ageing, Family history etc.Fats, cholesterol and other elements carried in the blood get accumulated in the inner wall of the arteries to form a plaque.

23232323

23

22

2

CompleteArterial Blockage

Permanent

Heart Damage

Fig. 2. Myocardial infarction

WHAT IS ANGINA , HEART ATTACK & TESTS TO DETECT IT

What is Angina?

Narrowed coronary arteries restrict the amount of blood, that can reach the

heart muscle. Fatigue, tightness in the chest or a peculiar crushing type chest

pain called angina, may accompany the decreased blood flow.

What is Heart Attack?

If a coronary artery suddenly closes, blood flow to a part of the heart may stop

completely. In these cases, some of the heart muscle may be permanently

damaged. This is often accompanied by severe chest pain that won't go away.

This is called a myocardial infarction or a heart attack (Fig. 2).

Test to Detect Heart Attack / CAD

Cardiac Enzymes ‐ Troponin , CPK‐MB , SGOT

ECG / Echo / Color Doppler Stress Test

Stress Echo Thallium Stress test

Coronary CT Angio Coronary Angiography

FFR / Spasm Test IVUS / OCT 7

23232323

23

22

2

WHAT IS ANGIOGRAPHY?

Fig. 4. Insertion of Catheter

Catheter

Main Artery or

Vein of the Arm

Coronary

Arteries

Catheter

Main Artery or

Vein of the Leg

Either the arm or

the leg site is used

This procedure is done to see where and to what extent the coronary

arteries are blocked. A fine tube is passed along artery in the right thigh

or forearm upto the heart (Fig. 4).

A dye is injected and a serial X‐ray films are taken to study the flow of

dye in the coronary arteries. The pictures will let your doctor see any

narrowed or blocked arteries.

Your doctor will inject x‐ray dye through the catheters. You may need to

take a deep breath when the picture is taken.

When the angiogram procedure is over, you will go to a recovery area.

The introducer sheath will be taken out before you go to your hospital

room and you can go home in few hours.

8

23232323

23

22

2

Ostial Stenosis

Thrombus

Left Main Stenosis

Long Lesion

WHEN WILL YOUR DOCTOR RECOMMEND ANGIOGRAPHY?

Your doctor will recommend angiography under the following

circumstances :

When you have chest pain called Angina on walking or at rest.

When ECG or Stress test shows changes suggestive of ischemia.

After a heart attack.

During a heart attack, in unstable patients with a view to coronary

intervention.

Sometimes, you may have no symptoms called 'silent ischemia' which may

be detected at rest, stress test or by Multislice CT angiography. This is to

prevent silent heart attack or sudden cardiac arrest

9

23232323

23

22

2

When the disease is localized in one or two arteries, the blockage can

be opened by stretching or dilating. This is done by using a small

balloon on a tube inside the artery, this procedure is called

percutaneous transluminal coronary angioplasty.

When the blockage is more complicated and involves more coronary

arteries, coronary artery by pass surgery is recommended.

HOW WILL THE DOCTOR KNOW THAT YOU REQUIRE SURGERY?

After BalloonDilatation

Final Result

Blocked Artery

Stent Deployment

WHAT ARE THE PROCEDURES TO RELIEVE CORONARY ARTERY DISEASE?

10

23232323

23

22

2

Fig. 6. Balloon Catheter

Guiding

Catheter

Aorta

Coronary

Arteries

Coronary

Arteries

Balloon

Catheter

Ptca

Wire

WHAT IS ANGIOPLASTY ?

Angioplasty is a non surgical procedure designed to dilate narrowed coronary arteries.

It is similar to your coronary angiogram procedure. It is performed in the cath lab. In

Angioplasty, a small catheter with a small balloon attached is passed into the artery.

From here, it is passed into the coronary artery (fig. 6). The balloon is passed through

the blockage. The balloon is inflated to expand the opening in the artery. More blood

can flow through the artery, when the balloon is removed.

11

23232323

23

22

2

Fig. 7. Blood Vessel Dilatation

Your doctor may recommend placing a coronary stent. The coronary stent is designed

to help keep the treated area in the artery open and prevent recurrence.

If you need a stent, you may need to take special medications like Aspirin, Clopidogrel,

Prasugril , Ticaglelor before it is placed.

12

WHY STENT IS IMPORTANT FOR YOUR TREATMENT

23232323

23

22

2

HOW IS ANGIOPLASTY/ STENT DIFFERENT FROM BYPASS SURGERY?

Both operations achieve the same result. They increase the blood flow to the

heart muscle.

In Angioplasty / Stent the obstructed part of the coronary artery is widened

with a balloon catheter and a stent is placed.

It is non surgical under Local Anaesthesia with patient awake talking during

procedure, no incision is made and can be done during angiography. Patient is

discharged in 24 hrs.

Coronary artery bypass surgery is a supra major surgery done under General

Anaesthesia, a detour around the narrowed or blocked part of the coronary

artery is constructed using a length of vein or artery taken from inside the

chest. It is a major surgery involving opening of the chest, putting the heart on

the heart ‐ lung machine, using octupus in beating heart surgery, a prolonged

hospital stay and a greater risk and morbidity. 13

Dr. S. A. Merchant in Cath Lab Treating multivessel blockage

with stents

23232323

23

22

2

WHAT ARE STENTS? WHY IS STENT SO IMPORTANT FORYOUR TREATMENT?A coronary stent remains in your body. It is shaped like a small round spring. A stent is usually made of medical cobalt chromium. The coronary stent is designed to support the wall of the coronary artery.

The stent is placed on a balloon catheter like the one used for a PTCA. The stent and the balloon catheter are passed through the blockage. The balloon is then inflated. This causes the stent to extend inside the artery.

WHAT ARE THE TYPES OF ANGIOPLASTIES AND HOW DOESYOUR DOCTOR RECOMMEND WHICH ONE IS BEST FOR YOU?

Rotablator / Cutting BalloonArtery with Plaque

Stent mounted on Balloon

THE TYPES OF ANGIOPLASTIES :Bare Metal StentsBalloon Angioplasty4th Generation Drug eluting Stent Soluble Stent

Rotablator, AngioSculpt, Flextome . Drug Eluting BalloonMesh‐covered StentsAspiration CatheterJapanese technique for chronic total occlusion

14

23232323

23

22

2

Stent with Balloon inflated

Balloon withdrawn - Stent implanted

AFTER YOUR STENT PROCEDUREYour stay in the hospital can be from one to two days. For the first eight to

twenty‐four hours after your procedure, it is very importance not to bend

your 'procedure leg'. You should also remain flat in bed. The nursing staff

will check your leg for warmth and color. They will also look for any

bleeding. After the introducer sheath is removed, you will be allowed out

of bed.

You will also take a daily dose of Aspirin and clopidogrel as well as a

combination of drugs. Some of these medications also help to thin the

blood and prevent blood clots.

It is very important that you take all of your medications until your doctor

tells you to stop.

After the stent has been expanded, the balloon is deflated and removed.

The stent stays inside the artery to help keep the artery open. This

improves the blood flow to the heart and helps relieve chest pain.

15

23232323

23

22

2

SOLUBLE STENT & HOW IT BENEFITS YOU ?

Made of PGLA (plastic like) and needs special technique to implant it

Restores natural blood vessel formation

Leaves behind no metal or foreign body

Regenerates the intima, media and endothilial lining as a ”new

coronary artery”

Disappears in 18 months with 18% increase in vessel area

Can stop blood thinners after 12 months

16

23232323

23

22

2

GOING HOME FROM THE HOSPITAL - Do�s & Dont�s

17Change of Life Style

You will be given instructions by your doctor about your physical activities, you will

receive information on how to reduce the risks of further coronary atherosclerosis.

THE NEED FOR ANGIOPLASTY MAY BE REDUCED OR AVOIDED BY :

Changing eating habits and reducing fats and refined sugar in your diet.

Participating in a regular physician ‐ approved exercise program.

Reducing or stopping smoking , Tobacco Intake

Changes in Life Style with Yoga , Meditation.

Control your Diabetes , Hypertension , cholesterol , improper habits & Lifestyle.

Taking the medicines Aspirin, Clopidogrel, Prasugril & Ticaglelor regularly as

prescribed by your doctor.

After several months, your doctor may want you to have a stress test or Thallium test.

This procedure monitors the result of your Angioplasty and stent placement.

23232323

23

22

2

18

WILL I NEED TO HAVE ANOTHER PTCA?

There are chances 2‐3% with 4th Generation Drug Eluting Stents. The dilated part

of the coronary artery may be narrowed in some patients, within the first six

months. After the first six months, if there is no recurrence, then it is not a

problem.

What are Medicated Stents (Drug Eluting Stents)?

Stents medicated with drugs like Everolimus, Sirolimus etc on a polymer have

virtually eliminated the chance of recurrence. It is very important that you take

Aspirin, Clopidogrel, Prasugril & Tecaglelor along with your other medications

under supervision of your doctor. Never stop it without consulting your physician.

4th Generation medicated Stent

23232323

23

22

2

LIFE AFTER ANGIOPLASTY / STENT

19

Angioplasty / Stent is performed to restore a person to an active and full life. The goals of

the procedure are to enable a person to improve the quality of his life and prevent heart

attack. It makes sense to reduce the risk factors by controlling high blood pressure, high

blood sugar, maintaining a low fat diet, keeping weight down, to give up smoking and

having a sensible exercise and diet program.

Full Life To Heart Patients

23232323

23

22

2

20

Pacemaker

Internal Carotid Artery Stenting

WHAT ARE NEWER LIFE SAVING INTERVENTIONS IN THE CATH LAB?

Angioplasty in acute Heart Attack.

Multi vessel blockages treated with newer stents replacing Bypass Surgery.

4th Generation Drug Eluting Stents with various drugs like sirolimus, everolimus etc. have

virtually eliminated the chance of recurrence.

Soluble Stent in Complex CAD.

Rotablation, Flextome, angiosculpt, scoring balloon, mesh covered stents, drug eluting

balloon and thrombectomy catheter

Angioplasty in post bypass patients with occluded bypass grafts (venous & arterial)

Neck artery stenting in paralytic stoke patients.

Renal artery stenting in hypertension / kidney failure.

New Imaging with Camera Tip Catheters ‐ IVUS / OCT / FFR

23232323

23

22

2

21

Kidney Artery Stenting

Leg Artery Stenting

Diabetes & Hypertension Multi Organ Cardiovascular Assesment With Whole body Angiography And DSA

(Digital Subraction Angiography)

Leg Arteries, Aorta, Peripheral Artery Disease & Below knee treated with Balloon Angioplasty & Stents

Cardiac resynchronization therapy, Combo device (Biventricular + AICD) in Heart Failure

Blocked heart valves treated with balloon Valvuoplasty.

IVC filter and local thrombolytic therapy in Pulmo thrombo ‐ embolism with leg vein Clot

Umbrella closure device for Holes In Heart.

Permanent pacemaker implantation in patient with slow pulse & giddiness / blackout.

Electrophysiologic studies with radio frequency ablation in pulpitations & fast pulse rate.

ICD (Implantable Cardioverter Defibrillator) in patient with Arrythmias, Heart failure and Cardiac Arrest

Below knee angioplasty with Drug Eluting Balloon / Stent / Soluble Scaffold for blockages in diabetic foot

TAVI (Transfemoral Aortic Valve Implant) for Blocked Aortic Valve

23232323

23

22

2

22

CAN ONE REDUCE THE PROGRESSION BLOCK AGES &THICKENING OF HEART ARTERIES

CHANGE IN LIFESTYLE TO REGRESS CORONARY ARTERY DISEASE

Low fat, low refined sugar diet consist of :

70% complex carbohydrates (grains, legumes, vegetables, fruits)

10% Fats (yogurt or non‐fat milk, cooking oil)

15‐20% Protein (dals, beans, egg white, fish, chicken)

Aerobic Exercise :

Moderate paced walks 30 mins a day or 1 hour every

alternate day

Stress Management Techniques :

Stretching Exercise (Yogic Asanas)

Deep Breathing (Pranayama)

Meditation

23232323

23

22

2

SECRETS OF A HEALTHY HEART

Quit Smoking, Tobacco chewing

Sr Cholesterol < 150, LDL < 60, HDL > 50, TG < 100 mg/dl

Maintain body weight to ideal body weight.

Control of Risk Factors : diabetes, hypertension etc.

Regular medicines as prescribed.

Aspirin, Clopidogrel ,Prasugril & Ticaglelor (blood thinners)

Statins (cholesterol lowering drugs)

Nitrates (arterial vasodilator)

Beta Blockers, ACE‐Inhibitors, Angiotensin Receptor Blocker, Calcium

Channel Blockers

Newer anti‐anginal drugs : Nicorandil, Ivabradine, Ranolazine

Regular Cardiac Fitness Evaluation : Clinical & risk factors assesment,

ECG, 2‐D Echo, Stress test, Stress Thallium, Multislice CT Angio, Sr lipid

profile.

23

23232323

23

22

2

Dr. S. A. MerchantDM (Cardiology) MD (Medicine)

Diplomat National Boards of Cardiology

Fellow of the American Society of

Cardiac Angiography & Intervention

CONSULTING ROOMS (By Appointment)Merchant Cardiac Clinic 100A Valentine Rest, Next to Mehboob Studio, Above Patel Stores, Hill Road, Bandra West, Mumbai 400 050. Tel.: 2655 0101 Clinic Mob.: 7738768888 Email: drmerchantsa@gmail.comTime: 4.00 - 8.00 p.m. Daily | Mobile : 98210 58030 / 98209 30389

Lilavati Hospital Bandra West, Mumbai 400 050.

Tel.: 2675 1000, 2656 8000

Time: 12.00 - 2.00 p.m. Daily

Hinduja Hospital Khar West

Tel.: 022-61746000 (By Appt.)

Saifee Hospital Charni Road, Mumbai 400 004. Tel.: 6757 0111

Wed/Sat Time: 1 p.m. - 4 p.m.

Navjeevan Medical Centre02 / 112 , Navjivan Society , Off Lamington Road,Mumbai Central , Mumbai - 400008.Tel.: 022- 23015258 Mob. - 9029977771

23232323

23

22

2