Heart Disease & CABG - My learnings

Note: This post of mine isn’t about innovation and this isn’t about me :).

My father, 76, underwent a coronary artery bypass graft or simply called a bypass-surgery, recently. He is recovering well, as the operation was uneventful and normal life is almost back. However, we were highly stressed for a period of around a month — since the discovery of his heart condition (4 severe blockages in the arteries) till the time of surgery, trying to find the right option for him. I am sharing this article to help the people undergoing similar situation of anxiety for their own or their loved ones’ heart disease condition.

I wanted to write this also because even after leading an ideal health routine throughout life, he developed arterial blockages. My father has been a teetotaller, non-smoker, vegetarian and moderate lifestyle person throughout and did not have any major disease. He is a retired professor of economics and currently publishes a quarterly magazine on economics (Economic Challenger). He usually does not get stressed and he is intellectually active till date. His food habits are moderate and he eats a lot of greens in the diet. And a notable feature- he has been walking 6–8 km every day for last 50 years. He sleeps 8 hours every day and is an early riser. So one can see that he has been doing all the right things a cardiologist would prescribe to stay away from this disease.

He still got this disease and we, like everyone else around us, were in a shock ‘how can this happen to him’? (a bad conclusion could also be that if such a person can get this, then indulge and have fun in life anyways:)

Detection and doubts
Trouble started when he was in Bangalore with my sister and he felt that his two fingers in the left hand went numb. Usually shoulder numbing or hand numbing is seen as a sign of a heart condition. My sister insisted that he should see a doctor immediately. The local doctor took an ECG which showed some abnormality. He was suggested an eco-cardiogram immediately. Eco-cardiogram showed NORMAL. While this was on, my father kept insisting that everything is okay with him and he just needed a Neurobian (vitamin) tablet which he took for numbness in limbs at times.

However, doctor suggested that further investigation must be conducted as these two tests are not enough. Later I came to know that Stress Test (tread mill test) and angiography (it is invasive one- inserting a catheter into the heart to see the condition) are the only techniques to know the heart conditions for sure (there is a non-invasive CT angiogram now possible). ECG and ECO-cardiograms are not sufficient. In asymptomatic cases (where no heart failure has been detected) both can be found normal and still the heart might have blockages.

My father finally underwent an angiography at Aditya Birla Hospital by Dr. Sethi (one of the top cardiologists in Pune). Angiography was a short procedure of 20 minutes but admission to report, took several frustrating hours. Doctor showed us the video of the angiogram (we were not allowed inside the OT) and told that there are at least three severe blockages. And he needs to immediately undergo CABG (Coronary Artery Bypass Surgery). Since he was admitted already, next day would be the best — we were told. Here was a situation-

1. We were not ready to still accept the findings due to our impression of his ‘ideal health routine’ of 50 years
2. A friend had told us (whose father also underwent angiography) that ‘usual’ practice is to suggest immediate operation
3. I didn’t even know that ‘angioplasty’ (putting stents, which could be done at the time of angiography itself, take only a few minutes and the person can start working the next day) was also an option that could be explored.
4. It was too sudden to react and accept the operation call.

We asked for his discharge from there and went home.

Now started a long winding cycle of advice and counter advices. We (my wife and I) also felt that we must explore non-invasive methods of heart blockage treatment, especially for a person like him who had no prior history of heart situation, no major disease (diabetes) and was walking kilometres till the last day when this discovery happened.

Second, third opinion and not settled

Anyways, we first wanted to take a counter opinion. Searching for a cardiologist for a counter opinion was a task. We zeroed down on Dr. Rahul Patil (a cardiologist with Ruby Hall hospital in Pune and has an independent practice right opposite the hospital). By this time we had read about angioplasty and had doubts that why angioplasty was not suggested by Dr Sethi and CABG was prescribed. Dr Sethi was a busy man and didn’t appear accessible to our queries.

Our plea to Dr Rahul Patil was to take a look at his reports, his health routine and explore possibilities of avoiding CABG. He listened to our story patiently and ordered just a few more tests (Carotid artery and Creatinine). One can’t imagine how relieving it can be to find a doctor who listens to you in these times of stress, with all his attention and with a gentle smile on his face. He also meticulously drew an illustrative picture of the state of his arteries to explained to us why CABG appeared to be the only option. Check out this wonderfully sketched diagram below. Since the Left Main Artery which supplies the majority of blood to the heart was choked 90% (there was also calcification- shown in black), any miscalculation in putting a stent there might choke up blood supply and there could be a death on the operation table. Dr. Patil did exchange some emails with his expert counterparts from Japan and said that CABG is the only option.

Concept of Collateral Arteries and Natural Bypass

We also learnt a new term called ‘collateral arteries — which had developed on the right side. His right artery was 100% choked as seen in the diagram but body had developed natural ‘bypasses’. We then understood how his ‘healthy routine’ saved him from so far from any active heart attack as these collaterals developed early on. Athletes tend to have an increased heart capacity due to a web of collaterals in the heart.

Schematic diagram shows that my father had developed collaterals on the right artery (shown below the 100% blockage)

While this was on, we were also watching videos by Dr. B M Hegde (cardiologist and ex vice-chancellor of Manipal University, India) who is a proponent of natural healing. (According to him ADR -adverse drug reactions — are killing more people than medicines specially in case of heart disease. Statins, the blood thinners have terrible effect on the whole body). Do watch his videos for general health awareness and building a perspective on limitation of drugs/current medical practices.

So we did write an email to Dr Hegde through his website, stating the reports of my father and checking if it would be wise to opt for some non invasive/natural/ayurvedic/lifestyle change cures rather than CABG. But no reply from him.

Minimally invasive surgery v/s open-heart surgery

We also wanted to find out if the surgery can be done through laparoscopy (only a small hole in the chest, rather than cutting the sternum bone). Our doubts were puts to rest, by the head of cardiology of Apollo hospital in Delhi (Dr. Meherwal, who was kind enough to receive my call and go through the Whatsapp message with reports). He said that in this situation when the left main has to accessed, that option is out. Also laparoscopy has different meaning (in terms of size of cut) for stomach vs heart. Regular CABG is the only option, immediate.

Our question to doctors has been that if my father could remove oil and minimise salt from the diet, walk slower — can’t he continue few more years as he has been, till only an invasive procedure found things out. But cardiologists had just one opinion — immediate CABG. No other option.

Natural/alternative methods
We still had hope. We came to know of Dr. Chhajed’s Saaol Clinic. His narrative of lifestyle change combined with some non-invasive therapies looked promising. Great number of simple-to-understand videos by Dr Chhajed, are free on YouTube and useful for everyday life to stay away from heart disease. We managed to get an appointment with Dr Chhajed in Jaipur (he is a busy man, with more than 100 clinics in India).

He pointed us to a recent research on how CABG does not alter the course of heart events for asymptomatic stable heart disease patients (do read this). It just improves the life quality (i.e. you may not live longer because the operation, but you will live better). It was encouraging.

He explained to us the situation well but remained non-committal about explaining how in my father’s situation, where left main artery has choking right at the mouth of it, will develop any ‘collaterals’.

Another not-so-nice stuff about his treatment was that he asked us to discontinue all the medicines my father had been taking and prescribed ‘Saaol branded’ medicines only (same salt, but own branded). Apart from non invasive EECP therapy (pumping the body to increase flow of blood towards the heart so that collateral arteries can develop). One of the treatment prescribed by him involved detox of the body by undergoing some sort of saline infusion in the body every alternate day for 30 days (with possible side effects on kidney and no protein intake during that time).

Although I did meet people who were benefitted from this treatment but in our case, it did not have a convincing answer. We summarily rejected the idea of living with uncertainty and decided to go for CABG.

CABG — Hospital Selection (Pune specific)
Now once it was decide to go for CABG, the next big headache was to choose the hospital and the doctor. We also came to know of the ‘package’ hospitals offer ranging from Rs. 2.5L to several lakh rupees (in USA, this could be 10 times as costly) depending on the kind of room (sharing, private, luxury) you choose. In Pune, we went and met the doctor at Deenanath Mangeshkar Hospital (DMH) which is in the heart of the city and known for good care. The doctor saw the reports and said, “with this diagnosis, if the patient had come to me and gotten the angiography, I wouldn’t have allowed him to go back without getting the bypass surgery done. Immediate surgery please” (it was a put off). Also, big hospital have their own hassles.

We also inquired about the top doctor Ranjit Jagtap in Pune, who had supposedly, done 30,000 operations like this but he visits DMH on call. We went and met Dr. Jagtap who, we came to know, had opened his own private heart specialty hospital. We went and met him there (meeting time 6am to 8am in the morning only and free of charge). He came across as a simple and warm person and of course, he also didn’t buy our ‘healthy routine’ so ‘operation can be avoided’ story. He also told us how they extract veins from the leg or hands using laparoscopy (so no long cuts in the leg, which otherwise take long time to heal). DMH didn’t have this equipment. But we took a round of his hospital (Ram Mangal Heart Foundation, Hadapsar) and we were a bit put off. It was running in a vacant mall space with a not-so-clean an entrance. We were still vacillating between DMH vs RMH as hospital. Charges were about the same at both the places. A friend of ours put the weight behind Dr. Jagtap and his hospital. He gave following reasoning:

1. His own father was operated there, successfully. 7 day recovery and took a flight to his hometown.
2. They used endoscopic method for extraction of veins from legs or hands for grafting, so that there are long cuts there. Healing is much faster.
3. Speciality and small hospital (RMH) so quiet and accessible for all help all times. DMH is large and all kind of patients come there, including the once with infectious diseases.
4. Staff is helpful and take a room facing the road. They have large glass windows. Your mother can sit and watch the city roads, compared to a four sides closed room, hospitals tend to have.
5. Ignore the unclean entrance. Inside the hospital it is clean and operation theatre is state of the art.
6. Dr. Jagtap even attends his patients on Sunday.

We bought into the argument. Overall reading was that, medically the doctor and the infrastructure is amazing, staff is supportive and trained but it does not have auxiliary services like canteen, in good shape. Well, he had to bite the bullet and fortunately nothing untoward happened because of these issues.

Everything went well and the wounds healed fast. My father is already reaching 1.5 km walk everyday (9 weeks post CABG). He should be regaining his 6 km routine soon.

Learnings in this process for our own health

We went around and saw at the hospital that my father was the most aged there. People from the age 35 upwards were admitted. Average age of patients with CABG was around 50. India is a heart disease and diabetes capital in the world and as Indians we have some genetic predisposition towards these diseases. Combined with everyday stresses, heart disease is becoming common even amongst younger folks. So, good health routine still does not guarantee this disease immunity. I met a sportsman opposite our room there, who used to feel some heaviness while running fast. He was 40 and lived in small town nearby. One would assume, he had no stressful life and contaminated food issue. He had 3 blockages in the arteries. I, my brother and my father always had HDL on the lower side (those who are new to these terms of cholesterol, please read-up on HDL, LDL and Triglycerides). So there is this genetics element we can’t do much about.

Dr Chhajed’s videos are very good to follow a good regime. We discovered how Indian style vegetables and curries can be prepared without oil (yes, no oil at all). We have reduced oil and ghee consumption at home, reduced fried stuff bought from the market. Refined oils, oily preparations bought from the market (reheated and reused oil) is a major source of triglycerides (not desired).

Cardiologists, by their training, will never take the side of natural recovery or life-style alteration alone as a route. Moment they see 60–70% blockage in multiple arteries, the advice would be to go under the knife (stent or CABG). It will take individual conviction alone, to take the non-conventional route. In our case, my parents were not really ‘in’ for trying alternative ways. I had to read their mind and go for ‘safer’ option of CABG (though it is scary to know the number of ways in which such a ‘routine’ operation can go wrong — I was presented with the indemnity contract to sign before this operation with the probabilities of different risks and failures).

30 minutes of cardiac activity everyday(brisk walking or running or sports) is a must for a healthy heart. Stress-test or treadmill test is a must to include in the yearly health-checkup plan. ‘Plant based diet’ (essentially, turn vegetarian) is the latest jargon entrant into the game. We are reducing our milk intake and staying vegetarian.

I still believe that if the patient is asymptomatic, stable (no previous known case of heart attack) and there are arterial blockages (not at the junction of left main artery, like my father), one should be able to avoid open heart surgery and can rely on life-style modification along with some medication.

With COVID19 already complicating life (or simplifying it for a while), it is time to recalibrate pace and quality of life. Nothing is more important than health in this world. Our bodies don’t have the kind of resilience our forefathers had, so we need to be more careful. Take it easy and stay strong.

For all the healthy cynicism I maintain for current medical practices, doctors are still angels when it comes to saving lives. My gratitude to Dr. Jagtap and his team of dedicated professionals.

I was benefitted reading a lot of reviews and articles on this disease. This article is my contribution to people undergoing this stress and decision making on this (a bit tilted toward Pune residents though, in terms of extra details provided here). There are several references here unlinked. I can provide the contacts/reference on request.

Note:
1. Medical terms used in this article are my amateur understanding as a commoner and should be double-checked with the doctors for precise interpretation.
2. Do consult your doctor before forming an opinion based on this article.

p.s. update Feb 2021: My father is doing well and absolutely no problem. he walks 3–4 km everyday and able to drive scooter and car without any hassle. Blood thinner and medicine for BP continue (doctors say, it is life long routine now). He does maintain some watch on oily food etc. but is not averse of moderate indulgence. So far, so good.