PECTUS EXCAVATUM MAY NOT BE LIFE-THREATENING UNLESS IN ITS MOST SEVERE FORM, BUT THE CONDITION IS NOT AN EASY ONE TO LIVE WITH. IT AFFECTS YOU PHYSICALLY, MENTALLY AND EMOTIONALLY.

More commonly known as ‘sunken chest’ or ‘funnel chest’, the condition afflicts one in about 1,000 births. Other names for it include ‘hollowed chest’ and ‘cobbler’s chest’. It is the most common type of congenital chest-wall abnormality, making up 90per cent of all cases, and is suspected to be familial—35 to45 per cent of cases have been reported within families.

It is also more dominant in males with a 3:1 male-to-female ratio. IN 2008, IJN marked a first by performing the Minimally Invasive Pectus Excavatum Repair (MIPER) or Nussprocedure (Donald Nuss, 1997) on two patients with Pectus Excavatum by Dr Jeswant Dillon, IJN Consultant Cardiothoracic Surgeon. 

Previously, the condition was treated with the Open Technique (Ravitch procedure, 1949) which was a difficult, complex open and invasive surgery. This procedure involved making a large, transverse sub-mammary chest incision, breaking the sternum, re-sectioning the costal cartilages and raising the pectoralis muscle flaps. The Open Technique operations are long. A procedure can take up to six hours and there is a high risk of blood loss. The patients have to stay in hospital for a considerable length of time and the post-operative pain is significant. The procedure also leaves a large, unsightly scar. While a scar may seem like the least of a patient’s problems, it is significant in these cases because many of those with the condition suffer from low self-esteem because of the way their chests look.

With the new procedure, the process is much simpler. The Nuss procedure is a minimally invasive surgical approach that inserts a customized stainless steel bracing bar into the chest cavity to brace and remodel the anterior chest wall. The operation has been used since1997 and has shown excellent results. It is based on the principle that the chest wall possesses remodeling and reconfiguration capabilities. The bar is left in place for two to three years (in children), or three to five (in adults). Once the chest wall is reconfigured, the bar can be removed in a simple outpatient procedure.

The operation does not have any side effects except for a small risk of displacement or infection. There is no rejection of the steel bar by the body. Most patients only need to insert one bar, but there are cases where two bars are needed. This happens when the depression of the chest is too long or too wide. Although the operation has been performed on toddlers aged 18 months and above, Dr Jeswant’s opinion the best time for someone to undergo the operation would be between the ages of eight and 13: This is so that when the growth spurt occurs, the chest does not sink in again.

Why has it taken so long for the procedure to come to our shores?

First there’s the demand. If there are a lot of people coming to us with a condition and it is a life threatening one, then it’s in demand. In the case of pectus excavatum, people were not referred before because the surgery was a long and complicated one. So they would only opt for surgery when it was life-threatening.

We do hope that, since this procedure is now readily available, more people will come for the procedure—while it may not be life threatening, it does have psychological effects that affect a patient’s lifestyle and confidence. The best thing about the procedure is that patients can be up and about again within two weeks. They can start competitive sports again in two to three months, and contact sports in six months.

Sunken Chest

According to Dr Jeswant Dillon, the depressed anterior chest wall can cause compression on the heart and lungs. In terms of the heart, it brings about lateral displacement (and compression) of the heart, producing right ventricular filling problems.

What is it?

Pectus excavatum is a progressive chest deformity that causes a depression (posterior displacement) of the sternum and anterior chest wall. This results in a caved-in or sunken appearance of the anterior chest wall or a concave “funnel shaped” chest.

According to Dr Jeswant Dillon, IJN’s Consultant Cardiothoracic Surgeon, the condition tends to progress with age: “It is usually present at birth but becomes most marked and worsens during puberty due to rapid bone growth during the teenage growth spurt,” he says.

What causes it?

Unfortunately, there are no known causes of the condition. It is still poorly understood and is only known as a mal-development of the anterior chest wall. There may be some association with Marfan’s syndrome (10 per cent of cases have Marfan’s) and many are Marfanoid with hyper flexibility of cartilage. It has also been associated with the Ehlers-Danlos and Poland syndromes.

What are the effects on the body?

According to Dr Jeswant, the depressed anterior chest wall can cause compression on the heart and lungs. In terms of the heart, it brings about lateral displacement (and compression) of the heart, producing right ventricular filling problems. The decreased flexibility of the chest wall and compression of the lungs affect respiratory functions causing restrictive respiratory dysfunction. “Compression can also cause restricted organ growth,” he says.

Diagnostic tests

Dr Jeswant says that there are a few ways to diagnose the condition.

These are:

• Chest x-ray: Shows angulation of the sternum; bone and cartilage deformity.
• CT-scan: Reveals cardiac displacement and sometimes compression. It also calculates Haller’s index of severity of pectus. A Haller’s index of more than 3.25 indicates severe pectus deformity.
• Pulmonary function test: Those suffering from the condition often demonstrate values less than 80 per cent of a normal individual
• ECG: Arrhythmia may be present
• Echocardiogram: A person may encounter filling impairment of the right ventricle especially when in an upright position.  There is often the presence of a mitral valve prolapse.

When you should opt for surgery

Not everyone is physically impaired by the condition, but when you do have some symptoms, it may be time to think about surgery. Some of the signals that you can look out for are:

A. Functional impairment

This is when there is a reduction in the amount of exercise that you can do, or if you have a drop in endurance. Dr Jeswant explains that some people become easily fatigued, have chest pains, back pains, arrhythmia or recurrent respiratory infections (pneumonia).

B. Psychological impairment

One of the more harming effects of the condition, says Dr Jeswant, are the psychological effects: “Many have poor self-perception. They withdraw from society and avoid any activity that exposes the chest.” This is a very real problem especially for adolescents who are looking for their own space in society.

C. Haller index (on chest X-ray or CT-scan)

Dr Jeswant adds that if a patient presents a Haller index of more than 3.25, this denotes clinical severe deformity and the patient should undergo corrective surgery.

MYTHS ABOUT EXERCISE

Each year 1.9 million people die because they are not active enough. It’s a sobering statistic; especially when it’s so easy to do something about it.

Many people don’t realise the health benefits that are afforded by being more active: Physical activity lowers the risk of coronary heart disease, typeII diabetes, breast and colon cancer and osteoporosis. People who are active are less likely to be overweight and more likely to live longer, and being active means you are less likely to suffer from conditions such as anxiety and depression.

There are many excuses for sitting on the couch. The most common one is that people don’t have time to exercise. The reality is that you can’t afford not to devote time to exercise because it has such an impact on general health and well-being.

The World Health Organization recommends minimum 30 minutes of moderate exercise at least five times a week. Moderate intensity exercise means pushing yourself slightly–such as a brisk walk, swimming laps or cycling. And you don’t need to do it all at once–shorter spurts of activity spaced throughout the day add up, so a brisk 15minutewalkduring your lunch break, 10minutes of housework and five minutes walking up and down the stairs during the day will all add up to the 30-minute recommendation. For schoolchildren, the recommendation is 60 minutes a day.

Myth: I don’t have enough time to exercise

Fact: You can’t afford not to allocate the time. Being active will improve your fitness levels, reduce your risk of heart disease, diabetes and cancer and help keep your mind active and alert. Smaller bouts of exercise add up to the sum total, so try to be more active in everything you do. Walk that two blocks rather than jump in a taxi; make it a habit to take the stairs rather than the lift or escalator; take a walk to get your lunch rather than drive out or have it delivered to the office.

Myth: You need special clothing and equipment

Fact: This is just not true. Walking can be done almost anywhere, anytime and it doesn’t require any special clothing. For many activities, you can just wear loose comfortable clothing.

Myth: You only need to exercise if you are overweight

Fact: While it’s true that being active will help you lose weight if you need to, or maintain weight, even people who are slim need to exercise to reduce their risk of disease and to boost their mood and sense of well-being.

Myth: Children are active enough already

Fact: Research undertaken by Asian Food Information Centre in four urban Asian cities in 2004 found that children listed television and computer time as some of their favourite leisure activities, with many children spending two to three hours a day in front of a screen. Parents need to encourage children to be more active. Take a family walk or bike ride; learn a new activity such as roller-blading together or take time to watch children at their favourite sports activities.

Source: Asian FoodInformation Centre, May 7,2008

HeartTalk Issue 4

BLOCKED CAROTID ARTERIES CAN CAUSE STROKES AND HEART ATTACKS BUT A FAIRLY LOW-RISK PROCEDURE CAN PUT THINGS STRAIGHT.

Place two fingers on the side of your neck– when you feel a pulse, you’ve located your carotid arteries. These arteries are the main route by which blood is carried to the brain--they branch off a short distance away from the heart and extend upwards through the neck, carrying oxygen-rich blood. Unfortunately, the vital roles of the carotid arteries leave them vulnerable to serious afflictions, such as carotid artery disease or carotid artery stenosis (the narrowing of the carotid arteries).

A blockage in the carotid arteries can also have severe consequences such as stroke. Such obstructions can be caused by atherosclerosis– a disease of the blood vessels in which fatty substances, cholesterol, cellular waste products, calcium and fibrin build up in the inner lining of an artery to form plaque, hardening the artery and causing a blockage. These can not only lead to a heart attack, but also reduce the supply of oxygen and nutrients to the brain.

If the narrowing of the carotid arteries becomes severe enough to block blood flow, or if a piece of artery plaque breaks off and obstructs blood flow to the brain, brain cells will begin to die after just a few minutes without blood or oxygen, causing a stroke.

Blocked or narrowed carotid arteries can be treated through a process called a carotid angioplasty. First performed in 1980 by Dr Sean F. Mullan of the University of Chicago, the carotid angioplasty is a less invasive alternative to a carotid endarterectomy, which requires the artery to be surgically opened.

A carotid angioplasty, on the other hand, only involves making a small puncture in the groin. A special catheter with a tiny balloon at its tip is inserted into the carotid artery to be treated, and the balloon is inflated once the catheter has been placed into the narrowed area of the artery. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow. A tiny expandable metal coil, known as a stent, may be inserted into the newly opened area of the artery to help keep the blood vessel from narrowing or closing again.

As with any surgical procedure, a carotid angioplasty does carry some risk: Clots can potentially dislodge from the plaque built up in the carotid arteries, move into the circulation of the brain and possibly cause a stroke during the operation. Embolic prevention devices, some with a filter-like basket attached to a catheter, are therefore positioned in the artery during a carotid angioplasty to catch any clots or small debris that might break loose from the plaque, thereby helping to reduce the incidence of stroke while the patient is in surgery.

The only setback is that not many neurologists believe that stenting works. There are many patients with severely narrowed carotid arteries who are simply being sent home with drugs. Such attitudes towards carotid angioplasties will only worsen a patient’s condition

Statistics demonstrate that a carotid angioplasty is in fact a fairly low-risk procedure—in 1993, its immediate success rate in North America already exceeded 80 per cent, while its stroke and mortality rate remained low at nine per cent. A later study conducted in 1996 by Dr G.S. Roubin revealed that out of 238 carotid angioplasties, the mortality rate was only 0.5 per cent, the major stroke rate was one per cent, and the minor stroke rate was 7.4 per cent.

The carotid angioplasty has always been a high-risk procedure. The risk is in the range of below 5 per cent, in that someone may get a stroke and other associated conditions such as a dramatic drop in blood pressure or a heart attack during the carotid angioplasty. Patient usually remains conscious during the procedure, though under a local anaesthetic, and will not be allowed to bend their leg nearest the insertion site (if the insertion is done in the groin) for several hours.

However, the relative lack of invasiveness during the procedure means that a patient who has undergone a carotid angioplasty may be discharged from hospital after two nights’ admission, depending on their progress.

There is usually no discomfort, except the patient has to lie flat until their groin is better. There should be no neck pain, although some patients may feel some discomfort at the site of the neck where the stent was placed. Aftercare mainly involves monitoring a patient’s blood pressure until their condition stabilises. They may also be prescribed double antiplatelets for one month.

HeartTalk Issue No 4

THERE'S ALWAYS A HELPING HAND

At IJN, there are three options a patient in financial difficulty can consider: The Medical Assistance Fund, the IJN Foundation and the Unit Taksiran Khas Kementerian Kesihatan Malaysian (UTKKKM)

Walking into a hospital is a scary time not just for the patient and loved ones but also for those who are wondering how they will afford the rising costs of healthcare. Government hospitals form a safety net for those who cannot afford the big bills at private hospitals, but what happens when treatment is not available anywhere else? What happens when a Government hospital refers you to IJN?

Some of our patients from the lower income group cannot afford the fees at the hospital. When they are asked for the deposit at admission, they are usually taken by surprise. The scenario is a familiar one: We’ve heard it from relatives, friends or read about it in the newspapers – but that’s where our knowledge usually ends. Most of us don’t know what comes next or how the story ends.

We assume that patients are turned away, refused treatment or end up at newspaper offices looking for help. While it’s true that some do look for public funds collected through the media or other organisations, patients can actually approach the hospital itself for financial help.

When they say they have no money to pay the deposit, they are brought to Patient Services Department. Here, each patient’s case is analysed before a decision is made about which course of action is best to take. At IJN, there are three options a patient in financial difficulty can consider:

First, there’s the Medical Assistance Fund (MAF, also known as the Tabung Bantuan Perubatan or TBP). The MAF is administered by the Ministry of Health and has an annual allocation of RM25 million. The fund covers treatment and purchase of medicine not otherwise available in government hospitals. For example, in the cardiothoracic field the MAF will fund, either in part or in full, the Implantable Cardioverter-Defibrillator (ICD). Neither the procedure nor the device is available in government hospitals, so the MAF covers those who need the implant. (The ICD is a device that sends an electric current to the heart if it stops beating. It is surgically implanted into a patient’s body and includes a pulse generator that constantly monitors the heartbeat like a small computer.) The device costs between RM30,000 to RM80,000.

In the last 3 years (2008-2010) we have 67 patients who implanted their ICDs funded by MAF. To be eligible for MAF assistance, a patient needs a government hospital reference with a signature and stamp, a medical report from the doctor, and must be a Malaysian citizen. Patients applying for the fund will also need to visit the Welfare Department to have their financial situation assessed. The department will weigh income levels, number of dependents, and other relevant details that affect one’s economic situation. With this, the department will then recommend an amount to be sponsored by MAF.

Besides the MAF, the IJN Foundation also helps those with financial difficulties, such as children without birth certificates who needed help. Finally, the Health Ministry’s Unit Taksiran Khas based at IJN can also be approached to subsidise cases that are referred to IJN from government hospitals.

IJN serves 500 to 600 outpatients daily, about three quarters are sent to the Unit Taksiran for financial assistance, and out of the 50 to 60 daily admissions, about 40 are sent for financial assistance. However, patients must keep in mind that charges are usually not subsidised fully. Patients are usually asked to contribute partly to the payments, no matter how little, as this gives them a sense of responsibility.

IJN ADVANCES AHEAD OF ITS SOUTH EAST ASIA (SEA) PEERS IN CORONARY ARTERY STENTING TECHNIQUES.

First to implant the revolutionary “disappearing” heart device.

INSTITUT JANTUNG NEGARA, 11 February 2011 - - Institut Jantung Negara (IJN) achieved another medical milestone for the country and became the first centre in Malaysia and South East Asia to implant a new stenting device called “Bioresorbable Vascular Scaffold (BVS)”.   The new technology has the potential to revolutionize the treatment of coronary artery disease – with the prospect for positive therapeutic outcomes resulting from its unique ability to treat a blocked vessel, potentially restore natural vessel function and disappear within approximately two years after implantation

The cardiology team headed by Tan Sri Dr Robaayah Zambahari (CEO/MD) and Dato Dr. Balachandran (Consultant Cardiologist), aided by the team of invasive cardiovascular laboratory staff and the Clinical Research team, performed the initial implant into a patient three days ago.  According to Tan Sri Dr Robaayah, the new BVS device is made of polylactide, a proven biocompatible material that is commonly used in medical implants such as resorbable sutures. Since a permanent metallic implant is not left behind, a patient's vessel treated with BVS may ultimately have the ability to move, flex and pulsate similar to an untreated vessel. Restoration of these naturally occurring vessel functions, or vascular restoration therapy (VRT), is one of the features that makes BVS a significant innovation for patients in the treatment of coronary artery disease. In addition, research indicates that the need to administer long-term dual anti-platelet therapy to patients may be reduced because the temporary scaffold is completely resorbed.

IJN is one of the two heart centre in South East Asia that are involved in the Clinical Trial for the device and IJN has successfully implanted the BVS device on the first patient. Tan Sri Dr Robaayah also briefed the media conference today that the treatment for coronary artery disease has come a long way since the balloon angioplasties, followed by bare metal stents and currently drug-eluting (metallic) stents DES. This revolutionary device, called ABSORB, has the potential to benefit patients even more. It functions as a scaffold; over the next 90 days or so, it elutes the drug, everolimus that prevents cell growth, and over the next months out to 2 years, it slowly dissolves, thereby ‘disappearing’, after completing its functions. The vessel regains its original status and functions. She also added that the device would potentially be even more beneficial to paediatric patients, in whom as the patient grows, the patient would ‘outgrow’ the implants. A metallic implant would require the patient to undergo surgery to remove the implant. But if the implant dissolves away, the child would not require such surgery.