Stuart Lander, M.D., F.A.C.C., interventional cardiologist in Baylor Scott, and Heart Health in Dallas, Texas, talks about how a controlled heart attack can saves someone’s life.
Interview conducted by Ivanhoe Broadcast News in November 2016.
What kind of work do you do in the cardiology field?
Dr. Lander: I’m relatively a jack of all trades. I do interventional cardiology which involves procedures on the heart and vascular structures, often with stents. I also do general cardiology, management of lipids, hypertension, coronary disease, vascular disease, also implant pacemakers. I deal with people with pulmonary hypertension, so I kind of do a little of everything.
Are you a surgeon as well?
Dr. Lander: I’m interventionist. I don’t cut people open, with the exception of a pacemaker, which is just a small incision. The surgery part of heart disease would be done by cardiovascular or a cardiothoracic surgeons.
You probably work with them?
Dr. Lander: We work with them all the time.
Bobby Bridges is a patient. Tell us a little bit of that story. What happened to him?
Dr. Lander: He had an arrhythmia or abnormal heart rate that caused his heart rate to go fast, and he passed out. It could have been due to a small blockage he had in his coronary artery but it was most likely related to his hypertrophic cardiomyopathy. He had a defibrillator placed, which is a special type of pacemaker that monitors your heart, so that if you have those life-threatening fast heart rhythms, the defibrillator monitors the heart rhythms and can shock you out of a life-threatening fast heart rhythm. To my knowledge he hasn’t had any more of those events.
That’s true right, this often results in fatality?
Dr. Lander: It does. Interestingly, it is more common in younger adults than in older adults, and people have probably heard it’s the number one cause of sudden cardiac death in young athletes: hypertrophic cardiomyopathy.
Define that, tell us what it is.
Dr. Lander: It’s actually a myriad of things. It involves the muscle fibers of the heart which have not grown or developed properly. It’s a genetic disease, and there are been probably a dozen or so genes that have been found thus far, with over fifteen hundred different mutations. Two of the genes probably represent about 75 percent of the cases. The incidence or occurrence in population is about one in five hundred. It’s relatively common. What makes it complicated is that even if you have the gene, you may not express what’s called the phenotype, or you may not have the abnormal structure in your heart, or anything that we can define as being abnormal. There’s a whole set of screening parameters that the American College of Cardiology and Academy of Pediatrics have published regarding the screening of young adults, particularly with respect to athletics.
But with older adults, the biggest symptoms they have are usually related to the level of obstruction. One wall of the heart gets thick and it causes obstruction. The heart function is normal. It squeezes normally but part of the heart, the septum, gets thick as it squeezes and causes a dynamic outflow obstruction. As the heart squeezes, it’s like putting your thumb over the end of the hose; it blocks the flow and it creates more pressure. Then your heart has to generate more force to get the blood out. That can cause symptoms of fatigue, weakness, shortness of breath, dizziness, and sometimes passing out.
That sounds like exactly what happened to Bobby?
Dr. Lander: He has pretty much all the classic features that you find. His syncopal episode was treated but he continued to have the shortness of breath. He was seen by one of my partners and the diagnosis of hypertrophic cardiomyopathy was made. He then was referred for evaluation. There are three main treatment choices. One is medical management and Bobby was on all the appropriate medicines to try to slow the heart rate to allow better filling time of the heart and also helps with some of the rhythm issues. He already had the defibrillator because he had sudden cardiac death.
The other two arms, if medical management fails, involves removing the obstruction, and getting rid of that thick part of the heart muscle to allow the blood flow to come out of the heart easier. Around mid-1990’s we started doing something called alcohol septal ablation which is a controlled heart attack. In every other instance, when people come to see me, I open up their arteries and put stents in them to make them feel better. In Bobby’s case, the goal was to close down an artery, and in every sense of the word give him a heart attack, but in a very specific part of the heart, by blocking the artery that feeds the muscle that’s thick. When he has that heart attack the muscle then gets thinner, scars down, and no longer obstructs the outflow.
That sounds like a great outcome kind of a counter intuitive approach?
Dr. Lander: Yes.
Right?
Dr. Lander: Very much so.
Explain that, I mean it’s like how can you help somebody’s heart by giving them a heart attack?
Dr. Lander: Whenever someone has a heart attack, a blockage in the artery from any form, it causes a lack of blood flow. If that lack of blood flow goes on long enough that part of the heart dies. In the healing process or recovery process, that heart muscle dies and becomes a scar. It’s no longer a functional muscle. For instance, if someone has a heart attack that affects this part of the heart, this part of the heart will still squeeze, but this part will be scarred. Obviously it doesn’t go away because the heart muscle is still there. It’s just a scar and is no longer functional muscle. It keeps the blood in the chamber but doesn’t move and doesn’t add anything to the heart function.
In Bobby’s heart we use that same principle. There is an artery in the base of the septum (the thick part of the heart) called the septal perforator. We put a wire in, then put a balloon that occludes the blood flow, and infuse down the end of the balloon with 95 percent alcohol. It’s desiccated alcohol. Just three and a half to five cc’s of alcohol infused in that artery causes that artery to shrivel up and basically go away. With no blood flow, that muscle has a heart attack in that specific little spot.
Basically you are destroying or killing part of the heart that was causing a blockage?
Dr. Lander: When people think of a blockage, they think of a blockage in the artery. He didn’t have any blockages of major consequence in his arteries. He had some small areas but not anything of consequence. He had a muscular blockage because the muscle was too thick.
Is this a procedure that is commonly done or is it an unusual approach?
Dr. Lander: It’s not commonly done but it is one of the appropriate methods for treatment of hypertrophic cardiomyopathy. The third arm is called septal myomectomy. That’s where the patient will undergo open heart surgery and the surgeons will actually scoop out, or cut out, the part of the muscle that’s obstructing the outflow track.
Is it my understanding that the team was right there just in case you needed it?
Dr. Lander: They’re available, but thus far in my career we never have.
But when you do the procedure that you’re talking about the alcohol ablation if something doesn’t work there you may have to resort to open heart surgery?
Dr. Lander: Potentially, although if something goes bad, then surgery may or may not be helpful. The biggest issue is if the alcohol goes where it’s not supposed to.
Now in his case he actually was awake through the procedure?
Dr. Lander: Yes.
Describe that, did you have any trepidation about allowing him to be awake?
Dr. Lander: No, I’ve actually done most of my patients awake. They’re in “sleepy” state called conscious sedation. Depending on what their level is, some people kind of sleep through it. Some people are more awake and drowsy. He wanted to be awake so he got just a minimal amount of sedation and pain control. It hurts when we give somebody a heart attack. Just like a regular heart attack, it hurts.
I guess unless you’ve had a heart attack you don’t really know how much real pain.
Dr. Lander: Yes.
In his case he’s quite an interesting man because in his work as a pastor, as a police chaplain he encounters life and death situations all the time. He feels like without this he wouldn’t be here today. Does that mean that this has got to be the kind of thing that makes a pretty good day for you?
Dr. Lander: Yes, it’s very rewarding. I love being a doctor and, in fact, that’s why I became a doctor. I used to be an engineer. I decided when I came home at the end of the day, I needed to feel like I made a difference in somebody’s life. So that’s the simple reason why I became a doctor.
How would you call this procedure, for somebody like Bobby it was a medical breakthrough. Would you call this like a breakthrough understanding of some aspect of cardiology?
Dr. Lander: It’s not something that you frequently nor should be. In the appropriate patients that are appropriately screened, it can be life changing as it was for Bobby. Now I have sent a number of other younger patients who have had thicker hearts or didn’t have the appropriate anatomy for alcohol septal ablation and hey have had similar results but it can become a life changing event. People don’t necessarily realize how bad off they are until they have had the procedure. A patient may not be entirely committed to the procedure and I don’t convince anyone in to it. I told Bobby after our first visit said, “Go and do some things and let me know how much it’s affecting your lifestyle. What things can’t you do?” Most people will accommodate to their bodies until they can’t do an essential activity or they get short of breath or whatever stops them from living a full life. Then we need to try and figure out what is causing that. In Bobby’s case, after further reflection and trying to do some things, he realized that he really was a lot more short of breath, winded and fatigued. He didn’t have the stamina that he had years before. At that point Bobby felt like he would go through the procedure.
If this procedure wasn’t available, if you weren’t able to do this for him what would his prognosis have been for his life?
Dr. Lander: Interestingly, people survive hypertrophic cardiomyopathy. What most people die from is the arrhythmia. The other issues are more symptomatic. More short of breath, they just can’t do things they have before, so it wouldn’t necessarily have had a huge effect on his longevity, but it would have had a huge effect on his functional status. He wouldn’t have been able to do what he enjoys. The things that he’s doing now he wouldn’t be able to do. He would have slowly deteriorated, become weak, muscle atrophy, etc.
This really did open up all kinds of new possibilities for him?
Dr. Lander: Well I think so, but you’d have to ask him for sure.
But that’s the idea isn’t it? I mean this is like people don’t know how much they could improve with something like this.
Dr. Lander: Right. There’s a series of screening that goes through. People have to have a certain degree of obstruction; they have to have certain degree of pressure change. We usually find that they need to have at least a difference of about thirty millimeters of mercury so the pressure inside the heart is thirty millimeter higher than the outside of the heart. In Bobby’s case it was close to a hundred. We know it has to have what’s called a provokable gradient, so either with a stress test or whatever of at least a fifty. His provokable gradient was a hundred and fifty. His, on every aspect of how you grade the severity of hypertrophic cardiomyopathy, his was severe.
He said maybe the initial consultation was with another physician, they weren’t sure that he was a good candidate for this procedure but you determined that he was a good candidate.
Dr. Lander: Yes. He has to have the pressure differences. If there’s not a big pressure difference, then removing the obstruction isn’t going to make you feel better, it’s kind of an intuitive thing. I had to look at his angiograms that he had at the other hospital to look at his anatomy. If there’s not a good sized septal perforator that goes in to that area of the heart, then occluding it won’t have the desired effect. You might have a little decrease in your heart muscle but not substantial. He would have also been a candidate for a septal myomectomy. There wasn’t a reason from a physical standpoint or surgical risk standpoint that he couldn’t have had that done, but his anatomy was such that he could have alcohol version.
Was this congenital or something that developed as an adult?
Dr. Lander: We have not done the gene screen on him, but most people with his kind of anatomy have some sort of genetic mutation. As I mentioned, there’s at least a dozen genes involved, and over fifteen hundred different mutations.
The young athletes you’re talking about like the basketball player that died on the court?
Dr. Landers: Yes, Reggie Lewis was one.
Those are both basketball players who suddenly just collapsed. They just had sudden heart attacks and they were gone. I think they determined they just had problems with their heart.
Dr. Lander: Yes, his autopsy showed he had hypertrophic cardiomyopathy. Some of these athletes may not have had any major symptoms before that.
Anything else about this for the general public that would be of interest?
Dr. Lander: Just being short of breath and told you have a murmur does not mean you have hypertrophic cardiomyopathy. The incidence is about one in five hundred; how people have it is very variable. Again, there’s a whole set of screening procedures that people go through to see if they would be a reasonable candidate for that. Alcohol septal ablation is done in most of the major cities across the country.
Septal myomectomy is done as well, although I tend to refer my patients to places that have experience with that procedure. That should be a consideration.
That’s something in your training, an advanced area that you chose or somehow you became involved with?
Dr. Lander: Yes, I did my training at Baylor University Medical Center in Dallas. There is a busy interventionist cardiology program there and that’s where I learned the procedure. I do this procedure at Baylor University Medical Center and at Baylor Scott & White All Saints Medical Center – Fort Worth.
END OF INTERVIEW
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