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.

Adding years to your Heart….Life beyond Heart surgery

Heart is the most important organ of body to sustain life….Adding life to heart means adding years to Life!” To Add life to your Heart now there is an Age-By-Age Guide  which help in bringing Small Changes, Big Results

•         Every 39 seconds in the United States, someone dies from cardiovascular disease, according to the American Heart Association (AHA). Most of those deaths are completely preventable by working with your doctor to understand your own personal risks for heart disease, and then making a few changes in your health habits to lower those risks. The best health habits are those you adopt when you’re young and continue throughout your life, but it’s never too late to make changes that can protect your heart and help you live a happier, healthier life overall. Here, an age-by-age guide to getting -- and keeping -- a healthy heart.

•         In Your 20s: Drink Water

Coming out of your teens, you may regularly drink soda, sports drinks or big glasses of juice. Switching at least one or two of these drinks a day to water will not only save you money, it may also save your heart. These drinks are the number one source of added sugar in the diet. The AHA recommends that women consume no more than 100 calories (6 teaspoons) of added sugar per day, and men no more than 150 calories (9 teaspoons). A single 12-ounce soft drink contains 130 calories, or about 8 teaspoons. Studies show that people who get a lot of their calories from added sugars often don’t consume enough fiber, calcium, iron, zinc and vitamin A in their diets. What’s more, drinking your “discretionary calories” is less satisfying than eating them, so you’re more likely to overeat, which may put you on the path to being overweight, having high blood pressure and being at higher risk for diabetes -- all dangers to your heart. If plain water is just too, well, plain, squirt a lemon or lime in it, drink seltzer or brew up some unsweetened iced tea.

•         In Your 20s: Find a Better Stress Reliever

Now is the time to switch your bad habits to good ones. If you started smoking cigarettes as a way to fit in and look cool in your teens, and in your 20s you’re doing it to reduce stress, stopping smoking is the number one thing you can do for your heart. “People who smoke in their 20s and continue for the rest of their lives die on average 12 to 14 years younger than non smokers. “However, it’s easier to quit smoking in your 20s than it is later in life, because the habit is less ingrained. Any form of exercise is a better stress reducer than smoking, but people in their 20s might want to take advantage of their natural flexibility and try yoga.”

·        In Your 20s: Learn Your Family History

Now is the time to fill in the leaves on your family health tree. Talk to your parents and other relatives to find out what medical conditions run in your family. Although most people in their 20s aren’t at imminent risk of heart attack or stroke, your risks of these conditions might be much higher if a close relative experienced them at an early age. If your father had a heart attack before age 55 or your mother had one before age 65, or even if a grandparent, uncle or aunt had a heart attack or stroke at these young ages, you may be at increased risk and need to be doing everything possible now to protect your heart. You should also have your blood pressure checked every two years starting at age 18

·        In Your 30s: Set Post-Pregnancy Exercise Goals

These are prime weight-gaining years, especially if you are experiencing pregnancies. “Women get into a vicious cycle,”  “They’ll have a baby, gain 40 pounds and lose five. They’ll have another baby, gain 40 pounds and lose 10, and then by the end of their 30s, they turn around and they’ve gained 90 pounds. The 30s are when many women start taking care of everyone but themselves, but these are important years to keep weight under control, and it’s easier to lose weight in your 30s than when your metabolism starts slowing down in your 40s.” Set exercise goals to help you lose your excess weight between pregnancies. Purchase a baby jogger and jog every day. Set a goal to participate in a charity walk in a couple of months and start walking every day. In other words, move more in any way you can.

•         In Your 30s: Do Something You Love Every Day

“Whatever activity makes you feel really good inside, make sure you do it for at least 15 or 20 minutes every day.”  “For some people it might be meditation, for others it’s running, and for others it may be reading. Whatever relaxes and restores you, carve out time each day to do it and it could become a habit for life.

·        In Your 30s: Know Your Numbers

By now you should be familiar with your “three Bs”: your body mass index, blood pressure and blood cholesterol. If any of your numbers are not in the target ranges for heart health, talk to your doctor about changes you can make to improve them. Here are the numbers you should aim for, according to the AHA:
-- Blood pressure: Less than 130/80 mm Hg.
-- Blood cholesterol: LDL (low-density lipoproteins, or “lousy cholesterol”) below 100 mg/dL; HDL (high-density lipoprotein, or “healthy cholesterol”) above 40 mg/dL for men and above 50 mg/dL for women;
-- Triglycerides: Below 150 mg/dL.
-- Body mass index: Healthy range is 18.6 to 24.9, with a waistline smaller than 35 inches for women, 40 inches for men.

·        Your 40s: Weight Train

“For women, the 40s are when your body starts losing a lot of its lean muscle tissue and metabolism slows, making you more likely to gain weight,”  “The AHA recommends women weight train at least two times a week, which can keep your metabolism up, strengthen your bones and help you look and feel great as you start heading toward menopause.”

•         In Your 40s: Nurture Your Relationships

“By the time you’re in your 40s, you realize how important relationships become in helping you get through difficult times and in helping encourage you to make healthy choices in your life.”“If you haven’t already done it, now is the time to create and nurture that network of support around you. Research shows that people who are isolated in their 50s and 60s have more health problems than those who are surrounded by people who care about them.” Spend time with people you love and care about, whether it’s your spouse, children, siblings, friends, fellow members or other loved ones.

·        In Your 40s: Add Another Number

The AHA recommends having your blood glucose (sugar) level checked every three years beginning at age 45 to help monitor your risks for diabetes and heart disease. The recommended level on a fasting blood glucose test is less than 100 mg/dL. If yours is higher, talk to your doctor about ways to lower your risk for diabetes.

·        In Your 50s: Rethink When You Eat

The often-repeated advice to eat breakfast like a king, lunch like a prince and dinner like a pauper is especially true as you age into your 50s and beyond. “Most people need to eat fewer calories overall when they hit their 50s, and it’s best to eat most of your calories earlier in the day and not be locked into the idea that you need three big meals a day.” “You need calories early in the day to rev up your metabolism and give you energy for the things you need to do, and it’s fine to have a good-sized meal at lunchtime, but eating a lot in the evening may interfere with your sleep as your body works to digest the food. Most people in their 50s don’t need a lot of calories for the activities they do at night. Those extra calories that aren’t burned off just contribute to weight gain.”

·        In Your 50s: Volunteer

In your 20s and 30s, there tends to be a lot to be excited about -- marriage, babies being born, careers taking off. By the time you reach your 50s, those big life events may be in your past, and you may instead be facing an empty nest, parents who are dying or already gone and the denouement of your career. “Volunteering is a great way to bring more positives into your life.” “Whether it’s by starting a new group related to a cause you care about or helping out someone in your community, having something that you’re committed to can have a very positive impact on your life.”

·        In Your 50s: Get Screened

The National Osteoporosis Foundation recommends a bone mineral density test after age 50 if you have risk factors such as being menopausal or having a family history of osteoporosis. Although not directly related to your heart, “conditions that predispose to osteoporosis also predispose to heart disease -- namely, inactivity and poor diet,”  A bone mineral density test may pick up thinning bone problems that could predispose you to falls. If you fall, you may not be able to exercise for a while, which could set you up for weight gain and health problems. Strong bones help you have a strong heart.

·        In Your 60s and Over: Adjust Your Exercise to Accommodate Your Body

It’s important to maintain the momentum that you built up in your 30s, 40s and 50s. If you continue to be active into your senior years, your heart will look and act younger. In their 60s, some people start experiencing issues like arthritis and back pain, and you may have to switch from running to walking or from tennis to water aerobics. Find what works for you and keep doing it. Continue strength training twice a week, too. It will help you to maintain your lean body mass.

·        In Your 60s and Over: Take Up Yoga

Studies show that yoga not only helps you de-stress, it helps to prevent balance problems that can lead to falls in your later years. It also helps reduce pain if you have any chronic conditions, and improves sleep, all of which are good for your heart,”

·        In Your 60s and Over: Get Talking

Call your doctor at the first sign of any unusual symptom, even if you don’t think it’s serious. “In terms of heart disease, symptoms including chest pressure, tightness in your jaw, profound fatigue and shortness of breath with activity all may indicate heart problems.”  Your doctor may recommend more detailed screening to assess your risks, and, if necessary, treatment to help you live a longer, healthier life

Add Years to Your Life by new ways to protect against heart disease:

•         Spice Up Your Meals..Indian masalas are full of antioxidants

•         Eat a Handful of Nuts Daily

•         Eat Fruit -- Especially Kiwis The kiwi’s lutein -- a plant compound that helps artery walls stay relaxed -- keeps your blood pressure down even when your stress levels climb.

•         Hang Out with a Friend.. The Cleveland Clinic research suggests that nurturing a couple of solid friendships can cut your risk of heart disease by 40 percent…But No FB

•         Eat Your Snack Mid-Afternoon.. Just trimming your waistline so it measures 34 inches or less -- even if you’re nowhere near your goal weight -- will cut your risk of heart disease by 72 percent. “Other fat stores -- like the stuff that gives people curvy hips and thighs -- just take up space, but belly fat produces a steady stream of heart-damaging inflammation,”

•         Take Fish Oil Daily..Hundreds of studies document fish oil’s heart-protecting powers: Its omega-3 fats lower your liver’s production of triglycerides .

•         Eat a Hearty Breakfast…Recent research shows moving most of your daily fat into your morning meal (and saving carbs for later in the day) reduces your production of artery-clogging triglycerides and prevents blood sugar surges -- two huge risk factors for heart disease. Eating fat first thing in the morning switches on your body’s natural ability to properly burn and   use all types of food -- so that far less of it ends up clogging your arteries and damaging your heart.

•         Consider an Air Purifier..If you struggle with bad allergies to dust, mold or dander, getting your symptoms under control could cut your risk of heart disease by 30 percent or more.

•         Tidy Up Your Home..Staying fit by getting roughly 30 minutes of light exercise daily can cut your risk of heart disease in half because exercise raises your production of artery-clearing HDL cholesterol by 10 percent or more. And you don’t have to lace up your sneakers to get this great health perk. In a surprising new study, the fittest women weren’t the ones exercising outdoors -- they were the ones with the cleanest houses!

•         Sip Green Tea/Hibiscus Tea..When folks with heart-damaging high blood pressure sip 24 ounces of Green/Hibiscus tea daily, their pressure readings can plunge 13 points in six weeks. That makes this flavorful brew as powerful as ACE Inhibitors, a class of prescription drugs used to lower blood pressure

Another important factor is Stress as a risk factor towards heart disease. How One Can Make Intensive Changes to Manage Stress?

•         Try directed breathing. Practice inhaling slowly and filling your belly, then exhaling and drawing your belly button toward your spine. You can also learn three-part breathing. Take in air smoothly, as a flowing inhalation from your abdomen, then your chest, and then your throat. Reverse the process as you exhale.

•         Meditate. If you meditate daily, you will learn to focus on the present moment. Most people who meditate do so twice a day. When you concentrate on your breath or on a candle flame, for example, you clear your mind of thoughts and feelings that may get in the way of relaxation.

•         Pray. Prayer allows you to turn your problems over to a higher power. When you trust in your faith, you realize that you may be guided by something bigger than yourself. This belief may help you to stick with your intensive lifestyle changes. 

•         Try progressive muscle relaxation. This is a series of exercises that teach you to first tense and then relax your muscle groups. Starting with your toes and feet, work your way up, stopping at each body part. First tighten them, then relax them.

•         Stretch. You may do any activity that gently extends the range of your muscles, tendons, and ligaments. You can start with these three moves. Raise your arms way above your head. Bend over, with your knees slightly bent, and reach for the ground so you feel a gentle stretch from your neck to your heels. Shrug your shoulders.

•         Use visualization. This technique teaches you how to use your imagination to help reduce stress. You focus on a positive experience you have had or would like to have. For instance, visualize yourself on a beach. See the sun, hear the waves, feel the salty air on your skin. Or pick any time or place where you were truly relaxed and your breathing was calm. You can use this mental experience to achieve a new kind of peace.

•         Try yoga. This ancient Indian practice involves breathing, relaxation, and stretching in a series of postures. 

If you have heart disease, a program of rehabilitation that is supervised by healthcare providers may help you do the following:

•         increase your ability to engage in activity

•         decrease your symptoms, such as chest pain, breathlessness, and fatigue

•         improve your blood cholesterol levels

•         get help to quit smoking, if you smoke

•         reduce stress

•         improve your psychological outlook

•         reduce your risk of death from heart disease

Our country is slowly witnessing a  cardiac rehabilitation program which is a program designed to support you. Rehab staff work with you to:

•         improve your diet

•         increase your exercise

•         change other habits that affect your heart 

•         Healthcare providers trained to help you in these areas supervise the program. Cardiac rehab is meant to help you recover faster and return to a full, active life. This is true whether you have had a heart attack or heart surgery. It can also help if you've had another procedure, such as bypass surgery.

Affordable healthcare only possible with value based medicine

           India is a developing country and 80 per cent of the population of our country cannot afford expensive healthcare. The facilities provided by the government are miniscule in front of the giant problem. Shortage of doctors, basic infrastructure, paramedical staff and expensive medicines makes healthcare even more out of reach for a common man. That is the reason we are still struggling with the certain communicable diseases and now added to that is the burden of non-communicable diseases.

Dr Virendar Sarwal

India is going to be the world capital for heart disease in 2030 as per the WHO report. Diabetes is rampant and there is total lack of awareness about prevention, lifestyle management, hygiene levels, sanitation and the healthy living with the result that we have huge load of patients whether it is communicable or non-communicable disease. Added to it is the shortage of manpower to treat these patients.
As per one study, our country has only 20 doctors per 10,000 people as compared to 650/10,000 in US. The budgetary provisions for healthcare are so low that even the primary healthcare cannot be delivered efficiently with the result the rural population is the worst sufferers. That is how there is mushrooming of quacks and invaluable lives are at risk.
In such a dismal scenario only alternative to improve upon the services and make each step in healthcare delivery more justified and economical, if we look at an evolving healthcare delivery system all over the world and even in developed countries like US, is Valve Based Medicine. So far, we have been practicing Evidence Based Medicine where in based on the evidence of the disease, we treat it with the costliest way of treatment. It ignores the logic of benefit vs cost ratio whether it is concerned with writing costly medicines or adopting the costliest intervention.
The value based medicine concept is different from the evidence based medicine concept in the sense that we are treating human beings and not symptoms. The treatment plan has to be based on the effective control of the disease with respect to the perception of the patient and his family in terms of benefit as compared to the cost involved in it.
Let’s say in heart disease a patient having coronary artery disease in two or three vessels can be treated with bypass surgery as well as ballooning and stenting. Now, whereas stents will cost him a big money and will also not be durable so bypass surgery becomes more economical and more durable. What the patient wants here is effective quality of life improvement with an economical and durable procedure. So, of course, bypass surgery is the best answer here. Similarly, a sore throat can be effectively treated with low-end antibiotic treatment and supportive therapy instead of expensive and high-end antibiotics.
Value based medicine is a means to compare all healthcare interventions on the same scale and a measure that can be combined with the cost of an intervention to arrive at a cost utility ratio. It provides most effective assessment of the patient perceived worth of an intervention. It also measures quality of life and/or length of life. The irony of healthcare industry is that it is one of the few industries where purchasers or the patients are unable to measure the valve of what they purchase.
So, value based medicine allows highest quality care, maximization of healthcare rupee and incorporation of patient based perception of quality of life. The goal of value based medicine is to promote what is best for the most important people in healthcare i.e. patients. It provides transparency backed by scientific opinion, communication by personal attention, no scare or fear by involving empathy, economics and 24×7 availability.
Similarly, if we come to procedures, the beating heart surgery is value based medicine. Minimal invasive surgery goes a step further in that direction as it makes the patient up and about early and the patient does not lose productive days of earning and is back to work at the earliest with less stress on the body. Also, in terms of logistics there is less ICU stay, less hospital stay, less use of blood products. Value based medicine also incorporates all the forthcoming evidence which is percolated to the patient level and helps in decision making for the patients.
Now, coming to stent vs surgery, two major trials — one in 2009 Syntax trial and the other in November 2012 Freedom trail — have clearly established and concluded that in multi-vessel disease and diabetes, bypass surgery scores over drug coated stents in terms of death, second heart attack and second or repeat intervention. So, all patients with multi-vessel disease should be offered bypass surgery as the first option for durable economical treatment.
In this scenario, value based medicine (VBM) stipulates that when it come to coronary artery disease each and every patient should meet the surgeon with his angiography report to reach to a conclusion whether he needs to go for stents or surgery. The other thing, which our country needs to incorporate into VBM is the availability of cost effective medicines, disposables and equipment. Most of the equipments, disposables used in high-end surgeries is still being imported and thereby making huge loss and leading to escalation of prices of these essentials.
The government has to encourage use of generic drugs, which should be free and easily available and encourage manufacture of disposables and equipments in our own country. It will do away the huge profit margin taken by the multinational companies when the middlemen and dealers add to the cost. There are very innovative products available in India and effort should be done to produce them at mass level and promote them at all levels. In fact, all hospitals should be told to use them as the first priority.
The infrastructural resources for the primary, secondary and tertiary healthcare delivery are very less so a policy needs to be made wherein the government and the private sectors should join hands in making the total available infrastructure at the disposal of all the patient population group. There should not be any differentiation and all available beds should be utilized to the maximum by one and all. It will help in reducing the waiting list and huge queues seen in government hospitals today. All it needs is rationalization of compensation to the private sector.
Today also many government agencies are utilizing the private resources for tertiary care by reimbursing them the subsidized cost of treatment. Why can’t it be applied to the primary and secondary care? The public private partnership (PPP) is another good concept of upgrading and bringing secondary and tertiary care in all cities and rural areas.
To promote healthcare delivery in rural areas the doctor should be encouraged by arranging for them good housing and transport facility and good schooling for their children. In fact, the concept of rural dispensaries should be abandoned and what we need is a good primary/secondary healthcare centre within a radius of 20 kilometres and that area on daily basis should be covered for OPD service by mobile vans with fixed hours backed by strong ambulance service which most states have already adopted. This will help getting the medical and paramedical manpower stationed at these centres as they will get basic facility and necessities of life for themselves and their family and doctors will be able to deliver better healthcare with better facility in terms of equipment and beds in an upgraded hospital environment. It will also help in running the various preventive healthcare programmes in true earnest.
These primary/secondary healthcare centres should be backed by tertiary care centres whether in private or government sectors at treatment cost rationalized by a committee of experts consisting of knowledgeable people from the government and the private sectors.
We need to understand that health is the ultimate necessity of life and is very important for the economic growth of this country. If we get developed this concept of value based medicine, it will see us through in building a healthy and capable society which in turn will produce a workforce which will work hard to take this country forward and will make it a world leader.

CROSSED 100 MARK IN CARDIAC SURGERIES AT MAX HOSPITAL,MOHALI WITH 99.2% SUCCESS RATE

Crossed the 100 mark in cardiac surgeries at Max Superspeciality Hospital, Mohali. The profile of patients varied from one year to 80 years. CABG included the highest risk  situations tackled successfully. Started the paediatric cardiac surgery program with a complex blue baby who was corrected fully.
GREAT TEAM WORK WITH GREAT INFRASTRUCTURE COUPLED WITH VERY QUALITY ORIENTED ETHICAL APPROACH.

A MIXED FEELING AND DEEP SATISFACTION ON TREATING A FAILURE TO THRIVE 7.5KGS AT 2.5YRS BABY WITH COMPLEX BLUE BABY SYNDROME WITH TOTAL CORRECTION.

High Risk End stage Coronary Artery Disease treated successfully with Beating Heart Surgery

High Risk End stage Coronary Artery Disease treated successfully with Beating Heart Surgery

Recently we operated upon a 63 yrs old male who had CAD since last 10years and was very symptomatic as he had myocardial infarction or heart attack couple of times with the result his heart function went down to bare 15%. He was refused intervention every where in view if the high risk involved in it. Even his one of relatives in USA is a cardiologist and he also advised very high risk for surgery. He went into heart  failure a number of times and was treated at local hospitals for that. Looking at the heart function he was refused surgery but treated medically or was suggested PTCA in one of arteries with doubtful benefit..

                                                              He came to us again and on ECHO his ejection fraction was only 15%, dilated heart and muscle looked to be thin. His angiography done in NCR showed severe triple vessel disease. Dilated heart with low heart function makes it very high risk surgery. His “Euro score” a criteria to assess risk of surgery based on the clinical and investigative parameters was 14 indicating a mortality of 40%.We decided to do a further work up and went for PET scan(positron emission tomography) which gives us a very good idea that whether the heart muscle is viable or not and can it be revived by revascularization. Luckily for him PET showed good muscle with reasonably good viability in most of areas except two areas. Based on this we came to a conclusion that he will benefit if preoperatively he tolerates the procedure. We decided to offer him a beating heart surgery a new technique adopted with us for last 10years where you avoid heart lung machine and its side effects which is very crucial in such cases for good recovery. Intra-operatively we used special gadgets to monitor functioning of the heart continuously with continuous cardiac output catheter. Adequate preparation i.e. decongestion and putting intra-aortic balloon pump (IABP) preoperatively was done which helps heart in giving more blood. After 24hrs we took him for OPCAB(beating heart surgery) and did three by- passes on his heart. His lung pressures were very high which were manipulated with drugs and they settled down after the grafting. He sustained the procedure well and in the post operative period did very well. IABP was removed on 3rd day and all drugs to help heart were off by 5^th post operative day. He was mobilised and shifted to HDU to see his early mobilization under close supervision. He was very comfortable in walking around extensively with normal parameters and was discharged on 9^th day. Before discharge his heart function came up to 30% from 15% a massive improvement. It will further improve but slowly. These patients are ideally suitable only for heart transplant but facilities for this in our country are few and too expensive to maintain it also. If left untreated the prognosis is not very good as low output state and repeated heart failure damages the other organs like kidneys, liver and they succumb to multi-organ failure. Careful planning and extra care with new technologies help saving such lives and gives them quality of life also.

                                       Thus “Time is muscle and do not lose it in waiting.” By- pass surgery done at appropriate time in stable condition is the best thing to happen to heart and it increases your quality of life and prevents further set- backs to heart muscle. He was operated by a team headed by Dr Virendar Sarwal, In charge Dept. Of CTVS Max hospital, Dr Ajay Sinha, Dr Arat Nahak, Dr Srinivas, Dr Goswami, Dr Shailender at Max Superspeciality Hospital, Mohali.

Invited to present a paper at Heart Valve Society of America in New York

Invited to present a paper at Heart Valve Society of America in New York on End Stage Valvular Heart Disease. Got good appreciation of the work. Pictures from conference Venue at Hotel Marriot Marquis, New York.