Pioneering work in angioplasty

Interview with Dr. Mathew Samuel Kalarickal.

Eminent cardiologist Dr. Mathew Samuel Kalarickal, who has been awarded the prestigious Dr. B.C. Roy award for 1996, started and established angioplasty in India. He also played a major role in introducing and establishing facilities for angioplasty in a wide range of countries in the Asia-Pacific region. In the 11 years since 1986, he has performed 5,000 angioplasties and has thus helped patients who were crippled by heart disease achieve a new quality of life.

Dr. Bidhan Chandra Roy was an eminent medical scientist, educationist and a statesman. He was the first President of the Medical Council of India, the apex body for maintenance of standards of medical education in the country. He was also Chief Minister of West Bengal from 1948 to 1962.

Dr. B.C. Roy awards, established under the aegis of the Medical Council of India, are given every year by the Dr. B.C. Roy National Award Fund to honour eminent persons who have achieved distinction in medicine, philosophy, science and arts.

Dr. Mathew Kalarickal is President, Asian-Pacific Society of Interventional Cardiology, for 1995-97, and Chairman, Interventional Cardiology, Asian-Pacific Society of Cardiology, for 1995-99. He is the founder-convenor of the National Angioplasty Registry of India, which is a forum for interventional cardiologists of the country to learn from each other, streamline the standard of procedure and maintain international standards.

Dr. Mathew Kalarickal is at present Director, Interventional Cardiology and Cardiac Catheterisation Laboratories, Apollo Hospitals, Chennai. He is also a visiting Interventional Cardiologist at hospitals in different parts of India.

Excerpts from an interview Dr. Mathew Kalarickal gave T.S. Subramanian:

You have been awarded the Dr. B.C. Roy award for medicine this year. Could you tell us about the work for which you have received the award?

It has been decided to give the award to me this year for my work in developing coronary angioplasty in the country and to acknowledge the work done by me to start and develop angioplasty in India. For medical practitioners, the Dr.B.C. Roy award is the highest recognition in the field. I consider it a great honour to be selected for this award.

What is angioplasty?

Angioplasty is a procedure done under local anaesthesia. We get to the blood vessel supplying blood to the heart muscle and remove blockages in the arteries supplying blood to the heart. There are three major arteries and branches supplying blood to the heart. When these blood vessels become narrow or blocked by deposits, the blood supply to the heart is reduced. When blood supply goes down, it usually produces what we call angina or pain in the heart. This is usually precipitated by exertion. Some groups of patients may not have the same symptoms. These are called cases of silent ischaemia. It goes unnoticed. Stress tests are commonly used to detect ischaemia. The confirmation is done by angiogram. When the arteries are blocked completely, they can produce heart attacks.

In angioplasty, we try to remove these blockages in order to re-establish the blood flow. Patients can usually get back to normal activity in three or four days.

Could you tell us of your efforts to establish angioplasty in India?

I came back from the United States in 1985 after training there under Dr. Andreas Gruentztig, who is known as the father of coronary angioplasty. At that time, I had two options: to stay back and practise in the U.S. or to come back to India, where angioplasty had not begun at all. At that time, India was behind the U.S. and Europe by ten years in the field of angioplasty. I decided to come back and get angioplasty work started in our country.

As in other procedures, the initial hurdles were many. The main reason was a feeling among physicians in India that Indians' coronary arteries were too small to be given angioplasty. I was convinced that this was not true: many Indian patients came to the U.S. to undergo angioplasty successfully there. Gaining acceptance of this procedure in India took about a year. The only hospital that could visualise a future for this procedure was Apollo Hospitals at Chennai. Dr. P.C. Reddy, Chairman of the Apollo Hospitals, provided the back-up and was very supportive during the teething period.

I was new to Chennai and to get patients was difficult. All credit should go to Dr. M.R. Girinath, cardiac surgeon at the Apollo Hospitals. Whenever he came across suitable cases for angioplasty, he referred them to me and we were able to treat 18 patients in the first year, 1986. People who saw results began to accept the value of the procedure, and by 1987, we treated 150 patients. This was the challenge I had to accept.

The enormous satisfaction I derive from the achievement of establishing angioplasty in the country is beyond what money can buy. The only treatments available at that time was by-pass surgery or medical management. I considered it part of a moral obligation and commitment to the country to try to develop this additional method of treatment for heart patients.

Angioplasty is an alternative treatment to by-pass surgery. After we established the credibility of the procedure, all our endeavours were directed towards teaching and training other cardiologists all over India. We began to do so in 1986 at the Apollo Hospitals. A large number of cardiologists came and spent time with me in the theatre and I travelled extensively in the country to teach and train people. Many hospitals in India have now been able to train people.

Then I took up the challenge of developing angioplasty programmes in neighbouring countries and in the Asia-Pacific region. I have trained people in angioplasty programme in Pakistan, Bangladesh, Sri Lanka, the United Arab Emirates, Abu Dhabi, Muscat, Indonesia, Thailand and Malaysia.

What are the latest developments in the field?

Among the latest developments is atherectomy - cutting and removing deposits by using cutting devices or drills at two lakh revolutions per minute. We do that in a moving heart, one that is functioning. Stents are another development. Stents made of stainless steel or other material are used to provide a scaffolding inside the artery to reduce the chance of the artery collapsing or re-narrowing. Other techniques are laser angioplasty and radiation during angioplasty, which are being tried in selected centres. Their long-term results are yet to be assessed.

In conventional angioplasty, we were only using a balloon to remove or compress the blockage. Now, with newer technology, we have been able to improve dramatically, the immediate and long-term results. And the risk of the procedure has been brought down substantially - to less than 0.25 per cent, against the risk of one to two per cent in surgery.

In the early 1980s, angioplasty was done only on patients who had single blockages or what we call single vessel disease. But from 1987-88 onwards, I began treating patients with multiple narrowing or multi-vessel diseases. Today, we have proved that this is a viable treatment with good long-term relief. The purpose of this treatment is to reduce the risk to life and give relief to patients who have symptoms of angina and are crippled and are unable to do their normal duties.

I understand that you have done more than 5,000 angioplasties.

We have been able consistently to give confidence to referring physicians as well as patients that angioplasty, properly done, is an extremely satisfactory mode of treatment. The majority of the patients come to me by word of mouth, from patient to patient. We have done 5,000 angioplasties; we are among the leaders in the field in the entire Asia-Pacific region. The consistency of the results, the commitment to teach and the willingness to spend time in over 138 hospitals in India and the Asia-Pacific region have brought us credibility and acceptance. That combination ultimately brought the headquarters of the Asian-Pacific Society of Interventional Cardiology to Chennai for the last two years; I was elected the President of the Society.

Some people believe that angioplasty gives short-term benefits, particularly when compared to surgery.

When angioplasty was started and only the plain balloon was used, the balloon was used to compress the blockages. The occurrence of re-narrowing at the same site was found to be between 30 and 35 per cent. Compared to surgery, this was definitely a higher recurrence rate. But today, the regular use of newer devices, mainly the stent, has altered long-term results remarkably. I insist on repeat angiography after six months to prove the long-term benefits. This has provided us with information that shows that in respect of arteries where we used the stent judiciously with or without atherectomy, the long-term benefit was 88 to 90 per cent.

Are these results obtained all over the world ?

If these stents are not appropriately or judiciously used, the result is not reproducible. Hence, the experience of the operator is an important factor in consistently good long-term results. Restudies after angioplasty prove beyond doubt that long-term success is reproducible in single vessel and multi-vessel coronary artery diseases, provided the proper technique is used.

We learn that you have said that from now onwards, you will waive your professional fees for any general ward patient treated by you. Angioplasty is an expensive treatment. How can it be made affordable?

As you rightly said, if I have decided to waive my professional fees for the general ward patients wherever I treat, it is primarily because I feel that there is a need to support poor patients in these countries. About 20 per cent of my patients are admitted to general wards. That share may go up to 30 to 40 per cent. I firmly feel that as professionals, we have a moral obligation to the country and the community. Since the nation has honoured me by giving me this award, I feel I have an obligation to do something for the country.

A lot of patients do go for by-pass surgery because surgery is often cheaper than angioplasty, especially with multi-vessel diseases. The major cost of the procedure is the cost of the disposables. The balloon, the stent and other equipment are imported from the West. With changes in currency rates between 1986 and 1996, the cost of these has more than doubled. We could do an angioplasty in 1986 for Rs.50,000 to Rs.60,000. It is over a lakh of rupees for a single block now. If we use a stent, the cost is likely to go up by Rs.40,000 or Rs.50,000. For a lot of people, this is unaffordable.

A lot of people are working to reduce the expenses involved in the procedure. Dr. B. Somaraju of Hyderabad has developed an indigenous stent that costs between Rs.10,000 and Rs.15,000. That is a laudable effort.

We have started a Trust with my funds and support from a lot of rich patients who were treated by me to subsidise costs. We have not yet got a large enough corpus to get the programme started, but we should be able to do so within a year.