Question 1

A patient has a lump in the right hand near the palm that comes and goes, with a heart rate of 120 and blood pressure of 110/90. What could be the cause?

Dr. Subhash Chandra · Accepted Answer

It is difficult to comment on this information alone. It could be a vascular lump or some kind of arteriovenous fistula in the palm. A thorough contrast CT scan, or perhaps a DSA, is needed to find the cause, and it can then also be fixed with a minimally invasive technique, such as a covered stent or coils. But one has first to prove what we are dealing with.

Question 2

What are the cost implications of minimally invasive procedures such as TAVI compared with traditional open surgery?

Dr. Subhash Chandra · Accepted Answer

Open heart surgery in India is cheaper than in the West, because hospital logistics, the bed and everything else over a six- to seven-day stay do not cost as much. Because a great deal of innovation goes into minimally invasive devices, those procedures cost slightly more, or at least the same, as the surgical techniques. In India, TAVI costs about double the surgical procedure. In the West it can even cost less than surgery, because their overheads and surgical procedures are much more expensive. In India we can offer TAVI for as little as $25,000, which may be the least in the world.

Question 3

Most doctors attending are from developing countries such as Ethiopia, Nigeria and Zambia. When they face such a patient, how should they decide which cases to prepare notes on and refer?

Dr. Subhash Chandra · Accepted Answer

From what I know of these countries and their neighbours, such as Kenya and Tanzania, local services for these procedures are still evolving; the doctors are very energetic about learning. Close to 60% of these procedures would qualify as complex, and those patients should come to a country like India, where it is most cost-effective. Direct flights take about six hours, so a patient comes for a week at most, perhaps three or four days, has the procedure and flies back. I have also helped build local capacity by working in their labs, and by inviting doctors to train in my lab for a year or two before returning home.

Question 4

Apart from cerebral protection devices, what other measures prevent complications of TAVI such as stroke and death?

Dr. Subhash Chandra · Accepted Answer

TAVI is all about planning. Doing the TAVI itself is not a great feat and does not need very high-level skills; the whole energy should go into planning before you embark on the procedure. That means a thorough CT scan, which can be done locally and sent to us, so that we can plan which valve is required and what we will face in terms of coronary occlusion, groin complications or stroke. That is the way to do the procedure, rather than doing it half-heartedly or unplanned and landing in complications. Mortality in TAVI can be very high if you are not careful about the groin: you must know how to manage it, because a patient can have a successful TAVI and still be lost because of a mismanaged groin. The whole thing is planning, planning, planning.

Question 5

What is the prognosis of SAVR compared with TAVI?

Dr. Subhash Chandra · Accepted Answer

SAVR is a very well-established technique, in use for more than 50 years, and given a choice it should be the default in terms of safety, in my opinion. Although I do a lot of TAVI, I prefer a technique that is well proven and well established, so surgery is the best option, especially if the valve is bicuspid, the annulus is small or the patient is not very elderly. If my surgeon accepts the patient and can operate safely, I send the patient for surgery; if the surgeon says the surgical risk is very high, I step in and take the patient for TAVI. Recent trials have shown TAVI to be non-inferior even in intermediate- and low-risk populations, with both self-expanding and balloon-expandable valves, but the decision should still be individualised to the patient.

Question 6

Does BLK run a TAVI training programme, what are the eligibility criteria, and how are the limited places filled?

Dr. Subhash Chandra · Accepted Answer

Any interventional cardiologist can apply. I currently have two fellows from Ethiopia who have worked with me for two years and are finishing; we will recruit two more in the coming years. Fellows first spend about a year on coronary angioplasty; in the second year we induct them into the structural heart programme and train them in TAVI, left atrial appendage occlusion, TMVR and other structural interventions. It is a full-fledged programme and any fellow is welcome, but they need a basic knowledge of interventional cardiology. To select among applicants, we go through their CVs and experience and interview them, in person or online.

Question 7

If we are conducting annual screening for high-risk groups, what are the minimum tests that should be done?

Dr. Subhash Chandra · Accepted Answer

In cardiology, the basic screening tools are a thorough echocardiography and an ECG, blood tests such as the lipid profile, CRP and HbA1c for underlying diabetes, and sometimes a stress test to uncover coronary artery disease. These classical tests are done in most people past the age of 40 or 45, and especially in the elderly. We then act on prevention, and if an intervention is required, we act in time.

Question 8

What lifestyle basics, such as exercise and diet, do you recommend for heart health?

Dr. Subhash Chandra · Accepted Answer

Running is a very good, complete exercise. In diet, avoid a lot of red meat, which is high in saturated fat and cholesterol; rely more on vegetarian foods, grains, millets and dry fruits, and limit saturated fats such as full-fat milk and milk products, choosing low-fat versions instead. A stress-free life matters, along with a daily routine that includes some exercise: yoga, which I do personally, running, weight training or any other. Staying happy is most important.

Question 9

How can doctors join your fellowship programme?

Dr. Subhash Chandra · Accepted Answer

They should get in touch with us and send their CVs, and be ready for an interview, online or in person here, after which we assess whether they are fit to be inducted into the programme. Some local regulatory bodies in their countries clear their CVs, and BLK handles that part too. There is a minimal fee, and fellows make their own arrangements for accommodation, food and living here. People have really benefited from being with us in our lab, and at some stage we give them hands-on experience.

Question 10

Is there a module for an exchange programme?

Dr. Subhash Chandra · Accepted Answer

Yes, a kind of exchange: I come to your country for five days to a week, you line up a number of cases of different kinds, and either I do them or you do them with me behind you as proctor. If I find that some cases cannot be done locally, I tell you to send them to me and I do them here.

Live Discussion with Dr. Subhash Chandra