Every heart attack leaves the heart muscle damaged and more the number of attacks, more the damage. After bypass surgery some part of its gets revived and some part remains damaged only. But major risk of damaged heat is whether it will be able to bear the stress of surgery and beyond a certain limit which is judged by echocardiography in terms of Ejection Fraction the risk is very high. These patients with Ejection fraction of 20% and below are generally the candidates for heart transplant which is itself is not very easy to go through because of shortage of donors especially in Indian setting and also because of life long heavy expenditure on drugs. World wide in view of this there is an effort to salvage a few patients by offering their bypass surgery though mortality for these kinds of patients is very high but otherwise also it is same if nothing is offered to them.
Beating heart surgery has proved a blessing to such patients as success rates of bypass surgery in this class of patients has improved a lot. These patients but definitely require extensive investigation to see the benefit and thorough stabilization and planning. Sometimes before surgery they are supported with intra aortic balloon pump to reduce the load on the heart as well as improve the blood supply to heart muscle to some extent so that heart improves a bit to tolerate bypass surgery.
Recently, we at Alchemist Hospital, Panchkula operated upon one such patient Mr. Tara Chand 50yrs Male. Dr. V. Sarwal, Head, Deptt. of Cardiovascular and Thoracic surgery along with his team Dr. Mubeen Mohammed, Dr. Ajay Sinha, Dr. Amit Ahuja, Dr. Dheeraj Dumir, Dr. Srinivas and Mr. Des Raj operated upon him successfully.
He came to OPD for an opinion for his heart disease and his condition was getting worse. Earlier, he had shown at many places even had angiography done at Bangalore but some how could not get operated and as per his previous record his ejection fraction was 30%. He was advised fresh angiography followed by pass surgery. On the night before his scheduled day of angiography his condition deteriorated, had chest pain, breathlessness and went into heart failure. He was admitted in the night itself and angiography showed disease had progressed and other investigations revealed a fresh heart attack. He tolerated angiography but his blood pressure was low and required drugs to support it. Echocardiography revealed further damage to heart and ejection fraction fell down to 12%. It was decided to insert IABP (Intra-aortic balloon pump) to support the heart and then stabilize him with medications for next 48-72 his before planning for surgery.
Angiography showed two arteries 100% blocked and third one was 85% in the proximal part and after that 100% blocked so all three arteries were completely blocked and he was surviving on 2-3 small branches of these main arteries.
Review of all investigations showed that he was ideally a candidate of heart transplant and bypass was quite risky but this was an option only theoretically. His Trop –I levels a marker for fresh heart attack was high so we stabilized him with drugs to take out water from lungs. Supported him on IABP for 3 days and when Trop – I level came down we decided to go for beating heart bypass surgery. Only positive thing on the whole scenario was that he was admitted with chest pain along with breathlessness which in itself on indirect indication of revivable heart muscles.
He was taken to Operation Room for surgery after 3 days and three grafts were put on him on beating heart. His vessels had quite a diffuse disease and one of the vessels had to be thoroughly cleaned (Endarterectomy) before putting up the grafts. He tolerated the procedure with moderate drug support and ventilator was removed on next day and IABP on 4th POD. Slowly his drug support was reduced, de-lined and mobilized and discharged on 12th Post op day in very stable condition.
His echocardiography showed marked improvement on his second follow-up and EF has come up to 30% now. His recovery is very good and his normal routine has started now. Beating heart bypass surgery is also quite risky in such conditions but is much better and helpful than conventional bypass surgery done on heart lung machine. This single technique has made quite a bit of difference in the outcome of such patients and our center is expert in this technique and has offered successfully this to very high risk and elderly patients even above 80yrs of age.

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