KARACHI, Oct 10: The need for emergency bypass surgery in angioplasty, as it is practised today, has reduced in a big way. It is no wonder then that the arrangement of surgical backup has become very informal throughout the world.

This was stated by Dr Imran Afridi, the administrator of the Cardiac Care Center at the South City Hospital, in response to a news-item, titled “Angioplasty deaths spark off controversy”, carried by Dawn on Oct 6.

He added that while a risk of 0.2 per cent to 0.3 per cent was quoted by the Journal of the American College of Cardiology, the only report from a Pakistani centre gave a 1.2 per cent need for emergency bypass surgery.

The statement said: Amiruddin Valika died unexpectedly approximately one hour after an angioplasty procedure; a tragedy for the patient, his family and his physicians, and no amount of explanation or investigation will change the impact of this great loss.

The news-item did not present any cogent facts or statistics, but creates panic and lack of confidence in these procedures, doctors and health care institutions. However, this should not detract from the efficacy and safety of coronary angioplasty procedures which can be life saving and in majority of patients improve the quality of life or can be a substitute for coronary artery bypass surgery.

Following are factual data relating to this particular event and angioplasty procedures in general:

1. The issue of surgical backup: At the Cardiac Care Center (CCC) at South City Hospital (SCH) facilities are present to provide a safe angioplasty procedure. A cardiac surgeon with his anaesthesiologist is present during the procedure, as records at CCC will verify. The equipment required for emergency bypass surgery and post-op care is available. Routine or elective heart surgery is not currently carried out at SCH, and no emergency bypass surgery has been required till now, which may have led to the misconception that there is no backup.

Following Mr Valika’s angioplasty, no condition was identified which required emergency surgery, so the issue of surgical backup is irrelevant. Mr Valika had suffered a cardiac arrest whereas the news-item states that he had “a massive heart attack”. Cardiac arrest can be due to a variety of conditions including diseases unrelated to the heart. An ECG done after the angioplasty and shortly before his death revealed no evidence of an on-going heart attack. The exact cause of Mr. Valika’s death cannot be determined without an autopsy. This news-item makes a medical judgement which even Mr Valika’s doctors are unable to do.

In current angioplasty practice, need for emergency bypass surgery has dramatically reduced, and a risk of 0.2 per cent to 3 per cent is quoted. The only report from a Pakistani centre gives a 1.2 per cent need for emergency bypass surgery. The arrangement of surgical backup has now become very informal throughout the world. The current practice is of “passive” backup; surgeons are usually performing other operations while angioplasty procedures are in progress. In case of an angioplasty emergency the patient is stabilized and waits for the next available operation theatre.

Centres in Canada, UK, Ireland, France, Germany, Australia, etc perform angioplasty procedures with no on-site cardiac surgery services. Cardiac surgeons at close-by hospitals provide surgical backup. Distant surgical stand-by is supported by the German Society of Cardiology for a number of years. The British Cardiac Society expressed: “risks ... are believed to be so small that patients should not be denied the benefit of angioplasty ... without on-site surgery (and) the practice of off-site surgical stand-by is ethical”.

2. Increased mortality: The news-item alleges: “mortality rate associated with angioplasty has gone up”, “medical practitioners ... conceal this to protect their businesses” and “incidence of angioplasty mortality was quite high at SCH”. The title refers to angioplasty deaths in the plural whereas only a single death is mentioned and one doctor and one hospital are targeted. No facts or figures are given to support the above- quoted allegations. This is a clear case of sensationalism as it is not possible to conceal a patient’s death after angioplasty. At SCH, 165 angioplasty procedures have been performed; apart from a 90-year-old patient, Mr Valika is the second person to die after an angioplasty. The statistics at CCC are of 1.2 per cent mortality, 1.2 per cent heart attacks, 1.2 per cent repeat procedures, 0 per cent emergency bypass surgery and 1.8 per cent risk of major complication. Any competent and qualified authority can verify these facts, present in medical records. The 2001 American Heart Association Angioplasty Guidelines list the risk of complications as mortality 0.4 to 1.4 per cent, heart attack 1 to 3 per cent and emergency bypass surgery 0.2 to 3 per cent. The reporter was told of the 1 per cent angioplasty mortality at SCH but failed to mention it, nor did he compare it to other data.

Statistics at SCH are comparable to experienced hi-volume centres in the US. Pakistan should be proud to have doctors and institutions providing services comparable to the best centres in the world. Local newspapers should laud individuals’ efforts rather than criticize and defame those who are providing a great service to their countrymen. These doctors have returned to Pakistan after giving up lucrative jobs in the US; they should not be discouraged by petty gossip and sensationalism.

3. Mr Valika’s transfer to SCH: Mr Valika was admitted at Aga Khan Hospital and was advised coronary angiography. His cardiologist and he both requested a second opinion from Dr Asad Pathan. The angiography equipment was out of order at Aga Khan Hospital. This fact was given in a statement by the hospital administration and can also be verified from the procedure log and the maintenance company for this equipment. Given the option of having the procedure at SCH, he and his family agreed stating that this suited them, as SCH is closer to their residence. The news-item states Dr Pathan insisted Mr Valika be transferred to SCH whereas he went of his own free will at what was only a suggestion. He could have declined and done whatever else suited him. Several members of the Valika family are under Dr Pathan’s care and three of them have already undergone successful angioplasty procedures. In fact, Mr Valika first came to SCH emergency room for upper abdominal discomfort, seeking treatment from the physicians here and was later transferred to AKUH. Subsequent ECGs, blood tests and evaluation by a cardiologist and a gastroenterologist led to the diagnosis of a heart attack and no abdominal problem was detected.

Whose interest it was in to transfer Mr Valika to SCH? It is obvious this was for the patient’s benefit, as the same physician would have performed the procedure in either hospital. Was the treatment this patient received was wrong or negligent in any way? Mr Valika’s family is encouraged to have his details reviewed by independent angioplasty experts from the US, for their appropriateness or wrongdoing.

The news-item mentions the American College of Cardiology and American Heart Association Guidelines for Angioplasty. These place more emphasis on the competency of the operator than on the issue of surgical standby. Three years of comprehensive cardiology training including 12 months of cardiac angiography is required. An additional 4th year is required during which the individual must perform 250 procedures and after an exam Certification in Angioplasty Procedures/Interventional Cardiology is obtained. The physician in question has been trained in the US at University of Texas/Texas Heart Institute, and Massachusetts General Hospital, Harvard School of Medicine and has already performed over 500 interventional cardiology procedures. He is certified by the American Board of Internal Medicine, American Board of Cardiovascular Diseases, American Board of Interventional Cardiology and is credentialed to perform angioplasty procedures in the US.

CCC/SCH has appropriate facilities in their angiography lab, a wide range of equipment, adequate backup facilities and highly qualified physicians. Their results are comparable to international standards and comply with medical ethics. The general public should be reassured that safe and effective treatment of heart disease is available in Pakistan and is being performed in a professional manner.