18-yr underprivileged boy from Kashmir gets new lease of life at Max Super Specialty Hospital, Mohali

His free cardiac surgery was funded by Max India Foundation
CHANDIGARH: Partially deaf by birth, 18-year old Asif Wani sordid tale of despair and victory is heart rending. The sixth child of a daily laborer, Abdul Azeea Wani, Asif was brought to Max Super Speciality Hospital, Mohali with complaints of breathlessness and palpitation.

He was diagnosed with complex birth heart defects multiple conditions of Atrial septal defect, PDA and severe Pulmonary Stenosis (Congenital disorder) comprising of hole in the upper chambers of the heart, along with a flowing channel between main artery of the body and artery feeding the lungs which normally closes soon after birth. The surgery that saved the life of this innocent teenager was not only complex from the medical point of view but also gave a new lease of life to the hapless boy.
Asif’s mother Zareefa Bano was speechless with gratitude as her son narrated the story of their strife to get treatment for their son. Asif had been diagnosed with the multiple congenital heart defects as early as 2 months of his birth. His parents took him to the local doctors at Srinagar but were turned away due to lack of funds. Even the best hospital in Srinagar refused free treatment to the boy. The procedure to save him, the family was told, would cost lakhs of rupees, which was impossible for the destitute daily wager to collect. Through a common acquaintance, Max India Foundation took up the case and Asif was successfully operated upon by Dr. Virendar Sarwal, Senior Consultant, Cardiology at Max Super Speciality Hospital Mohali. The 5-hour surgery involved one week of post operative care under expert supervision of critical care experts.
Belonging to an obscure little village Handwara in the far reaches of Kupwara Distt about 10-12 Kms from LOC, Asif’s parents were devastated when they realized that he was suffering from congenital heart disease. Asif was advised immediate surgery. Helpless and penniless, Asif and his family were in a dilemma as to how they would bear the cost of such an expensive surgery. It was then that he was referred to Dr Sarwal, who volunteered to take up his case. Since Asif belonged to a poor family and his parents could not afford the expensive treatment, an acquaintance, who had been helping the family since last 2 years in arranging funds, approached Max India Foundation for financial assistance. Max India Foundation decided to help the young boy by bearing the entire cost of surgery and offering him world class medical treatment at Max Super Speciality Hospital.
Ever since Abdul Azeea Wani, Asi’s father lost his eyesight 5-6 years back, Asif’s mother has been working as a labourer on a meager daily wage with no other source of income. We have been running from pillar to post for 2 years but all efforts to secure funds for the surgery bore no fruit. Our fellow villagers managed to gather Rs 16000 for our travel and stay once they came to know that Max Hospital was helping us, said .
Dr. Sarwal said that since these were birth defects, these were high risk surgeries. Asif lungs had developed early hypertensive changes and it was a long on pump surgery because of three congenital defects. His pulmonary valve was too small for his age. Asif underwent intracardiac repair on Cardiopulmonary bypass at Max Super Speciality Hospital on October 14 and soon recuperated. He would be requiring regular medication to support his heart condition.
For the past 18 years, my world was full of just pain and helplessness, said an emotional Asif, while expressing gratitude towards Max India Foundation for their support With this crippling disease, all I could do was sit or lie down on my bed and take a few faltering, painful steps to go to the toilet. It was a very depressing state of affairs for my family and me and many times I would wonder what was the point of existing like this, he remarked.
Ms Mohini Daljeet Singh, Head, Max India Foundation said that living up to our social responsibility of an integral part of the core philosophy of Max India Foundation, we were very glad that we have been able to get an opportunity to serve the needy. We would continue doing so in the times to come with sincerity and passion, she asserted.
It may be mentioned here that under various CSR programs like immunization, health awareness and health camps, artificial limbs camp, palliative care for cancer patients, Max India Foundation has now crossed the 1435 free and subsidized surgeries mark. Over 477147 people have benefitted from the various CSR programmes of Max India Foundation till now.
Dr. Ashutosh Sood, GM operations at Max Super Speciality Hospital Mohali said that this whole package bearing cost of Rs 2 lacs, was done entirely free of cost. However, it was well worth it because today Asif presented a heartwarming sight. Having recovered very well, he was up and about, talking and playing like a normal teenager.. The joy on his face was priceless and nothing compared to the satisfaction of having helped tears turn into smiles, remarked Dr Sood.

High risk Octogenarian successfully treated for Coronary Artery Disease with Beating Heart Bypass Surgery successfully

 

·         Patient presented with critically blocked and calcified heart vessels which are difficult to tackle surgically

·         Off Pump Coronary Artery Bypass (OPCAB) or Beating Heart Bypass Surgery is a safe and proven option for bypass surgery in elderly patients

 3^rd September, Mohali: Elderly patients, compared with patients of a younger age group, present for surgery with a greater burden of risk factors and reduced functional levels. Short‐term outcomes are hence poorer in them. But symptomatic relief occurs in most patients and is accompanied by excellent rates of long‐term survival and a good quality of life when treated with beating heart surgery. Max super speciality Hospital Mohali recently treated an 84 year old male, Ramnarayan, who had his all three major heart arteries critically blocked. Along with this complication, the major arteries going to his brain were also blocked on both sides by 90% and 60%. The main artery on the left side of the heart (called left main ) was having 90% stenosis- in such critical conditions, bypass surgery becomes an urgent requirement. Also other three arteries, two on the left and one on right side were also blocked by 90% and 99%.

“He was very symptomatic” avers Dr Virendar Sarwal, Principal Consultant and Chief of Cardiac Surgery, his treating physician “Ramanarayan was offered high risk bypass surgery on beating heart at the time of angiography because of his age. In octogenarians, the risk to life becomes very high as all organs of the body are aging due to wear and tear. Reserves  are substantially low which make it difficult for the body to undertake the stress of surgery.”

Ramnarayan decided to take some time off and went home but had to get readmitted twice in the next 10 days because of severe heart symptoms. The family accepted the high risk  involved and the medical team collectively decided to work him up for surgery. “For this category of  patients  beating heart surgery which is now an  established technique  serves as very good  option . But, an individualized risk–benefit profile must be carefully constructed by clinicians, taking into account several different factors and not just age alone.

On investigations, it was found that Ramnarayan’s both carotid arteries (supplying blood to the brain) were also critically blocked and we had to take extra care to avoid brain damage during surgery especially because of acute blood pressure variations. His CT scan had dilated lateral ventricles and cerebral atrophy. As there was no evidence of any major stroke we decided to go ahead with beating heart bypass by taking special precautions in the OT. Three grafts were given to him on beating heart by using octopus stabilizer and maintained higher blood pressure intra operatively.”

Ramnarayan was fully mobilized  on 3rd day and discharged from the hospital on 5th day.

 

Discussing the advantages of off pump coronary artery bypass (OPCAB) or beating heart Bypass surgery as it is commonly called, Dr Sarwal said “ OPCAB is though technically demanding is a safe and prove option for high risk bypass surgery. Doing surgery on a beating heart eliminates the need for heart lung machine,  results in fewer side effects. Some potential benefits of beating heart surgery are lower risk of stroke, fewer problems with memory loss and thinking skills, reduced injury to the heart, fewer heart rhythm problems and shorter hospital stay, less ICU stay and less usager of blood. Long term success of OPCAB includes improvement or complete relief of their symptoms and being symptom-free for several years. They may recover from surgery more quickly than those who go "on pump" and they may suffer from fewer post-operative complications.”

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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