Healthcare Delivery

Surgical Case Study: Dr. Pramod Reddy, Medicover Hospitals treats a patient with Aortic Dissection through the Frozen Elephant Trunk Technique

A young male student of 20-years from Nagpur reported with Aortic Dissection with Marfan Syndrome – an inherited disorder that affects the connective tissue at Medicover Hospitals, Hitech City Hyderabad. Aortic dissection is a medical emergency in which the inner layer of the large blood vessel branching off the heart (aorta) tears. Patient presents with severe chest or upper back pain that radiates to the neck or down the back, loss of consciousness and shortness of breath.

Aortic dissection is relatively uncommon. The condition most frequently occurs in men in their 60s and 70s. An aortic dissection occurs in a weakened area of the aortic wall. Chronic high blood pressure may stress the aortic tissue, making it more susceptible to tearing.

Dr Pramod Reddy, Medicover Hospitals Hyderabad explaining the procedure

Also seen in people born with a condition associated with a weakened and enlarged Aorta, such as Marfan syndrome, bicuspid aortic valve, or other rarer conditions associated with weakening of the walls of the blood vessels. Aortic dissection can quickly lead to death from not enough blood flow to the heart or complete rupture of the aorta.

Dr Pramod Reddy, Chief Cardiothoracic and Aortic Surgeon, Medicover Hospitals and teamcarried out this complex procedure by replacing half of the aorta from the aortic root by using new technique called FROZEN ELEPHANT TRUNK. The complex nature of the procedure is that the main arteries which supplies blood to the brain and heart are present in the affected part and requires precision care and expertise to repair and replace the aorta from the root.

The images of the procedure, before the surgery and after repair, as you can see the dissection has been treated

Dr Pramod further explained that the patient is required to be put under Deep Hypothermic Circulatory Arrest – which means cooling the patient’s body to a temperature of around 18-20 degrees and stopping blood circulation to the entire body except the brain for a period of 45 minutes.

“Mortality rate in such cases is 30-40%. There is also a chance of a stroke and Paraplegia.

Dr Pramod Reddy, Chief Cardio Thoracic Surgeon, Medicover Hospitals, Hyderabad

The entire procedure is expected to be done during the window of Deep Hypothermic Circulatory Arrest and any delay would result in losing the patient.

Dr Pramod Reddy & the team successfully carried out the procedure and stabilized the patient. The patient is now recovering and would soon be leading a normal life.

Very few centers across the globe perform this surgery. Usually, this procedure is done in a two-stage process, but we were able to successfully manage the whole procedure in a single stage which is done by using a special tube with a stent. (FROZEN ELEPHANT TRUNK TECHNIQUE). This technique reduces the necessity for subsequent additional operations and therefore may improve long-term survival.

(This case study has been developed by Dr. Pramod Reddy and his team at Medicover Hospitals, Hyderabad)

Healthcare Delivery

Help Vihaan Sharma get treated for Burkitt’s Lymphoma

A few days ago we were tagged on Twitter in a story where the father of a 3-year-old Vihaan Sharma had reached out to us to help him raise funds for his treatment. While many such requests come our way, we wanted to help the child but befire that we had to verify the genuineness of the case.

Original Tweet from the handle – @VihaanS88920491

While offline methods to verify the validity of the case did not work out due to restrictions on the sharing of patient information, the hospital, Manipal Hospitals in Jaipur themselves confirmed the case through their Twitter handle.

Manipal Hospital confirming the case

Burkitt’s Lymphoma is a type of Non-Hodgkins Lymphoma that is caused due to cancerous growth in the B Cells of the body. It spreads rapidly if left untreated. The reason why it is dangerous is that it seriously hampers the immunity of the patient. There two types of Burkitt’s Lymphoma African- endemic to children in Africa and Sporadic which is more global. The Sporadic variety is attributed to Epstein Barr Virus (EBV)

Typical Symptoms include

  • Loss of appetite.
  • Weight loss.
  • Fatigue.
  • Night sweats.
  • Unexplained fever.

Vihaan is admitted to Manipal Hospital in Jaipur and is receiving treatment from Dr. Satyendra Katewa who is the head of the Department of Oncology. Vihaan’s parents have set up this link in Milaap where you can support the treatment. They have raised close to INR 9 Lakhs for the treatment while the ask for the treatment is INR 17 Lakhs. The link to the site where you can contribute is here-

Please do contribute with whatever help you can, while times are tough, and things are uncertain, it is our ability to do good, that would go a long way in establishing Ram Rajya of the 22nds century.

Do let us know if you have any questions or concerns and we would be happy to address them.

Healthcare Delivery

Surgical Case Study: Medicover Hospitals-Transcatheter Aortic Value Replacement (TAVR)

(Below is a case study from the Medicover Hospitals in Hyderabad)

A 65-year-old male with systemic hypertension presented with Class II DOE. He had undergone IVUS-guided PTCA to LMCA and mid LAD along with PTA to left ICA in 2015. He has a history of peripheral artery disease (right leg claudication), severe restrictive and obstructive lung defect, and S/P right iliac stenting (2015).

2D Echo showing calcified bicuspid Aortic valve

Further evaluation of the echocardiography revealed a bicuspid aortic valve with severe calcified aortic stenosis. He approached us for transcatheter aortic valve implantation/replacement (TAVI/TAVR). Transcatheter aortic valve replacement was a necessary option due to his high-risk surgical profile (renal dysfunction, COPD, bicuspid valve, and coronary status) and to improve his quality of life.

CT with Aortic valve dimensions

After discussion with the Heart Team (Interventional Cardiologists, Cardiac Surgeons, and Cardiac Anaesthetists), we decided to go ahead with TAVR under conscious sedation due to poor lung function. After thorough CT analysis, we proceeded with a 23 mm Sapien-3 valve, which was deployed through the femoral artery.

We used Preclose ProGlide Closure device to manage the arterial puncture site. The procedure was completed within an hour and a half, and the aortic valve gradient reduced from 107/70 to 20/11. The aortic valve was replaced in a single sitting without the need for coronary revascularization and conversion to open-heart surgery. He was mobilized within two days and discharged on day 5.

Coronary Angiographic image showing Transcatheter Aortic value implantation of 26 mm Sapiens -3 valve

TAVR is an excellent alternative for all patients with high surgical risk (STS score > 4, Logistic Euro Score > 10, Re-do surgery and post-chest radiotherapy patients, and patients with multiple-organ dysfunction).

Authorerd by  Dr. Sharath Reddy & Team, Medicover Hospitals, Hitech City, Hyderabad

Healthcare Delivery

Neuroendocrine Tumours: Management and Treatment

Do you know what is common to Steve Jobs and Irfan Khan? Well apart from the fact that both were brilliant individuals and masters of their field, they also suffered from Neuroendocrine Tumours and died as a result of those.

Steve Jobs – Source CNBC

So what is a Neuroendocrine Tumour?

A Neuroendocrine Tumour or NET is a specific tumour affecting the endocrine glands. Specifically a variant known as the Carcinoid Tumour is very common and lethal. It affects the Gastrointestinal Track (Stomach), Intestine, Lungs, Pancreas, Testicles and Ovaries.

This is the distribution of the NET – Carcinoid Tumours

  • Intestines -39%
  • Rectum-15%
  • Lungs -10%
  • Appendix -7%
  • Colon-7%
  • Pancease-3%
  • Liver-1%

Both Steve Jobs and Irfan Khan has the variety that grows in the Pancreas. Interestingly NETs strike later in life mostly around the 50s and 60s. Also there is a misconception that NETs are benign, but in reality there is nothing like a benign NET, according to Dr P Jagannath at Lilavati Hospital, this misleading information was one of the reasons Steve Jobs did not aggressively treat his condition when he was diagnosed.

The Treatment

  1. Surgery- The number one line of treatment seems to be surgery. This is specially if the tumour is detected early and has not spread. Another minimal invasive surgery is Laparoscopic surgery.
  2. Radiation- If the NET has spread then radiation is the best line of treatment. Both external beam radiation and internal beam radiation called brachytherapy are options that are available.
  3. Medication- A new medication called Everolimus has emerged on the scene that controls the tumour for a long time.

Innovation in treatment and therapies

1) PPRT – Peptide receptor Radionuclide Therapy – A radio isotope based therapy is showing good result specially in Pancreatic NETs, acts like a magic bullet just eliminating the cancer leaving the other healthy cells intact.

2) DOTA NOC – Scanning method is specifically helpful in treating gastrointestinal NETs.

The diagnosis and successful cure of NETs depends on early detection. The symptoms depend on the site of the tumour. Example in cases with Pancreatic NET, patients might see dizziness and increased fainting as blood sugar levels are not in line with the expectations as the tumour releases Insulin.

In conclusion, India has made many advances in the detection, cure and management of NETs. There is a registry of NET cases with the India chapter of the Asia Pacific Neuroendocrine Tumour Society. Also hospitals like Lilavati, KEM, JJ Hospital are all leading the charge on the treatment of NETs.

Healthcare Delivery

Decoding Total Knee Replacement

Total knee replacement is a surgical process in which the joint of the knee is replaced using an artificial material. If any part of the body experiences intolerable pain, it is difficult for a person to use it and the same is true for knees as well. If a person’s knee is damaged due to an injury or due to arthritis, then he/she may find it difficult to person daily tasks and activities such as climbing stairs, walking and general moving around.

Diagnosis is a critical part of managing total knee replacements

The pain remains even while lying down or sitting. In such a situation, a doctor may first prescribe medications and physiotherapy but in extreme cases, one may have to undergo total knee replacement.

Total knee replacement is also termed as resurfacing of the knee mainly because in the process, only the surface of the bones is replaced. The process combines of 4 broad steps and they are given as follows:

  1. Preparing the bone- in this step, the cartilage surfaces present at the ends of femur and tibia are removed together with a small part of the underlying bone.
  2. Positioning of the metal implants-metal components are used in place of the removed cartilage and bone so that they can recreate the surface of the knee joint. These parts of metal are press-fit or cemented into the bone.
  3. Resurfacing the patella-patella is basically the kneecap and in this step, the under surface of the patella is cut and a plastic button is used for its resurfacing. This process or step may vary depending upon patient to patient.
  4. Inserting a spacer- in between the metal parts, a plastic spacer is placed so as to create a smooth gliding surface. This plastic spacer is of course of medical grade quality.

If you are wondering whether total knee replacement is a process for you, then it is best to consult a good doctor. Most patients who undergo this process are between the age 50-80 however the treatment does not depend upon the age but rather the severity of the problem. One is likely to stay in the hospital for 3 days and has to recover at home for pain management and movement for a few weeks.