Joined Max Superspeciality Hospital, Mohali

It is great priviledge for me to announce that I have joined Max Superspeciality Hospital ,Mohali in the Dept. of Cardiac Sciences now as Senior Consultant and Incharge of CTVS. This hospital is part of one of the largest chain of hospitals in India known for best infrastructure, quality care and utmost ethics in healthcare. A large rapidly expanding group focussed on providing best possible care to all.

End Stage Valvular heart disease treated successfully with Double Valve Replacement on CPB

29 yr old male presented with severe breathlessness, palpitation and giddiness. On examination he was found to be having severe leakage of both Aortic and Mitral valve. He was in heart failure with enlargement of liver and fluid collection in the lungs. His lower blood pressure was very low, & it was unable to nourish the heart. On investigations his echocardiography, his heart was grossly dilated and added to that his aorta was dilated grossly to 5.7cm and left side chamber was 8.4cm. All this made him a very high risk for routine surgery and only alternative available to him was heart transplant which again was not very feasible. In last 4-5yrs he went to Bangalore, Delhi and other hospitals in Chandigarh but did not get a definitive answer for surgery. We decided to investigate him in detail and stabilize him by decongestion and prepare his heart for surgery. In view of his dilated heart changing the aorta along with mitral valve was a very challenging procedure which was the ideal treatment. On admission he had chest pain in night and his heart stopped. He was put on a ventilator and started on drugs to maintain his blood pressure. Luckily he responded and was extubated and underwent CT scan. We examined the CT scan very thoroughly and found that aorta at the place where our clamp was to come was 4.7cm, which was comfortable for this procedure.
So we decided to change the plan to more conservative in the form of simple double valve replacement and save the aorta if its wall was well preserved. We planned to preserve heart muscle by perfusing blood cardioplegia with higher frequency. The plan paid off and he tolerated the procedure and in the post operative period he recovered slowly, but well, under the very strict supervision of our expert critical care team. He was discharged from hospital on 9th day and his echocardiography after one month showed marked improvement. His heart size has come down to 7.1cm from 8.4cm and aorta to 3.8cm from 5.7cm. He wants to ride a bicycle now, whereas he was barely able walk earlier.
The challenge in these cases is that since left side of heart has got dilated so much that it is difficult to preserve it during surgery as reserves of the muscle are very limited. One needs to devise special techniques to do that and one is to perfuse cold blood with additives to keep the heart arrested very frequently (every 15 minutes) and this gives the heart the required oxygen and nutrition to maintain cell metabolism. Other is to keep the heart totally empty and not to allow it to get distended. These are few of the techniques, coupled with making the procedure as short as possible. This was the real challenge and if one goes by bookish conclusion he required replacement of the whole aorta along with mitral valve replacement , a very extensive procedure and probably he would have not survived this procedure. Hence it was reduced to only replacement of both valves.

Badly Damaged Heart Requiring Heart Transplant Treated Successfully With Beating Heart Surgery on IABP

Every heart attack leaves the heart muscle damaged and more the number of attacks, more the damage. After bypass surgery some part of its gets revived and some part remains damaged only. But major risk of damaged heat is whether it will be able to bear the stress of surgery and beyond a certain limit which is judged by echocardiography in terms of Ejection Fraction the risk is very high. These patients with Ejection fraction of 20% and below are generally the candidates for heart transplant which is itself is not very easy to go through because of shortage of donors especially in Indian setting and also because of life long  heavy expenditure on drugs. World wide in view of this there is an effort to salvage a few patients by offering their bypass surgery though mortality for these kinds of patients is very high but otherwise also it is same if nothing is offered to them.

Beating heart surgery has proved a blessing to such patients as success rates of bypass surgery in this class of patients has improved a lot. These patients but definitely require extensive investigation to see the benefit and thorough stabilization and planning. Sometimes before surgery they are supported with intra aortic balloon pump to reduce the load on the heart as well as improve the blood supply to heart muscle to some extent so that heart improves a bit to tolerate bypass surgery.

Recently, we at Alchemist Hospital, Panchkula operated upon one such patient Mr. Tara Chand 50yrs Male. Dr. V. Sarwal, Head, Deptt. of Cardiovascular and Thoracic surgery along with his team Dr. Mubeen Mohammed, Dr. Ajay Sinha, Dr. Amit Ahuja, Dr. Dheeraj Dumir, Dr. Srinivas and Mr. Des Raj operated upon him successfully.

He came to OPD for an opinion for his heart disease and his condition was getting worse. Earlier, he had shown at many places even had angiography done at Bangalore but some how could not get operated and as per his previous record his ejection fraction was 30%. He was advised fresh angiography followed by pass surgery. On the night before his scheduled day of angiography his condition deteriorated, had chest pain, breathlessness and went into heart failure. He was admitted in the night itself and angiography showed disease had progressed and other investigations revealed a fresh heart attack. He tolerated angiography but his blood pressure was low and required drugs to support it. Echocardiography revealed further damage to heart and ejection fraction fell down to 12%. It was decided to insert IABP (Intra-aortic balloon pump) to support the heart and then stabilize him with medications for next 48-72 his before planning for surgery.

   

Angiography showed two arteries 100% blocked and third one was 85% in the proximal part and after that 100% blocked so all three arteries were completely blocked and he was surviving on 2-3 small branches of these main arteries.

Review of all investigations showed that he was ideally a candidate of heart transplant and bypass was quite risky but this was an option only theoretically. His Trop –I levels a marker for fresh heart attack was high so we stabilized him with drugs to take out water from lungs. Supported him on IABP for 3 days and when Trop – I level came down we decided to go for beating heart bypass surgery. Only positive thing on the whole scenario was that he was admitted with chest pain along with breathlessness which in itself on indirect indication of revivable heart muscles.

He was taken to Operation Room for surgery after 3 days and three grafts were put on him on beating heart. His vessels had quite a diffuse disease and one of the vessels had to be thoroughly cleaned (Endarterectomy) before putting up the grafts. He tolerated the procedure with moderate drug support and ventilator was removed on next day and IABP on 4^th POD. Slowly his drug support was reduced, de-lined and mobilized and discharged on 12^th Post op day in very stable condition.

His echocardiography showed marked improvement on his second follow-up and EF has come up to 30% now. His recovery is very good and his normal routine has started now. Beating heart bypass surgery is also quite risky in such conditions but is much better and helpful than conventional bypass surgery done on heart lung machine. This single technique has made quite a bit of difference in the outcome of such patients and our center is expert in this technique and has offered successfully this to very high risk and elderly patients even above 80yrs of age

STENT OR SURGERY… its not a DIELEMMA any more. Surgery scores in durability and event free years.

Heart Disease or Coronary Artery Disease is the largest single killer in our society. The changing life style and added to that the stresses and strains of life have made this disease an almost epidemic. In India it is fast growing and soon we will be the number one country with patients of Coronary Artery Disease. The WHO report is scaring and it points towards a total disaster. Keeping this in new we all need to take preventive steps to lessen the burden of this disease. First and foremost step towards this will be to have an organized lifestyle, regular exercise and diet control. But the next more important step will be to go for preventive check ups. The incidence of this disease is rising now in younger population so it will be advisable that anybody who is above 35 years should have all his investigations carried out from heart point of view at least once a year so that if there is any alarming sign it is tackled well in time. This particularly holds good in those persons who have a strong family history.

This is one scenario and the other is that someone is having coronary artery disease, which is significant enough to produce symptoms, and requires some treatment. In this second scenario one has to act immediately. Rather than have a wishful thinking that symptoms are not related to heart and may be due to gastric trouble or muscular pain one should immediately go for stress test and if it is positive then to see how much exactly the disease is, one undergoes angiography which is the only gold standard test to quantify this disease.

            The real dilemma starts when one is found to be having significant coronary artery disease, which requires interventional treatment. As of now two types of interventions are available (both are invasive and require hospitalization).

            Angioplasty and Bypass Surgery there can be situations where both can be offered as treatment of coronary artery disease and of course Bypass Surgery can be applied and is the solution in any type of situation. Angioplasty means that the diseased area of coronary artery is repaired by dilating the diseased porition with a balloon catheter and these days to support the weak dilated wall of the artery a stent is put in place for better long term patency rates.

            Bypass Surgery is where surgically the disease part is bypassed with a new route of blood supply via a graft taken from the human body only in the form of vein or an artery. These days we used more and more of arterial grafts either the Internal Mammary Artery that runs at the beck of sternum or radial artery, which runs in the arms. 

            Angioplasty is less invasive than surgery in terms of that it is done under local anaesthesia and there are no major incisions. Bypass Surgery has also become less invasive in terms that it is being done on beating heart and no longer the heart is arrested to carry out these grafts. So the stressful effect of heart lung machine on the body is gone now and recovery is much faster. Bypass surgery is beyond doubt the long term, time tested solution which improves quality of life, prevents sudden heart attacks and freedom from second procedure is great.

            In case of Angioplasty with stents also improves quality of life but the other two factors do not hold good. If the stent fails or blocks again it will lead to a fresh heart attack and also the chances of blockages second time are more with stents where a second procedure may be required early. The earlier stents had high re-blockage rate but the new generation of medicated or drug coated stents have better durability and patency rates but still they have above 9% re-blockage rate during the first year only. The procedure is beneficial only in short-term basis, in terms of no major incision, less or shorter stay in hospital and no general anaesthesia but at the cost of durability.

            Bypass surgery is a proven durable treatment for coronary artery disease but when a patient is detected to have this disease there are certain situations where both the treatments can be applied and there the dilemma starts. If you look at human psyche anybody and everybody in the world will want a less traumatic treatment where angioplasty comes in mind but at the same time no one wants to suffer again and again and one wants a long term solution to the disease or to that effect eradication of disease (which though is not possible) but something close to that is possible with bypass surgery. As new route of blood flow is create via grafts, which are disease free, bypassing the diseased part of artery, which means in an indirect sense removing the diseased path from the route of blood supply to the heart.

            Whenever a particular form of treatment is adopted it is backed by lot of research first in animal models and then in human beings as clinical trials. Then only it is offered to public en mass. Even after the procedure is accepted it is constantly evaluated by further trials and also it is compared to the already existing procedures or other newer procedure so that the best form of therapy can be chosen for the patient population. In this direction lot of trials were conducted on cardiology front about 15 major ones and some were compared with surgical arm. Even with the advent of drug eluting stents, bypass surgery scored over angioplasty with stents in terms of better long term results i.e. event free years and less chances of second procedure. Patients in the angioplasty arm had more incidence of major adverse coronary events after the first procedure.

            What are the issues here lets have a look ! Agreed any patient will choose a less invasive treatment out of two available treatments. But here is a catch; these two terms of treatments have to be equally effective in terms of their results. In case of angioplasty vs surgery key issues are:

1.            Is angioplasty in multi-vessel disease evidence based?

2.            Are the limitations of angioplasty known to the patient?

3.            Is it economical in multi-vessel disease as compared to surgery?

There is another major flaw. The trials on which we base our treatment are conducted on western population, which is genetically different than Asian or Indian population. In the sense that in western population the size of coronary arteries is much bigger than the Asian population like it is 4-6mm as compared to 2-4mm in Asians. So treatment applied there cannot hold good here.

            As such if we look at Angioplasty vs CABG the two forms of treatment are not equivalent in terms of:

1.            Bypass Surgery not only tackles culprit lesion but also deals with future lesions as it is done distal to the diseased part.

2.            In certain situations angioplasty carries very high mortality like Left Main Disease.

3.            Even the repeat revascularization or second procedure requirement is higher with angioplasty in multi-vessel disease or left main disease. As per two latest trials even in western population Arterial Revascularization Therapy Study (ARTS), Stent or Surgery (SOS) trials the incidence of second procedure in angioplasty group is 3 times higher than patients treated with surgery. Also the risk of death in both the trials with surgery is very low 1.2% in ARTS trial and 0.8% in SOS trial.

4.            The trials included only simpler form of disease like single or double vessel but the results are being applied to multi-vessel group. The need for re-intervention in ARTS trial was 30% as compared to 9% in surgical group.

5.            Again in diabetes the bypass surgery scores over angioplasty in terms of long term benefits as in ARTS trial it was 43% in angioplasty as compared to 10% in surgery patients.

6.            Surgery offers more complete revascularization with better durability especially arterial grafts.

7.            Left main disease is a very serious situation, which requires urgent intervention and bypass surgery so far has been the best form of treatment.

8.            Another major disadvantage with drug coated stents is what we call “Late Stent Thrombosis” or sudden occlusion of the stent after a year or so when the blood thinners or antiplatelets are withdrawn or reduced and infact FDA in USA has issued a warning to all these companies for this dreaded complication.

Other myths about angioplasty safety have also been proven wrong.

1.            Risk of heart attack during angioplasty is 10%

2.            Risk of restenosis with in first year is 10% to 30%.

3.            There is no reduction in neurological complications with this.

4.            Even in trials including drug coated stents multi-vessel disease, small vessels, long lesions, diabetes and restenosis patients have been excluded but in practice they are applied in even these subset of patients also.

Recently a lot of studies have come in the reputed International Journals, two of which I quote here which have proven beyond doubt that CABG or Bypass Surgery is much superior to angioplasty in multi-vessel and left main disease and these subset of patients should only be treated with surgery for long term benefits and economics.

1.            One paper was published in Annals of Thoracic Surgery Dec. 2006 entitled, “Coronary Artery Bypass Grafting is still the best treatment for Multivessel and Left Main Disease… But patients need to Know” by Dr. David P Taggart from John Radcliffe Hospital, University of Oxford, United Kingdom.

2.            Does off pump or minimal invasive coronary artery bypass reduce mortality, morbidity and resource utilization when compared with percutaneous coronary Intervention? A Meta analysis of randomized trials. …In Journal of Thoracic and Cardiovascular Surgery March 2007 by David Bainbridge & Colleagues from Canada.

            Both these papers have detailed about pros and cons of two procedures. In Lancet in Jan. 2006, the headline cover stated, “In view of the survival benefits shown for CABG the real controversy is why patients with symptoms and anatomy known to benefit from surgery are still submitted to angioplasty”.

            Again the dilemma is summarized by Dr. Califf, Head of Interventional Cardiology at Duke University, “Stenting or Surgery” in Journal of American College of Cardiology”. It is likely that most people undergoing Coronary Angioplasty are not told the entire story when a decision is made about undergoing angioplasty. He attributes this to conflicts of self-referral and financial incentives and concludes, “Without Surgical Opinion the patient is in no position to have a rational input into the decision.”

            The great father of interventional cardiology, Andreas Gruntizg, who died prematurely in a plane crash at age of 46 stated in 1979, “We estimate that only about 10-15% of candidates for bypass, surgery have lesions suitable for angioplasty. A perspective randomized trial will be necessary to evaluate the usefulness in comparison with surgical and medical management”.

            So to conclude stent or surgery is not/should not be a physician’s choice. It should depend on what disease demands keeping in view the long term benefits and the economics. Pros and Cons of both the procedures should be made aware to patient in detail. Durability of treatment rather than short stay should be the goal and important factor for deciding treatment.

            In the end I think the best way to remove this dilemma is have multidisciplinary team consisting of a physician, a cardiologist and a cardiac surgeon to decide about the treatment plan for coronary artery disease in a particular patient on individualized basis

YOUNG PATIENT SALVAGED WITH HEART SURGERY FOR TERMINAL STAGE BY- BIRTH DEFECT

Atrial septal defect is an abnormality present in a person from birth where there is a hole in the partition between the upper chambers of the heart called the atria. As a rule many times if it is small it can close on its own by 2yrs of age beyond that[a1]  if it is of simple nature then one comes to know of it only in second decade. If the type of this defect is atypical which is called Sinus Venosus  type of defect then symptoms happen earlier and needs early intervention also. Here most of times one vein carrying pure blood from lungs which was to drain into left upper chamber is opening into right upper chamber this increasing the flow to lungs. Or some time all veins from right lung are opening into the superior Vena Cava (Vein draining impure blood from upper parts of body to right upper chamber) along with large gap in the partition between the two upper chamber. In such a situation the flow to the lung increases markedly and permanent damaging changes start setting in and a stage comes when resistance of lung vasculature increases so much that blood flow direction reverses. Normally it is left to right but then it becomes right to left and patient start becoming blue also. This is a stage where surgery is not possible and patient become in-operable. Otherwise if heart surgery for this carried out at the right age and time is suitable and patient becomes absolutely normal for rest of his /her life.

Recently a 21yrs female who had given birth to a child 4 months back presented to us at Alchemist Hospital, Panchkula with severe breathlessness and palpitation. On examining we found her to be having a hole in the heart in both the upper chamber and investigating her with echo-cardiography and going through her previous record we found that she had atypical sinus venous type of atrial septal defect which manifested after child birth but along with her pressure in the lung vasculature had become very high almost equal to the body’s blood pressure. In view of this outside other peripheral  hospitals had denied her surgery in view of very high risk including the risk to life. Infact she was sent Delhi for  opinion.

When she presented to us we also felt the same way but then we decided to further investigate looking at her young age. The only chance for correction or treatment through surgery was now and otherwise it could be fatal. We admitted her and did a cath study on her. The lung pressures had peaked to 110mmHg which was equal or slightly more than her own blood pressure and shunt across the defect got reduced to 1.3:1 (normal criteria for surgery is shunt more than 1.5:1 or 2.1). The pulmonary vascular resistance came out to be 12 wood units, close to the terminal  limits, where one becomes in- operable. Only positive finding in the study was that she was still maintaining almost normal oxygen levels in left side of upper chamber i.e left atrium about 97% that was a sign that she was not de-saturating but other parameters pointed towards non-operability.

We decided to plan her treatment and give her a chance. We started her on certain newer drugs to lower her lung pressure before surgery, talked to the family of high risk involved and total picture and need to prepare her for about a week before surgery by drugs including lungs pressure lowering drugs, to flush out extra fluid from body and to give rest to right heart and also some thing to improve the contractions of right heart.

Looking at the literature again she was in that rare group where surgery was not possible. After nine days of preparation we decided to do a repeat echocardiography and she did responded to medication but  marginally and also there was no bluish discoloration involved, so we felt that changes were not irreversible. On 17.06.2011 she was operated for open heart surgery and her hole was closed with a patch made out of the outer layer of heart called pericardium, diverting all the right lung veins which were connecting to lower part of superior Vena  Cava  to the left. We did one more innovation in creating a flap- valve type of patch in her case. The idea of this is that incase after surgery the right heart pressure increases the flap valve allows the right chamber to dicompresss by opening up. Heart  muscle  was  protected well during surgery with various newer Techniques. She responded well to treatment and surgery and her lung pressure came down to 50% of arterial pressure in the immediate post- op period. They further were controlled with the new drugs which we had started earlier in the pre- op period. Over all she responded very well and lung pressure almost came to normal range.

She was discharged on 8^th day with detailed explanation about the medications and precaution and on her follow up visit  on 1^st June it was very heartening to see her healthy and progressing well. Well thought of strategy and extra effort in treatment goes a long way in saving these high risk patients along with a good and skilled infrastructure and highly experienced team of doctors. 6 Senior doctors were involved in her care on day to day basis and it was very satisfying for all of us to save this young life. She was operated by a team headed by Dr Varinder Sarwal, Head- Dept. of CTVS, Alchemist hospital, Panchkula, Dr Arath Nahak, Dr Ajay Sinha, Dr Deepak Oberoi, Dr N Srivastava and Dr Dheer

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