Friday, December 31, 2010


To continue the story.
At the turn of the century, in 2000, we begin to hear of the initial results of the first-in-man trial of a drug-eluting stent. We all know that the "achilles heel" of POBA and coronary stent is re-stenosis. Having done a good job, after 2-3 months, 20-30% of the lesions will recur. So interventionist the world over were working hard to see how to reduce that. The early work was done in Sao Paulo, Brazil. They published their first 40 patients, first-in-man use of the sirolimus eluting stent ( made by JnJ cordis ). The results were very impressive. That led quickly to a clinical trial in Europe. The trial was called RAVEL, and the results were very good. Of course, I asked my JnJ manager for permission to use the stent.
On 28th May 2002, I implanted our first DES ( DES ). Over, across the city, my colleague Dr Robayaah Z in IJN was also doing the same for her patient. Both implants were successful.
In turns of progress, the 2000-2010 decade did not see much. More and more companies brought out their drug eluting stents. Before the close of 2010, we now have second generation and also almost final improvement of what could be 3rd generation DES.
I have always stuck on to pure, cardiac interventions. I did not venture into peripherals, renals or carotids, as I felt that to be good and excellent, you must do hundreds, if not thousands of them. Doing 5-10 carotids a year, is not being fair to my patient. But that is very much a personal philosophy. I am writing that because, 2000-2010 also saw tremendous progress in our understanding and role of renal interventions ( now larger proven not to be helpful in controlling resistant hypertension, except transiently ). There was also much progress with carotid angioplasty, but its role is still highly controversial, proven in many large trials not to be any better and in some sub sets, to be worse then standard carotid enarterectomy.
The last few years of the decade of 2000-2010 saw the innovation towards percutaneous valve implantation, without the heart-lung machine, through the femoral artery. Nice procedure for those who were too ill for surgery, but the cost of one of those TAVI ( tranfemoral aortic valve implantation ) device, is about RM 100,000, and they are trying it out in IJN, with tax payers money. In all these extra-coronary procedures, I have stayed clear. Let the young boys learn and be good.
The new millennium also saw the development of cardiac centers in all the major public hospitals. Johore Baru cardiac unit, took off after some initial teething problems, then the Kuching Heart Center, the Pinang Heart Center, and more recently, the Serdang Heart Center. The Kota Kinabalu heart center was started early, but its development was stunted by some " political" issues and issue of "tuft". It is still there but undergoing revamp ( as I understand it ). These developments are healthy, and allow the public to get treatment at hospitals nearer to them. This also means that there are now 200 hundred or so interventionist ( starting from 3 in 1998 ).
This decade also saw the social development of interventional cardiology. I am a founder member of the " INTERVENTIONAL CARDIOVASCULAR SOCIETY OF MALAYSIA", which is a society under the auspices of the National Heart Association of Malaysia, of which I am a member. You will not believe the amount of racial politics going on in the association and society. Even medical professional societies, suffer from the national disease. I left the committee. We are too straight-forward for all the twisting and turning required, to work in the system. They have gone ahead to run their annual live demo courses, at tremendous cost to the device companies and pharmas, who have no choice but to support, as they need the help of the organisers of these expensive live demo courses, to get their products into the public hospitals. They forget that all the money given to sponsor such big ( can I say wasteful ) meetings, come from the A&P ( advertisement and promotion ) budget of their companies, which ultimately return to the higher cost of product. I was involved in the planning for the first live demo course back in 2004, but found that we could not get along, because of some personalities, who have their own selfish agenda. Together with a small group of like minded interventionist, we have gone to organise our low cost, year end interventional cardiovascular forum. A forum of discussion,case reviews, amongst interventionist only. At 10% the budget of the expensive ( not necessarily well attended by interventionist ), we are able to share our experience and expertise with the younger group of up and coming interventionist, hopefully for the betterment of cardiac care in the country.
I still travel across Asia, to some " friendly" meetings as faculty, to help share our experience. Working without publicity ( low key ), is a challenge, but frees you from all the politics, and you can be true to yourself. I felt that for someone without connections, who loaf publicity and politics and with no government support ( all private or self funded ), what we have achieved for the country is reasonable.
Seeing that the " sun is setting ", yearly we also oversee two weekend seminar in cardiology for GPs. One in the Klang Valley and another through the country, at various location. It is our attempt to improve cardiac care in the country.
As we come to the close of 2010, I can see that interventional cardiology innovations have come to a plateau. We should see the coming to the market place of the 3rd generation DES, what I would term the biodegradable drug eluting stents. The early results now, look promising. Hopefully, the " stem cell" boys ( those working on stem cells to regenerate dead heart muscles ) will get their act together, and discover for us, new ways to grow heart muscles, which we can incorporate into our standard PCI. Of course there will be more devices coming to the market place, some of use to patient care, some is only hype, and ultimately fall away. In my 30 years in this field, I have seen many fall away. The wisdom is to know which to go for, that will stand the test of time and that will make treatment cost effective. The business of practice of medicine, is fast encroaching on the good clinical practice of medicine. So far, I believe, we have made more good choices in the devices that we adopted, and promoted, good clinical practice of medicine, than choose harmful ones.
Well, no regrets for 30 interesting and challenging years in interventional cardiology. If I have the blessings to see to the next decade, I will write my thoughts on 2010-2010, as I see it.
In the meantime,

Talk to you all next year.

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