BEST CARDIAC SURGERY

CORONARY ARTERY BYPASS SURGERY

Surgical myocardial revascularisation, popularly known as Coronary artery bypass grafting or CABG operation is done for critical coronary lesions. This means that when there are blocks in the arteries supplying the heart, we need to give blood supply to those parts. The common methods to give blood supply is either by medicines (medical management), angioplasty and stenting (PTCA or PCI) or bypass surgery.

There are clearly defined criteria upon which decisions are to be made as to which line of management the patient should follow. If there are very few blocks or if the blocks are discrete (small in length) or if there are some problems that may complicate surgery (= comorbidities) then percutaneous balloon angioplasty and stenting becomes a good option. In other cases, if the blocks are multiple or very near the origin of the main blood vessels and in diabetics (as stents block faster in diabetics), surgery is preferred.

The common method of doing CABG is the "off pump" or beating heart technique as this gives a faster recovery to the patients. However, if there are many grafts required or the patient is unstable, then we do  not hesitate to put on the heart lung machine. Studies have revealed that there is not much difference in the outcome if you use or do not use the heart lung machine except if there is some kidney or lung dysfunction.

Normally we use LIMA (left internal mammary artery) as the main artery to give long term results. We use radial artery if there is good circulation and if the vessel is not calcified and it also gives good long term results in our hands as well in recent studies. In some patients we use right internal mammary artery (RIMA) so that we can achieve total arterial revascularisation. This we avoid after the age of 70.  All other grafts are vein grafts.

What are grafts?

Grafts are conduits that are used to bypass the blocks in the blood vessels. Artificial grafts are not  available and those that are used for bypassing peripheral arteries do not have any good short term result when used for coronary bypass. We therefore use the grafts made of the patient’s own blood vessels. This means that we have to remove those arteries and veins which are expendable.  Usually we take the artery from the chest wall known as left internal mammary artery or LIMA. Sometimes we use the RIMA (right internal mammary artery), however in patient who are short, obese, severely diabetic or very old, we tend to avoid this graft if the LIMA is being taken. Additional graft may be taken from the arm (radial artery) when it is having good flow from its neighbouring artery (the ulnar artery). In case we need more grafts or we these above mentioned grafts are not good in quality, we would also take the superficial veins from the leg to act as grafts. The veins can be removed by open technique or by endoscopic (closed ) technique,  however there are reports that in the closed technique there is some chance of injury to the innermost layer (intima) and this may lead to graft failure earlier.

The order of preference for our unit is internal mammary artery followed by radial artery followed by leg veins. This is as per scientific evidence too. Radial artery has recently been reported to have very good long term results although they may not match the results of the mammary arteries. In elderly patients, we tend to use less of arterial grafts, as the arteries may be diseased themselves.



ABLATION OF ATRIAL FIBRILLATION

Surgical ablation of the Atrial fibrillation can be combined successfully along with mitral valve replacement or with other open heart procedures as shown in the picture. We are getting about 80% success rate and it is better if the left atrial wall is thicker. We have successfully completed 20 cases.

If we are confident to convert an atrial fibrillation to sinus rhythm with a mitral valve replacement in the senior age category, we should do it so that we can use a tissue valve rather than mechanical to avoid long term problems of anticoagulants. The success prognotication would be based on atrial wall thickness and size of the LA.

OFF PUMP CORONARY ENDARTERECTOMY

Coronary Endarterectomy is done when the bood vessel supplying the heart is so totally diseased that there is no room for either a graft or a stent. The vessel is totally sclerosed and in such a situation many physicians and even surgeons tend to deem the vessel as "inoperable" and condemn the patient to only medical management in a situation where actually much better could be done.

In Coronary Endarterectomy, we remove the total scerosis of the vessel and leave only the outer layer behind. In this way, the blood channel gets opened out and then a graft can be placed. Usually endarterectomy is done with the help of the heart lung machine and using extra-corporeal circulation, but  our unit has successfully performed many coronary endarterectomies with beating heart technique and found that the results are very encouraging. The complication rate is very low and most patients are able to go to a fully active life

Our protocol is to maintain oral anticoagulation and maintain an INR (prothrombin time) of >1.5 for over 6 weeks to 2 months period. During this period we usually give additional one antiplatelet also. After this period is over, we usually supplement with double anti-platelet regime and no anti-coagulant for a period of one year and then downgrade it after that to a baseline dose.

RARE CASE: FONTAN SURGERY PATIENT HAS LIVE PREGNANCY

Six years ago, a 16 year old girl with univentricular heart (single ventricle) underwent Fontan surgery (total cavopulmonary connection). Being an adult case at the time of surgery, she did go through a stormy postoperative period. She faced severe problems at that time with her hemodynamics.

Over the years, she has gradually improved and was carrying on her life. She eventually got married last year and then had a pregnancy. We wondered as to whether to allow her to undergo the stress of going through pregnancy. We finally allowed her to undergo the pregnancy as her condition was good.

She reached full term and underwent a caeserian section done by Obstetrician Dr Prameela Shekhar and the anaesthesia was managed by Dr U Srinivas. In the world, there are very few reports of Fontan surgery patients undergoing live childbirth. This makes the case a rare one and shows that the team effort between us and the Obstetric team along with anaesthesia is one of the best and also a standard one of international calibre.