29 yr old male presented with severe breathlessness, palpitation and giddiness. On examination he was found to be having severe leakage of both Aortic and Mitral valve. He was in heart failure with enlargement of liver and fluid collection in the lungs. His lower blood pressure was very low, & it was unable to nourish the heart. On investigations his echocardiography, his heart was grossly dilated and added to that his aorta was dilated grossly to 5.7cm and left side chamber was 8.4cm. All this made him a very high risk for routine surgery and only alternative available to him was heart transplant which again was not very feasible. In last 4-5yrs he went to Bangalore, Delhi and other hospitals in Chandigarh but did not get a definitive answer for surgery. We decided to investigate him in detail and stabilize him by decongestion and prepare his heart for surgery. In view of his dilated heart changing the aorta along with mitral valve was a very challenging procedure which was the ideal treatment. On admission he had chest pain in night and his heart stopped. He was put on a ventilator and started on drugs to maintain his blood pressure. Luckily he responded and was extubated and underwent CT scan. We examined the CT scan very thoroughly and found that aorta at the place where our clamp was to come was 4.7cm, which was comfortable for this procedure.
So we decided to change the plan to more conservative in the form of simple double valve replacement and save the aorta if its wall was well preserved. We planned to preserve heart muscle by perfusing blood cardioplegia with higher frequency. The plan paid off and he tolerated the procedure and in the post operative period he recovered slowly, but well, under the very strict supervision of our expert critical care team. He was discharged from hospital on 9th day and his echocardiography after one month showed marked improvement. His heart size has come down to 7.1cm from 8.4cm and aorta to 3.8cm from 5.7cm. He wants to ride a bicycle now, whereas he was barely able walk earlier.
The challenge in these cases is that since left side of heart has got dilated so much that it is difficult to preserve it during surgery as reserves of the muscle are very limited. One needs to devise special techniques to do that and one is to perfuse cold blood with additives to keep the heart arrested very frequently (every 15 minutes) and this gives the heart the required oxygen and nutrition to maintain cell metabolism. Other is to keep the heart totally empty and not to allow it to get distended. These are few of the techniques, coupled with making the procedure as short as possible. This was the real challenge and if one goes by bookish conclusion he required replacement of the whole aorta along with mitral valve replacement , a very extensive procedure and probably he would have not survived this procedure. Hence it was reduced to only replacement of both valves.

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