Thousands of lives could be saved by finding the best time to perform heart surgery. Jennifer Grech speaks to Alexander Manché, cardiothoracic chairman at Mater Dei Hospital, to discover more.

Hundreds of people in Malta have some form of cardiovascular disease, which is linked to heart failure, strokes and heart attacks.

According to the latest WHO data published in May 2014, annual coronary heart disease deaths in Malta reached 695 or 27.15 per cent of total deaths. These statistics make it the leading cause of death in Malta.

Data extracted from Eurostat statistics in October 2015 shows that while over the past 30 years the number of deaths from coronary heart disease has remained stable locally, the mortality rates have shown a downward trend. This is due to an increase in the age at death as well as an actual decline in the rate.

In Malta overall mortality rates from coronary heart disease are higher than the EU average for both males and females. However, the rates for those under the age of 65 years for Malta are comparable with the EU average.

Many of those who suffer from heart disease will have to take medicine or undergo dramatic lifestyle changes to keep the disease at bay – yet some will also need surgery to survive.

Experts hope to save thousands of heart disease patients’ lives by finding the right moment to operate.

A new €1.7 million study aims to help doctors better pinpoint when to operate on heart disease patients. This study will look at tracking more effectively when a heart is starting to fail, helping medics decide the best time to perform surgery while minimising the risk to patients’ health.

Operating too early can put heart patients at unnecessary risk but intervening too late can mean heart muscle becomes irreversibly damaged.

The Edinburgh study, which will recruit between 200 and 300 patients in Scotland, will focus on patients with the most common form of valve disease, known as aortic stenosis.

“This is yet another study that will help surgeons decide when to operate on patients with aortic stenosis,” Alexander Manché, cardiothoracic chairman at Mater Dei Hospital, says.

The condition is caused by the narrowing of a major valve, which puts heart muscle under pressure and reduces its capacity to pump properly. It can lead to heart failure and sudden death.

“Aortic stenosis is a narrowing of the aortic (outflow) valve of the heart, commonly caused by build-up of calcium with advancing age. Because of a general increase in life expectancy, the condition is becoming a major healthcare issue, with up to 12 per cent incidence in the over 75s in some countries,” Mr Manché explains.

Because of a general increase in life expectancy, the condition is becoming a major healthcare issue- Alexander Manché, cardiothoracic chairman at Mater Dei Hospital

Until two decades ago, aortic valve replacement made up 10 per cent of Mr Manché’s practice – last year the figure rose to 33 per cent.

“Patients with this condition typically develop symptoms which herald impending death, with four out of five patients not surviving beyond five years. Thus, the onset of chest pain gives an average of 4.5 years to death, dizziness 2.5 years and heart failure less than a year.

“In these circumstances, surgery is indicated if the patient is willing and able to proceed. For very high risk patients with other health problems, TAVI (keyhole aortic valve implantation) may be offered instead of open surgery,” Mr Manché adds.

Difficulties arise when patients, known to have severe aortic stenosis on special heart tests such as an echocardiogram, are not experiencing any symptoms. In these cases, the degree of valve calcification, the velocity of blood past the narrowed orifice, or the response of the patient to a stress test can help determine which patients are more likely to benefit from surgery.

Mr Manché continues to say that aortic valve replacement carries a mortality of about two per cent and this must be taken into consideration, especially in patients who feel well.

“The benefits of surgery are certainly immense: local studies have shown that when we operate on patients over 68, we not only prolong life but can also restore a normal life expectancy.”

Gauging the severity of heart valve disease can pose difficulties, particularly in older patients who may suffer from a number of other health conditions.

The Edinburgh study is going a step further in that patients will be randomised into receiving early or later surgery, no doubt recruiting some with minimal or no symptoms. The researchers plan to follow the patients’ post-operative course in order to determine the ideal time for surgical intervention.

The trial will see patients undergo detailed heart scans and blood tests to track the capacity of their heart to pump blood, providing a baseline against which their future heart function can be compared.

Half of the patients will receive early surgery, and the other half will be given treatment later.

By analysing patients’ heart function before and after surgery, doctors will determine the impact of replacement valves. They will also be able to tell at which point the surgery has had the greatest effect.

“We look to the future and hope that valuable information from this study may help us make wiser decisions in what can be very difficult situations,” Mr Manché concludes.

The biggest killer

Cardiovascular disease is the leading cause of death globally and is projected to remain so.

Cardiovascular disease is caused by disorders of the heart and blood vessels, the WHO explains on its website (www.who.int). Among its forms are coronary heart disease (of the blood vessels supplying the heart muscle), hypertension (raised blood pressure) and peripheral artery disease (of blood vessels supplying the arms and legs).

Heart attacks and strokes are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels. Strokes can also be caused by bleeding from a blood vessel in the brain or from blood clots.

The most significant causes of heart disease and stroke are unhealthy diet, physical inactivity and tobacco use.