Just because you’re getting older doesn’t mean you’re too old for many heart procedures. While open-heart surgery is often the first procedure that springs to mind, there are many treatments that fall into the “minimally invasive” category.
In everyday language, that means there’s no big incision, it’s lower risk and it’s an available option for older patients who might be at risk in a major operation.
“We do ‘interventional’ procedures, not surgeries,” explained interventional cardiologist Dr. Arbin Katwal.
He and the team at Novant Health Heart & Vascular Institute - Mooresville offer those treatments for illnesses including coronary heart disease and peripheral vascular disease.
At Novant Health, we provide some of the nation's best individualized heart and vascular care, conveniently located, and focused on you.
Is a patient ever too old for open-heart surgery?
Age can be relative. You may be 80, but otherwise healthy patients may be considered just 70 from a biologic perspective and eligible for an open-heart operation to open blockages in the heart, Katwal said.
What are some of the common, non-surgical procedures?
What I do primarily is structural heart intervention, which avoids opening the patient’s chest. This includes percutaneous (through the skin) coronary intervention, which involves an angiogram to take pictures of the arteries supplying the heart. If we find a blockage we can go in, open the artery with a balloon and put in a stent. And this does not require surgery.
Previously, if the arteries had a lot of calcium buildup, we had limited tools to treat such a complex disease. Some of these patients would be referred to heart or vascular surgeons for open surgery. But we now have safe technology where we can use ultrasound waves emitted from balloons to crack the calcium. It’s known as intravascular lithotripsy. This allows us to safely place stents in complex blockages. Stents are metal spring-like tubes that can be inserted to improve blood flow.
The making of a cardiologist
Interventional cardiologist Dr. Arbin Katwal was medically trained in Nepal, where he graduated from B.P. Koirala Institute of Health Sciences in 2004.
“We had very minimal medical resources in Nepal, at least when I was growing up,” Katwal said. “It’s still a lot further behind the healthcare system here in the United States. The reason I came here was for the best training in the world. It’s very inspiring to go from primarily limited resources to helping patients in the best way possible.”
Katwal completed his residency training in internal medicine at the University of South Carolina. He says he’s been fascinated with cardiovascular disease since he first observed the squiggly lines of an EKG.
“As an interventional cardiologist, I like being able to help patients,” Katwal said. “I want them to have the right medicine and help themselves by making the right diet and lifestyle changes. I would rather they stay out of the hospital and put me out of a job. But if they have a heart attack or lifestyle-limiting symptoms and need stents, I am happy to help.”
Furthermore, over recent years, we have started doing structural heart interventions, which commonly involve a heart valve replacement through the groin. One common form is known as TAVR, which is performed in larger medical settings. Back in the day, the only option might have been open-heart surgery.
Another common minimally invasive technique is angioplasty. That uses a catheter and a balloon to address a blocked or narrowed artery associated with coronary artery disease, the most common form of heart disease. Then stents can be inserted.
Each year Katwal’s team performs as many as 350 heart angioplasties and stent placements.
What type of patient do you see most often?
We see people of all ages, 40 and onward, though predominantly it’s people in their 50s and 60s who have had no prior procedures. But, as people are living longer, we are seeing more patients in their 70s who have had procedures in the past, including stents or a bypass. That said, I had a male patient with a heart attack who was 27, though he had a family history of heart disease.
So people in their 40s should make an appointment and get checked out for heart disease, just in case?
Yes, after age 40, you should see a primary caregiver for an overall evaluation: Do you have high blood pressure? Do you have diabetes? Do you have high cholesterol? Do you have a history of smoking tobacco? And do you have a family history?
The next thing to look at is symptoms. If you’re active and you regularly exercise without symptoms, then usually we don’t recommend any stress testing. Good exercise is 30 to 45 minutes of brisk walking a day, and climbing a couple of flights of stairs with no problems. But if you have symptoms – shortness of breath with activities, chest pain or discomfort – that would be sent to us cardiologists for further evaluation.
Not infrequently, we are seeing asymptomatic patients with a strong family history who get referred to us after an abnormal calcium scan of the heart. In these cases, we assess the risk factors in each individual patient and their ability to do a good level of exertion before considering further tests.
So usually, by the time a patient comes to you, they have already experienced a heart scare?
Yes. Most patients who come to us have the classic symptoms of heart pain or angina -- chest pressure, tightness, squeezing that may run from the jaw to the left arm. Many patients come to me when they have shortness of breath or a decline in their ability to exercise; in the last six months they’ve not been able to walk uphill without getting tired or short of breath.
Some people who are especially elderly or diabetic can have atypical symptoms; they don’t have the classic chest-pressure tightness. Some people can have heart attacks without knowing it, known as silent heart attacks.
Overall, preventive care wins in the long term. Medication combined with lifestyle changes can keep people out of the hospital. In today’s world, we focus a lot on treating the problem. But there’s a lot we need to do when it comes to prevention – dietary changes and lifestyle changes.
