How advanced imaging and physiologic assessments are revolutionizing cardiology
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Not all patients with a blocked artery need a stent: that’s the message Dr. Yasir Parviz, interventional cardiologist at Clemenceau Medical Center Hospital in Dubai (CMC Hospital Dubai), is passionate about expanding in the region. With the latest in imaging and physiological assessments at CMC Hospital Dubai, patients can lead a normal life without any treatment or with only minimal interventions.
“The perception that if there is an obstruction it is necessary to place a stent is wrong. It’s called the oculostenotic reflex: your eyes see an obstruction and you think you need to put a stent in,” says Dr. Parviz, who has dual certifications from the United Kingdom and Canada, as well as a fellowship in imaging and physiology from Columbia University. NY. “But multiple large-scale randomized trials conducted around the world over a 15-year period have shown that in many cases no stent is needed and treatment can be safely postponed.”
The problem is that most of the time doctors base these decisions on angiograms. But an angiogram, which is an x-ray of the heart, doesn’t give us enough information, according to Dr. Parviz.
With angiography, a two-dimensional image is obtained, which is not the answer to the complex three-dimensional structure of blood vessels. To do this, we need a physiological evaluation of the arteries.
– Dr. Yasir Parviz, interventional cardiologist at Clemenceau Medical Center Hospital in Dubai
Intracoronary physiology, in its simplest form, refers to the measurement of rates or ratios, such as fractional flow reserve (FFR), that indicate how blockages affect blood flow through the arteries. “We check the pressure before and after the block, and then see if this pressure difference is significant,” explains Dr. Parviz. “We want to have this pressure difference as close to one as possible. If it is less than 0.8, then it becomes significant and the patient needs to be treated.”
Patients travel to CMC Hospital Dubai from countries such as India, Pakistan and Nigeria for this cutting-edge analysis, and this can make the difference between being told they need a triple bypass or no intervention at all. Dr. Parviz gives the example of a patient from Pakistan who was told that he had three arteries with 70 percent blockage, but physiological evaluations showed that the FFR was negative in the arteries.
“The blockage shown on the scan doesn’t matter; For the patient, blood flow is important,” says Dr. Parviz. “If the flow ratio is greater than 0.8, even if the blockage is there, studies show that these patients do very well without a stent.”
When physiological evaluations show that intervention is necessary, intravascular imaging such as ultrasound (IVUS) or light waves (optical coherence tomography or OCT) can help provide the doctor with very detailed images of the internal structure of the blood vessel to perform the procedure accurately.
“We can offer computerized treatment instead of relying on human judgment,” he says. “Before, during and after the procedure, imaging will give you the precise coronary intervention you deserve in 2023, instead of using technology from 1978.”
He gives another example of a patient who traveled to CMC Hospital Dubai from Oman after being told he had triple vessel disease; that is, he had three blockages in major arteries and required bypass surgery.
Image credit: supplied
But a physiological evaluation showed that one of the blockages did not require any treatment, the second only required a small stent and in the third case, the calcification in the artery was removed using state-of-the-art minimally invasive procedures and IVUS imaging.
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Image credit:
“We were able to turn a patient who could have had a bypass into someone who only needed a small, simple procedure and was discharged the next day,” says Dr. Parviz.
These advances are particularly important for those suffering from diabetes, hypertension or chronic kidney disease, many of which are now epidemic in the country. “These are complex, diffuse conditions that are difficult to control, and physiology and imaging help treat them more effectively,” he says. For example, it could allow you to treat kidney patients with less use of dyes and contrasts needed for an angiogram, or monitor the thinned arteries of diabetic patients more efficiently. Above all, it can avoid unnecessary interventions in older people.
The problem is that although these remarkable advances are routinely used in places like Japan and the United Kingdom, knowledge about them is still low in the region. But CMC Hospital Dubai is at the forefront, trying to bring about change.
“We need to educate and train doctors,” says Dr. Parviz. “They can say [these treatments] take more time or use more money and hospital resources. But we have to do it for the patients, who deserve the best possible results,” he says. “Whatever the obstacles, we are happy to persist: teaching, live streaming cases and speaking at conferences, to advance science in the region.”
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