Rarest heart surgery performed in which three heart diseases treated in one operation!!
A rare case of three diseases of heart was successfully operated in one patient at Divine Heart Hospital & Research Centre at Gomati Nagar Lucknow on 17 of April 20013. This operation is second heart operation in the world since last 30 years. The first operation was performed in Japan and was published in 1991 in japans journal (Kyobu Geka, 1991 July: 44 (7): 569-72.).
Patient Mr. Ram Singh Kushwaha 68 year male, resident of district Ghazipur, was admitted here with complaints of breathlessness and palpitation since one year. He also complained of weakness vertigo and swelling over feet and face since 3 months. There was no history of angina. He received treatment from local doctors without any improvement. He was advised for an X-Ray chest, which revealed enlarged heart. He went to another centre at BHU where echocardiography diagnosed that he has tumor in the heart which has affected his one of the heart valve (mitral valve) made incompetent to close. Thus he was further referred to SGPGI and then to a corporate hospital at Delhi. Finally he came to Divine Heart Hospital where he was further investigated including coronary angiography which revealed that his all three coronary arteries were blocked from 80 to 100%. Thus he had three diseases inside the heart including a large tumor (LA Myxoma) floating in the cavity of heart, severe mitral valve leakage and three coronary arteries blockage.
The seriousness of heart disease was explained to the relatives that there is a possibility that his heart may not beat after such a prolonged surgery. They consented for the operation and he was taken for surgery. Operation consisted of removal of heart tumor, heart valve replacement, closure of defect and bypass surgery of blockage of 3 coronary arteries, performed with the help of cardiopulmonary bypass and lasted for eight and half hours. His heart was stopped for 90 minutes whereas safe period is in between 60 to 70 minutes. With the help of assist device, heart lung machine was weaned off with moderate support of stimulants drugs. There after he made uneventful postoperative recovery. He is with you.The purpose of presenting this case is to highlight the rarity of combination of all three diseases in one patient. However individual disease is routinely operated by most of the surgeon world- wide.      Safe period of stoppage of heart is in between 60 to 70 minutes. If individual disease is operated it takes about 40 to 45 minutes. Divine Heart hospital is the only hospital in Uttar Pradesh which exclusively provides the management of all kinds of heart diseases including coronary angiography, angioplasty, stenting, pacemaker implantation, beating heart bypass surgery, heart valve replacement and closures of birth defects in children.

Rare Surgery Performed at Divine Heart Hospital

The case is of Mohd. Mukhtar Khan, 63 years old gentleman from Basti, who suffered from a massive heart attack on 13th Feb, 2009. Heart attack was so severe that the walls of the heart ruptured leading to impending death. He was operated on 23rd Feb 2009 with help of open heart surgery in which his heart hole was closed with decron patch and the heart wall was repaired and bypass surgery was performed with  help of heart lung machine and ventricular assist device. The entire successful operation lasted for more than 8 hours.

The patient had no history of chest pain or heaviness before, nor was he suffering from high blood pressure or diabetes. On 13th feb, he complained of severe chest pain and the local doctor gave him an injection and referred him to Lucknow for further treatment. His sons brought him to SGPGI and landed up in cardiology department there. He was first suggested to undergo angioplasty with stenting. After an echocardiography test, it was revealed that the heart walls had ruptured due to the attack and he needed an urgent open heart surgery to save his life. The patient stayed in PGI for 10 days however due to unknown reasons he was not operated there. When his condition worsened he was referred to delhi on the pretext that some of the life saving equipments were not working and other operations were postponed for 4-5 days. Since the patient could not be transferred to delhi due to his serious condition, his sons were trying to find other options; as a result of which he then went to KGMU where also he was told by concerned doctor that it’s a very high risk case hence could not be operated there and since there is no other centre in the city he should go to Delhi.  Finally he came to Divine Heart Hospital where Prof. AK Srivastava assured him that the surgery was possible at this centre although it carried risk and chances of survival were only 50%. Since almost 10 days had been wasted under misguidance, the patient was immediately brought to Divine on his own risk on 23rd Feb. The patient was in a state of cardiogenic shock and after quick evaluation by our Senior cardiologist, Dr. Naveen Chandra, and Prof. AK Srivastava, he was immediately supported with intra-aortic balloon pump, a device that assists the weak heart. After few hours of stabilizing him, our team of doctors led by Prof. AK Srivastava, Dr. Piyush Srivastava, Dr. Subodh Kant and other members performed the surgery.

At operation, the inner surface of the entire heart was dead leading to a big hole between two ventricular chambers. The hole was closed with an artificial decron patch and heart was further repaired. After the operation, heart was assisted with heart assist device and artificial respiration with help of ventilator continued for 48 hours which stabilized him and at the moment he is off from all life saving assistance and is breathing on his own and the heart is functioning on its own

The incidence of coronary artery disease in this country is rampant due to rapid urbanization and sedentary life style and rich intake of fatty food. Despite wide awareness, people are not serious about their health and only 15-20% have financial constraints. The incidence of heart wall rupture after heart attack varies between 5-10% when the attack is massive. This leads to death in 50-60% cases. Remaining, if not operated, die within 24-48 hrs. A small percentage of 5-10% survive when the defect is small.

According to Dr. Naveen Chandra, Sr. Consultant cardiologist at Divine heart hospital, anyone suffering from coronary artery disease must undergo the complete evaluations including ECG, echo, TMT and if required then angiography to know the status of their disease. This would help in preventing future complications and averting life-risks.

 
» Performing daily angiographies, angioplasties, pacemaker implantation, beating heart bypass surgery, valve repair & replacement, closure of septal defects and various other open and closed heart and vascular surgeries.

 » Performed Open heart surgery in 18 yr old boy for Traumatic innaminate artery aneurysm and tracheal compression.


Patient Name: Abhishek Singh

Disease: Traumatic Innaminate Artery Aneurysm Tracheal Compression

One of such extremely rare survivor Mr. Abhishek , 18 years old boy, a student of BA part I, sustained blunt injury on right shoulder after fall from scooter and was hit from the rod of scooter mirror in December 25th 2006. Initially he had pain in the chest but after 2 months he developed pulsating swelling in the lower part of neck in middle above his windpipe. He further developed difficulty in breathing as swelling was increasing and pressing the windpipe.

Initially he consulted an ENT doctor in Faizabad for complaints of difficulty in swallowing and breathing. He underwent some test including the chest X ray of chest, which revealed widening of upper portion of chest from inside. He was then sent for CT scan which revealed that major vessel aorta arising from heart has developed unusual enlargement and swelling is pressing the windpipe. He was advised to consult a cardiovascular surgeon and he was referred to SGPGIMS. Doctors at SGPGIMS refused to treat him as concerned doctor explained that the facilities to deal with this type of cases do not exist in the institute and you may better go to AIIMS for specialized treatment.

Ultimately he came to Divine Heart Hospital & Research Centre. He was fully investigated including the angiography, which revealed that there was a communication between major vessel, which was supplying his brain and right arm at origin from aorta to the cavity, which was full of clot.

His family was explained about the risk of anesthesia and operation as while opening of chest through aneurysm he may die due to torrential uncontrolled bleeding. After obtaining full consent from family he was taken for surgery.

We took the body temperature down till 25 Degree Celsius and even stopped blood flow for few minutes with the help of heart-lung machine to quickly fill up the leakage point in the vessel. During Surgery Direct Repair Innaminate Artery hole and covered with a pericardial Patch was performed with help of cardiopulmonary bypass, systemic hypothermia and circulatory arrest.

“Prof. A. K. Srivastava said.

The operation lasted for 9- hours but those five minutes were crucial as without the blood flow in the body a neuro-damage was most likely to happen.

This was first of its kind of operation in my three-decade-old career. The patient is normal now and can lead a comfortable life with out any future routine follow ups,” Dr. Srivastava said.

 
»
Open Heart surgery performed in 7 year old girl with misaligned Ventricular Septal Defect, Severe Infundibular stenosis, Severe Pulmonary Stenosis. Right to Left Shunt


Patient Name: Bushra Bano

Disease: Congenital Cynotic Heart Disease, Tetralogy of Fallot

This young pleasant baby a known cynotic heart disease patient since birth was admitted with histroy of dyspnoea and fatigue on exertion for corrective surgery. Earlier in March 2006 she underwent cardiac catheterization at this centre and was advised to undergo ICR.

Cardiac Catheterization performed in March 2006 revealed misaligned Ventricular Septal Defect, Severe Infundibular stenosis, Severe Pulmonary Stenosis. Right to Left Shunt

Intrcardiac Repair including Dacron Patch Closure of VSD, Infundicular Ressection+ Pulmonary Valvotomy + Trans Aannular Patch Across the Annulus was performed on 22/04/2007

Procedure: Intra cardiac Repair of TOF was performed with aid of CBP and blood cardioplegia. At operation there was mild cardiomegaly and PA annulus was smaller than expected. There was severe infundibular stenosis was present. Parital and septal bands were hypertrophied. There was a large malaligned perimembranons VSD 2 cm 2 cm.

Pulmonary valvular stenosis was present..Infundicular ressection was carried out through trans artral approach as well as through pulmonary artery. VSD was closed with Dacron Patch with 4/0 pladget prolene in inturrpted manner. Pulmonary valvotomy was performed through pulmonary artery. Pulmonary annulus was very small. Right ventricular tract was opened and further infundubular ressection was carried out. In view of narrow annulus RVUFT was enlared with a pericardial patch extending across the annulus.. Post correction systemic pressure was 124mmHg while right ventricular pressure was 60mm Hg almost 50% of systemic pressure. Correction was graded as good correction..CPB could be weaned off easily with small dose of inotrops.

She was sifted to ICU in stable vitals. Now she is living normal life.

 » Performed Double Ligation Of Patent Ductus Arteriosus on 5 months old baby kunal.


Patient’s Name: Master Kunal Kushwaha

Diagnosis: Congenital Acynotic Heart Disease Patent Ductus Arteriosus (5mm), Left-Right Shunt, Moderate Pulmonary Artery Hypertension, Congestive Heart Failure

Procedure Performed: Double Ligation Of Patent Ductus Arteriosus was done at 09-05-09

History: This 5 month old cute baby boy was admitted with complain of high grade fever.

Procedure Details:
Double Ligation Of Patent ductus arteriosus was performed on 09-05-09.There was moderate cardiomegaly.RA,RV,PA were dilated. PA was twice the size of aorta.Ductus was very large 5 mm in size which was bigger in size for a baby and larger than left pulmonary artery. Ductus was co-meeting main pulmonary artery between LPA and RPA.There was thrill all over the aorta.Left subclavian artery was smaller than PDA. Ductus was looped and a trial clamping of ductus for 5 minutes revealed no change in hemodynamics.It was then doubly ligated. After ligation thrill disappeared. Procedure was performed through left postero-lateral thoracotomy through 4th space.Mediastinal pleural over discending aorta was incised open.Initially it was very difficult to identify the ductus as it was so large mimicking aorta.To confirm the origin of PDA ,pericardium in upper part near PA was opened and it was inspected.Ductus was then seen giving PA at junction of LPA and RPA origin instead if LPA.Aortic arch was dissected beyond origin of left subclavian artery.PDA was confirmed and it was doubly ligated.Thrill

disappeared. Chest was closed after putting ICD. The baby boy recovered well and was discharged.