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.
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.
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.
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)
The surgical approach to heart surgery depends on the heart problem and requirements of the patient, their general health, their medical history and other factors. This article explores the alternate types of heart surgery with special emphasis on open heart surgery as an approach in treatment.
Open Heart Surgery:
It is important to remember that open heart surgery is a surgical approach with different techniques. Surgery can be performed on the arteries, muscles or valves of the heart. It is often done to repair or replace heart valves that have become blocked or damaged, to implant devices in the individual to help the heart beat properly or even to aid in heart transplantation, where a donor heart is inserted in the place of the original heart.
Open heart surgery involves an incision or cut being made by the doctor into the chest of the individual, usually in the rib cage. This is done to also separate the muscle fibers around the heart. The incision is usually between two to five inches in length.
At the same time, the heart is then connected to a heart lung bypass machine. This machine helps the heart pump blood but shifts the blood away from the heart, thereby ensuring blood flow to the body. This ensures the individual stays alive during the procedure. Technically, in this situation, the heart is not beating and does not have blood flowing through it. The pumping of blood and distribution of blood to the body is done by the machine.
The most common technique in open heart surgery is the Coronary Artery Bypass Grafting (CABG). After the surgery is done, the incision will be closed with special stitches. Electric shocks are often administered to the patient to restart the heart. Once completed, the patient is then disconnected from the machine. The patient then needs time to recover and this may take up to a week or even ten days. They usually spend time in the Intensive Care Unit immediately post the surgery where they are kept under observation.
Off Pump Heart Surgery
This is an alternative approach to open heart surgery. Just like in the former, the doctor will make an opening in the breastbone/ sternum area. The difference is that, here the heart lung bypass machine is not used and hence the heart does not stop beating.
Minimal Invasive Heart Surgery
These surgeries are done as an alternate option to open heart surgery. Very small incisions are made between the ribs, without cutting any of the bones and the surgeon inserts the tools to perform the surgical procedure. This is usually opted when the surgical proceedings are intricate such as replacing heart valves or inserting pacemakers. Minimally Invasive Coronary Bypass Surgery has become popular now for many reasons. There is less pain and less chances of infection as the bone is not cut. The patient can resume normal functioning activities such as driving sooner and the entire hospitalization and recovery period is shorter than in open heart surgery.
Techniques of Heart Surgery:
Coronary Artery Bypass Surgery (CABS):
This is the most common type of heart surgery. It involves the replacement of a blocked artery with a healthier one. For those with severe coronary heart disease, their arteries are clogged with plaque, a fatty deposit that lines the walls of the arteries and hardens them. Hence, the blood flow through the artery is interrupted. The walls of the artery can then rupture over time and this can result in a blood clot being formed over the rupture. The blood clot will mostly completely stop the blood flow through the artery and this may result in a heart attack. In CABS, a vein or artery is taken from another body part, usually the leg, and then grafted onto the blocked coronary artery. This creates a new pathway for oxygen enriched blood to flow through. It is possible for multiple graftings to take place during one surgery.
This is a nonsurgical procedure that opens the blocked or narrowed artery. A thin tube is inserted through a blood vessel, which has a balloon at the tip. The balloon is inflated to push the plaque away. Sometimes a stent is inserted to keep the artery open.
Heart Valve Replacement/Repair Procedure:
This is usually done when the valves that direct blood flow do not open and close properly. To fix this, the surgeon either fixes the valve or replaces it. To repair it, the surgeon will insert a catheter whose one end will be inside the valve. The catheter will have a small balloon at its tip which is inflated in order to widen the valve opening and allow blood to flow through unrestricted. Apart from this, surgeons may replace the valve with valves made from tissues of pigs and cows. You can find more information about heart valve replacement surgery in India here.
Transmyocardial Laser Revascularization:
The surgeon makes an opening in the chest and lasers are used to make channels. This is used to relieve angina.
Abnormal heartbeat rhythms could prove problematic for the heart to pump blood properly and the doctors may need to insert pacemakers or defibrillators to regulate this.
When the patient’s heart is unable to pump blood enough to meet the body’s needs, the heart becomes very weak and reaches the end of its functional capacity. Here the doctors may suggest a heart transplant. The heart of the patient will be removed and a healthy heart from a deceased donor will be used in its place. However, while waiting to source a suitable donor, the patient may have to undergo other forms of heart surgery or treatment.
Post treatment Precautions:
It is important for the recovering patient to be careful after the surgery. The incision should be kept warm and dry; hence care is to be taken while bathing. Hands must be properly sanitized when dealing with dressings. The patient should watch out for signs of redness or fluids oozing from the incision.
About the author
Pousali Dey is an M.Phil in English literature & likes to explore genres related to arts and aesthetics. She is an ardent believer of the ‘learning, unlearning & relearning’ process. She truly enjoys writing on different concepts.