Question 1

Regarding valve repair strategies in heart failure, specifically a tricuspid valve case where the options are mechanical valve, bioprosthetic valve, or transcatheter edge-to-edge repair (TEER) — which is preferred and when?

Dr. Biswarup Purkayastha · Accepted Answer

The tricuspid valve is more often repaired than replaced. Even in a moderately aged patient in the 50 to 60 age group, if tricuspid valve replacement is necessary, a bioprosthetic valve is preferable to a mechanical valve — the right side is a low-pressure circuit, so a mechanical valve there carries a very high thrombosis risk that can embolise to the lung and be fatal. The preferred approach overall is tricuspid repair, either a traditional DeVega repair or an annuloplasty ring. TEER (TriClip for the tricuspid, MitraClip for the mitral) warrants real caution — for the mitral valve it's the surgical community's last resort, used only when every other repair technique and replacement are precluded by financial or anatomical constraint. With today's preoperative 3D imaging of the mitral annulus, a surgeon can nearly always plan intervention in advance instead.

Question 2

What is the role of traditional alcohol in cardiomyopathy?

Dr. Biswarup Purkayastha · Accepted Answer

The evidence is unambiguous: any form of alcohol predisposes to cardiac dysfunction. Traditional drinks have been examined alongside commercially available alcohol in studies, and the myth that red wine protects the heart has been comprehensively debunked. Chronic alcohol consumption damages the heart, full stop. Whether someone chooses to drink socially is a personal decision, but scientifically there is no basis for recommending any alcohol for cardiac health.

Question 3

How do you manage the bleeding risk when loading a patient with 600mg aspirin and clopidogrel?

Dr. Biswarup Purkayastha · Accepted Answer

You do not manage it — you accept it, because that is your best option to open the coronary artery blockage. The bleeding risk is only a problem in a living patient. If the patient dies from a myocardial infarction for lack of intervention, there is no bleeding to manage.

Question 4

What is the primary indication for using sacubitril/valsartan, and how is it dosed?

Dr. Biswarup Purkayastha · Accepted Answer

It should be started at the lowest possible dose — half a tablet, 25mg once daily, titrated over a week to 50mg, then 100mg, not typically exceeding 100mg once daily or 50mg twice daily. The primary indication is ejection fraction below 45% with elevated NT-proBNP. In a patient with ejection fraction below 35% and high NT-proBNP, it should be initiated at the lowest dose and titrated carefully upward.

Question 5

From your experience, what is the relative epidemiology of coronary artery disease in Africans, Asians, and Caucasians? Are there differences in surgical outcomes across these populations?

Dr. Biswarup Purkayastha · Accepted Answer

In Africans and Asians, coronary artery disease is largely driven by genetic predisposition. In Caucasians, the predominant driver is sedentary lifestyle combined with diet — high-fat foods, alcohol, physical inactivity — which more than compensates for their lesser genetic predisposition. Surgical outcomes are comparable worldwide, with success rates upward of 90% and combined morbidity and mortality after CABG around 5 to 7% regardless of country. But the numbers in Asia and Africa are hugely underrepresented — if one million cardiac deaths annually in sub-Saharan Africa is the current reported figure, the true number with adequate diagnostic infrastructure would likely be closer to three million.

Question 6

Regarding the 2-3-4-5 plant-based diet pyramid — India has a large vegetarian population that nominally follows this diet, yet cardiac events have increased significantly over the last two to three decades. How do you explain that?

Dr. Biswarup Purkayastha · Accepted Answer

The traditional Indian vegetarian population was genuinely following something close to this diet. What changed was cooking oil. Industrial cooking oils were repackaged and marketed under omega fatty acid branding — omega-3, then omega-6, now omega-9 — persuading consumers to abandon traditional cooking fats like mustard oil and olive oil for artificially processed, packaged products whose health claims aren't supported by meaningful clinical evidence. If the population simply returned to traditional cooking oils, it would likely cut the cardiac disease burden significantly. The pyramid isn't the problem; the oil in the pan is.

Question 7

Very fit people and even elite athletes are having sudden cardiac events. Does physical fitness guarantee cardiac health?

Dr. Biswarup Purkayastha · Accepted Answer

No, it does not. Gyms typically require only a basic medical certificate, not triglyceride, homocysteine or CRP levels. The supplement industry is enormous, largely unregulated and mostly not FDA-approved. And building muscle mass ignores that the heart is also a muscle — when it hypertrophies beyond physiological bounds, that's called hypertrophic cardiomyopathy, not fitness. The footballer Christian Eriksen is instructive: he had a cardiac event at Euro 2020, received an ICD, returned to professional football, and years later the ICD detected and treated an arrhythmic episode with a single defibrillation — he felt dizzy, walked off, and was alive. Shane Warne's death, by contrast, fit the classic pattern: lifelong smoking, crash diets, and heavy alcohol.

Question 8

Can LVADs replace heart transplantation altogether? What is the future of this space?

Dr. Biswarup Purkayastha · Accepted Answer

For patients above 55, LVADs have to a reasonable extent already replaced transplantation as destination therapy — they can run fifteen years without complications on antiplatelet and anticoagulant therapy alone, with no immunosuppression needed. Three developments will transform deceased-donor transplant over the next decade: donation after circulatory death, which could roughly double the donor pool; ex vivo machine perfusion devices like the TransMedics Organ Care System, which keep a donor heart beating outside the body for twelve to twenty-four hours or more, making cross-continental transport feasible; and xenotransplantation, with genetically modified pig hearts already transplanted into two human recipients. It's unlikely any engineered device will fully replicate a natural heart, though — transplantation will stay relevant for at least the next fifteen to twenty-five years.

Question 9

What is the best approach to managing peripheral oedema — swelling of the feet — in a patient with HIV, pulmonary tuberculosis, and hypotension?

Dr. Biswarup Purkayastha · Accepted Answer

The first step is an urgent echocardiogram to establish ejection fraction precisely using Simpson's biplane method — the clinical picture at 35% and at 20% are entirely different territories. Below 20%, options are very limited; diuretics alone won't fully resolve the oedema. The Aquadex SmartFlow ultrafiltration system, with a 15ml prime volume removing 60 to 100ml of fluid per hour, is the logical next step when diuretics are failing. But with ejection fraction below 20% in the context of HIV and TB, and hypotension further constraining options, the situation is close to endgame — peritoneal dialysis is theoretically possible, but introducing a device into the body cavity of a patient with active communicable disease carries an infection risk that makes it unsafe in most circumstances.

All About Heart Failure & Coronary Artery Disease in African Population: The Way Forward

Questions Doctors Asked Dr. Biswarup Purkayastha