Max Hospital, Mohali helps save life of a critically ill Poor Patient with Life Saving Heart Surgery

RP a 31years old gentleman presented to max hospital, Mohali with acute breathlessness, vomiting for last four days. He was having this problem for the last one years and was in the follow up of another hospital where he was diagnosed to be having leakage of both the major valves of heart  following fever and cough with expectation. For the last four days even he was not able to lie down flat in the bed because of severe breathlessness and heart failure. His liver was severely enlarged and his echo cardiograph showed  a dilated heart with severe leakage of one valve and moderate leakage in the other with a hole in the leaflet of one of the valve (aortic valve) with sign of vegetation  on it. He was on medical treatment with the other Institute before getting admitted under Dr Anurag Sharma Sr. Consultant Cardiology. He was put on decongestive treatment and echo here showed ruptured leaflet of aortic valve with severe leakage and liver was congested with fluid in the lungs. After two days of his treatment he was planned for valve replacement surgery .As he started responding to medical treatment he was shifted to the ward from ICU but as he was poor and was not able to afford surgical treatment which was required urgently for him, Max Hospital, Mohali decided to arrange finance for him through Max India foundation and they very graciously  arranged 1.2 lakh for him for the surgery with further contribution from the hospital. But a day later his condition worsened and he went into shock state because of congestive heart failure with his heart rate dropped to 30/per mint. His urine output also dropped and he went into renal shutdown. He was shifted back to ICU and had to be put on ventilator as an emergency and drugs started to maintain his B.P. Next day his condition improved and he started stabilizing under Doctor Anurag Sharma and this team.  With great efforts again he stabilized and was removed  from the ventilator  but still was  on medication to support his heart. After five days of aggressive treatment he was weaned of from all drugs but his liver functions were still deranged. As there was no other alternative he was planned for emergency surgery requiring replacement of both the valves as his echo showed second valve also leaking severely after this episode.  The case was renewed by Dr. Virendar Sarwal, In charge of Cardiac Surgery and his team and  a request for more funds was made to Max India foundation  and additional money was sanctioned for him. After four days of more stabilization and with improvement in liver functions he was taken for surgery with a plan to change the ruptured aortic valve and repair of  the mitral valve. On Trans Esophageal echo cardiograph in O.T it  was observed that the leakage in mitral valve is due to jet of leakage of the aortic valve and as such mitral valve was normal. Other factor for the leakage of this valve was dilated left chamber of  the heart. So it was planned that with the change of aortic valve the leakage of mitral will go down because the jet from aortic valve will disappear and dilatation of chamber will also go down. Under cardiopulmonary bypass his aortic valve was changed with a 22 sized mechanical valve by a team composing of  Dr.Virendar Sarwal, Incharge dept. of CTVS, Dr.Ajay Sinha, Cardiac Anesthesia, Dr. Aratatran Nahak , Dr Goswami, Dr Deepak Oberoi,  and Dr Rajit and after coming off CPB, TEE was done again which showed disappearance of the leakage of the other valve.He was shifted to ICU with moderate inotropics support and was weaned off from ventilator next day. He progressed very well in his post operative period and was discharge on the 5^th day from the hospital in a very stable condition. On first  follow up he is doing very well back to normal life after about a month of hospitalization and stormy course which could have been life threatening for him. Thanks to the untiring efforts of the whole team and a big help from Max India Foundation he is alive today.

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.