There are few diseases and condition which can lead to dilatation of Aorta i.e Aneurysm or tear in Aorta leading to Aortic dissection. These conditions can lead to life threatening complication or can be life threatening itself in form of Type A dissection thus leading to surgical intervention on priority or emergency as per the presentation of the patient.Common cause of the same may be
- Connective tissue disorder like Marfan syndrome
A variety of surgical procedures are done as per the presentation like Aortic valve with Ascending Aorta replacement (Bentall Procedure), aortic arch, descending Aorta, thoracoabdominal or Abdominal Aorta repair. Also we have option of endovascular repairs whenever feasible in our multidisciplinary team.
The Bentall procedure is a surgery performed to correct defects of the aorta. The procedure involves the replacement of the aortic root (base of the aorta) and valve (three flaps that ensure the one-way flow of blood from the heart to the aorta), and re-implantation of the coronary arteries (that branch out from the ascending aorta). The current and most common type of surgery is called the button Bentall surgery.
The Bentall surgery is indicated for the following conditions of the aorta:
- Aortic regurgitation or stenosis with enlargement of Aorta
- Marfan’s syndrome (genetic disease that causes aortic wall weakness)
- Aortic dissection (separation of the layers of the aortic wall)
- Aortic aneurysm (enlargement of the aorta)
Aortic root replacement with a composite valve-graft is a surgical treatment for aortic root aneurysms with a diseased aortic valve. It involves replacement of the root and aortic valve with a graft and either a biological or mechanical valve prosthesis. This procedure is performed under general anaesthesia, and with the heart temporarily stopped using cardiopulmonary bypass. First the aorta is cut and the diseased portion is removed, including the aortic valve. The coronary arteries (blood vessels that supply oxygen-rich blood to the heart muscle) are disconnected. A graft with a valve inside it is then sewn to the heart and to the other side of the aorta. Two small holes are made in the graft, and the coronary arteries are then re-connected through them.
Usually after the procedure patient remains in intensive care unit for 2-3 days , where he will be on moniter with few line and drainage tubes. After that he is shifted to wards where we keep him for 3-5 days as per recovery then discharge him once all parameters are satishfactory and anto coagulant levels have been achieved.
The aortic valve controls the unidirectional flow of blood from the heart to the entire body. Diseases that cause narrowing (aortic stenosis) and leaking (aortic regurgitation) of the aortic valve decreases the function of the left ventricle and cardiac output, and increases the risk for congestive cardiac failure and death. The Ross procedure is a technique used to treat the diseased aortic valve and prevent further damage to the heart. The procedure involves replacing the diseased aortic valve with your pulmonary valve, which controls the unidirectional flow of blood from the heart to the lungs for purification. This is also called a valve switching procedure as the patient’s own pulmonary valve is used to replace the diseased aortic valve.
The procedure is performed under the effect of general anaesthesia. During this open heart procedure, the heart’s function of pumping blood is taken over by a heart-lung machine. Your doctor introduces medication to temporarily stop your heart from beating. An electrocardiogram is used to continuously monitor your heart rate and rhythm throughout the procedure.
Your surgeon makes an incision in the middle of the chest and separates the breastbone to gain access to the heart. The pulmonary valve is excised. The damaged aortic valve is carefully removed and replaced with your own pulmonic valve. A pulmonary valve taken from a human donor is then placed into the pulmonic position. The heart is disconnected from the heart-lung machine and its function resumed. The breast bone is brought together and the chest incision is closed with sutures.
After the procedure, you are moved to the cardiovascular intensive care unit, and your heart rate, rhythm and vital signs are closely monitored. You may experience numbness, itching and tingling, which will subside after a few days. Your doctor will prescribe medication to relieve pain, reduce discomfort and improve mobility. Scars will fade within 3 to 6 months. You should include a balanced diet to promote healing and improve your strength after the surgery. Your physical therapist may suggest a home walking program and physical exercise to improve flexibility, circulation and muscle tone. Avoid lifting heavy objects, pulling or pushing for a few months after the surgery. Inform your doctor if you experience high fever, shortness of breath, irregular heartbeats, or swollen feet and ankles.
Risks and complications
As with any surgery, the Ross procedure may involve certain risks and complications. They include:
- Bleeding and infection
- Stroke, heart attack
- Breathing problems
- Irregular heartbeats or death
Advantages and disadvantages
The advantages of the Ross procedure include:
- Improved performance of the patients’ pulmonary valve in the aortic position
- Superior blood flow with reduced wear and tear of the heart
- Anti-coagulants not necessary
- Less chance for infection
The disadvantages of the Ross procedure include:
- Complex surgery
- Follow-ups required for both aortic and pulmonary valves
CABG is a surgical procedure to restore normal blood supply and flow to significantly narrowed or blocked artery.
CABG has significantly changed the outcome of ischemic heart disease which happens to be the leading cause of death worldwide. All patients with coronary artery disease may not need CABG but can be treated with lifestyle modification, medicines and procedures like Angioplasty. Role of CABG definitely can be emphasized if all above mentioned treatment options fail to alliate the symptoms and in certain situation it the management of choice i.e. the best option available.
Spectrum of CABG procedure varies from an emergency procedure following a heart attack or planned surgery for coronary artery disease with stable symptoms.
Talking about the procedure, in CABG we harvest a healthy blood vessel from patient’s body like leg (long saphenous vein), arm (radial artery) or chest (internal mammary artery). These conduits help in bypassing g the blocked arteries of heart to restore the good blood supply.
CABG is the most commonly performed cardiac surgery worldwide. It can be done as open technique or minimal invasive technique. Again coming to open technique, the procedure can be done on pump and off pump (beating heart). Best option for the patient needs to be individualized as per the severity and extent of disease, Also we need to keep in mind the comorbidities with the patient.
Whatever option is being taken aim of surgical outcome is to bypass maximum no of diseased or blocked artery and give adequate revascularization.
The risks and complications of CABG procedure are higher if it is done as an emergency procedure or if other comorbid conditions are there like kidney disease, diabetes, blocked artery in your legs, and lung disease.
The possible complications associated with CABG include:
- Heart rhythm irregularities
- Heart attack
- Infection of the wound
- Nerve and blood vessel damage
- Blood clots
- Recurrent chest pain
Post-operative guidelines and prevention of CAD
After the CABG surgery, few post-operative instructions need to be followed which include:
- Physical activity such as lifting heavy things or strenuous exercises should be avoided for first few weeks after surgery
- Medications may be prescribed to reduce chest pain and prevent blood clots
- Your doctor may recommend you to wear tight elastic bandage around the calf muscles
- May have to contact your doctor in case of redness, bleeding, irregular heart beat, palpitations chest pain, difficulty in breathing, and weakness
You can manage or prevent the occurrence of CAD by few lifestyle modifications which include
- Regular Exercise
- Consume a healthy diet low in salt and cholesterol
- Avoid smoking and alcohol intake
- Lose weight if you are obese
- Control diabetes and high blood pressure
- Beating Heart Bypass Surgery (off Pump)
- On-pump CABG
- High Risk CABG
- CABG In Heart Failure
- CABG With Valve Replacement or Repair
- CABG With Aneurysm Or VSD Repair
- Coronary Endarterectomy
- CABG With Carotid Endarterectomy
- Total Arterial Lima Rima Y Grafting
- Minimally Invasive CABG
A congenital heart defect represents the problem with the structure of the heart which is present at birth. In these spectrum of disease some part of the heart doesn’t form properly before birth thus changing the normal flow of blood through the heart.
There are many types of congenital heart defects. Some are simple, such as a hole in the septum. The hole allows blood from the left and right sides of the heart to mix. Another example of a simple defect is a narrowed valve that blocks blood flow to the lungs or other parts of the body. Few are more complex. They include combinations of simple defects, problems with the location of blood vessels leading to and from the heart, and more serious problems with how the heart develops.
State of art Care for Children of All Ages
Our team offer the most advanced surgical therapy for congenital heart disease for pediatric patients of all ages, from newborns to adolescents. The conditions that we treat most often in the various age groups like
Transposition of the Great Arteries
Transposition of the great arteries results from a switch in the anatomical positions of the pulmonary artery and aorta such that the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. This anomaly causes oxygen-poor blood to be circulated to the body instead of oxygen-rich blood, a life-threatening medical emergency requiring immediate treatment.
Hypoplastic Left Heart Syndrome
Hypoplastic left heart syndrome (HLHS) is caused by an incompletely formed left side of the heart. We have limited experience with the Norwood procedure and multi-stage palliation for HLHS.The reason being these patients generally slip through the cracks of an imperfectly developed and uncoordinated, largely private based healthcare network. This results in not diagnosing the condition in time and thereby not allowing timely diagnosis and prompt intervention.
Tetralogy of Fallot
Tetralogy of Fallot, in which the heart delivers less oxygen to the body than normal, is the most common cyanotic defect. This complex congenital condition consists of four developmental defects that require surgical correction early in childhood.
Ventricular Septal Defects
Ventricular septal defect an opening in the wall that separates the two ventricles of the heart. This causes mixing of oxygen-poor blood with oxygen-rich blood. Also leading to high lung pressures leading to recurrent lower respiratory tract infection and failure to thrive.
Atrial Septal Defects
Atrial septal defect, an opening in the wall between the right and left atria, results in abnormal blood flow through the heart. Left untreated, this condition can cause enlargement of the right side of the heart, arrhythmias and, in some cases, pulmonary hypertension.
Coarctation of the Aorta
Coarctation of the aorta, a constriction in the aorta, causes blood pressure to increase above the narrowed area while limiting blood flow to the body.
Atrioventricular canals are large openings between the right and left sides of the heart. Usually, one large common valve replaces the normal mitral and tricuspid valves. Left untreated, this defect can cause the poor growth, malnourishment, enlargement of the heart, and even pulmonary hypertension.
Single Ventricle Disease
Single ventricle is a collective term that describes defects in which oxygen-rich and -poor blood is mixed in a single ventricle. Our expertise in the Fontan procedure, which directs oxygen-poor blood directly to the pulmonary artery and lungs. The single ventricle is reserved for collecting oxygen-rich blood from the lungs, then pumping it to the aorta and the rest of the body. We generally believe in staging the procedure in children, unlike older individuals who ,if eligible could have a single stage operation.
Valve repair, is performed for damaged mitral, tricuspid, or aortic valves. We perform the Ross procedure for children with congenitally damaged aortic valves that require corrective surgery.
Adult Congenital Heart Disease We provide highly specialized cardiology and cardiac surgery care for adults with congenital hear
In heart transplantation surgery the diseased heart is replaced by healthy heart obtained from human donor usually patients who are declared brain-dead but on life-support, having no heart diseases.
It is recommended as a treatment in patients with following conditions:
- End-stage heart and lung disease
- Complex congenital heart disease
- Eisenmenger syndrome (atrioventricular canal defect, transposition of the great vessels, and truncus arteriosus)
- Irreversible right-sided heart failure resulting from pulmonary hypertension.
Donor operative procedure
The patient is given general anesthesia and made comfortable throughout the procedure. The surgeon makes an incision through the centre of the breast bone for initial inspection of the heart and lungs. The heart and lungs are then mobilised without harming the lung tissues. The heart is flushed using cold cardioplegia solution and at the same time the lungs are flushed with cold, modified Collins solution. Then, the heart-lung block is removed and placed in a sterile, cold electrolyte solution for storage.
Recipient operative procedure
The surgical procedure in the recipient is performed under heart-lung bypass machine which maintains the blood circulation and oxygen levels of the body. The diseased heart and lungs are removed. The phrenic nerve and bronchial artery circulation is preserved so that post-operative complications are avoided. Then, the donor heart and lungs are inserted followed by fusing of the trachea, right atrium and aorta. After the completion of this procedure the heart-lung bypass support will be disconnected.
Risks and complications
Some of the potential risks and complications involved with heart and lung transplantation procedure include:
- Transplanted organ failure
- Rejection of the transplant
- Infection because of anti-rejection medications (reduce body’s ability to fight infections)
- Blood clots
Recovery from organ transplant takes a long span of about 6 months. Anti-rejection medications should be taken as prescribed to prevent rejection of the transplant. Frequent follow-up visits and routine blood tests will be necessary.
Ventricular Assist Devices
With heart failure, the heart becomes too weak to efficiently pump blood to other parts of the body. Some patients benefit from drug therapy. But others may require a heart transplant or other intervention. When heart failure reaches this advanced stage, it can be life-threatening. We care to help these patients live longer and enjoy a better quality of life.
Since there are not enough donor hearts to meet the needs of all the patients who require them, patients with end-stage heart failure may benefit from mechanical cardiac assist devices, the most common of which are ventricular assist devices (VADs). VADs can be used in patients as temporary support while waiting for heart muscle recovery, as temporary support while awaiting a heart transplant (“bridge to heart transplant”), and as “destination” (permanent) therapy for those who are not eligible for a transplant.
The left ventricle is the chamber responsible for pumping oxygen-rich blood from the heart to the aorta for transport to the rest of the body. Left ventricular assist devices (LVADs) take on the workload of the left ventricle, helping the heart to pump oxygenated blood to the rest of the body. As a result, all tissues and organs receive the blood supply they need to do their jobs. The patient feels better and can return home to live a better quality of life with family and friends.
In addition, some patients require support of the right heart as well, which pumps blood to the lungs, where it can receive oxygen. Right ventricular assist devices (RVADs) are commonly used in conjunction with LVADs, and are referred to as biventricular assist devices (or BiVADs).
We specialize in the implantation of a wide variety of VADs, selected and tailored for each individual patient and their particular situation. A multidisciplinary team — comprised of surgeons, cardiologists, nurses, physical therapists, psychiatrists, nutritionists, and social workers — assures that patients receive comprehensive care, both in the hospital and once they are discharged home.
The VAD consists of:
- A pump: The pump is implanted in or near the upper part of the abdominal wall and is connected to the heart at two points. A tube carries blood from the ventricle to the pump. The blood is pumped through a second tube to the aorta or pulmonary artery, and distributed to the lungs or throughout the body.
- An electronic control system: A third tube extends from the pump and contains wires that connect the pump to the electronic control system.
- A power supply (rechargeable batteries): The control system is connected to small batteries. Patients wear the controller on a belt and the batteries on a vest-like shoulder holster.
In Minimally Invasive Cardiac Surgery (MICS), cardiac surgeons perform heart surgery through small incisions on your chest, as an alternative to open heart surgery. Surgeons operate between the ribs and don’t split the breastbone (Sternotomy), which results in less pain and a quicker recovery for most people. In minimally invasive surgery, your cardiac surgeon has a better view of some parts of your heart than in open heart surgery.
- MICS CABG
- MICS MVR
- MICS ASD CLOSURE
- MICS AVR
Cardiac surgery requiring resternotomy (so-called ‘redo’ surgery) is technically difficult and carries a higher operative risk than a first-time operation. The particular problems are well recognised and include difficulty with access to the heart (due to adhesions, scarring, fibrosis or calcification around the operative site) making dissection and suture placement difficult, prolonged operation times and increased postoperative mortality and morbidity.It covers the spectrum of redo cardiac operations, including coronary artery bypass, mitral valve repair, reoperation for prosthetic mitral valve endocarditis, aortic arch reoperation, descending and thoracoabdominal aortic reoperation, and reoperations following endovascular aortic repair. All redo cardiac surgeries present a complex array of challenges beyond what the original procedure demands.
The heart has four valves. These are:
- Mitral valve
- Tricuspid valve
- Aortic valve
- Pulmonary valve
Heart valve plays a key role in one way flow of blood by opening and closing with each heart beat.These valves open to aloe blood to be pumped forward and they closes to prevent blood from flowing backward.
Abnormal or sick valves allow less blood to pass through and/or make it leak backwards. This may be due to:
- Weakened flaps
- Fusion of the flaps
- Holes or tears on the flaps
- Deformity on the valve due to scar tissue
- Hardening of the valve due to deposits that are either waxy or calcified (called plaques)
To resume efficient function, diseased valves need to undergo a surgical procedure called valve repair or valve replacement. If valve damage is mild, we may be able to treat it with medicines and if the damage is severe then the option of surgical Repair or Replacement is given to the patient.
Valvular issue broadly fall into two categories i.e
Stenosis- when the opening of the valve is too narrow that it interferes with the forward flow of the blood
Regurgitation- when the valve doesn’t close well thus leading to leakage of blood backward
Valve problems can be Congenital i.e by birth or acquired which could be Rheumatic, endocarditis, degerative, ischemic or connective tissue disorder.
Preferred treatment when ever possible. It can be done through Valvuloplasty, Commissurotomy, decalcification, Annuloplasty etc.
Various Annuloplasty Rings are available in the market for the same and are used according to the disease per say.
The damaged valve is replaced with metallic valve or a biological valve (from pig, cow or human tissue).
Metal valve or Bioprosthetic valve
- Metal valves last longer than bioprosthetic valves
- Metallic valves requires maintenance with lifelong warfarin (a blood-thinning medicine) while those with biological valves are not
- Metal valves are recommended for younger individuals; Bioprosthetic valves are recommended for the elderly and for women of childbearing age
The surgical procedure is performed under general anaesthesia. Chest is surgically opened with exposed heart. The patient is put on a heart-lung bypass machine (also called cardiopulmonary bypass pump) to ensure continuous oxygenated blood flows to all parts of the body except, of course, the heart.
Meanwhile, the heart is made to stop beating by injecting a substance. Actual repair or replacement of the faulty valve is done.
The heart resumes its beating. When the heart is seen to be beating normally again, the heart-lung bypass pump is withdrawn and excess blood around the operation area is suctioned off and a drainage system is set up.
The chest opening is then closed and dressed, and the surgery is considered officially over.
Initial few days you will be kept in ICU for adequate monitoring. Most often, pain medication, antibiotics and anti-coagulant are given. When the range and duration of movement and physical activity have increased (usually in 5-15 days), you are allowed to go home. In a month or two, you may feel stronger than you were before the operation.
Recovering at home, you need to consider certain things, such as:
- Medications, which may be prescribed for a lifetime (such as the anti-clotting medicine warfarin)
- Wound care
- Exercise and physiotherapy
- Complications to watch out for
- When to go back to work
- Check ups
- Lifestyle modifications
- Cardiac rehab
- Mitral Valve Replacement or Repair
- Aortic Valve Replacement or Repair
- Double Valve Replacement or Repair
- Atrial Fibrillation Surgery
- Minimally Invasive Valve Replacement