Heart Disease or Coronary Artery Disease is the largest single killer in our society. The changing life style and added to that the stresses and strains of life have made this disease an almost epidemic. In India it is fast growing and soon we will be the number one country with patients of Coronary Artery Disease. The WHO report is scaring and it points towards a total disaster. Keeping this in new we all need to take preventive steps to lessen the burden of this disease. First and foremost step towards this will be to have an organized lifestyle, regular exercise and diet control. But the next more important step will be to go for preventive check ups. The incidence of this disease is rising now in younger population so it will be advisable that anybody who is above 35 years should have all his investigations carried out from heart point of view at least once a year so that if there is any alarming sign it is tackled well in time. This particularly holds good in those persons who have a strong family history.
This is one scenario and the other is that someone is having coronary artery disease, which is significant enough to produce symptoms, and requires some treatment. In this second scenario one has to act immediately. Rather than have a wishful thinking that symptoms are not related to heart and may be due to gastric trouble or muscular pain one should immediately go for stress test and if it is positive then to see how much exactly the disease is, one undergoes angiography which is the only gold standard test to quantify this disease.
The real dilemma starts when one is found to be having significant coronary artery disease, which requires interventional treatment. As of now two types of interventions are available (both are invasive and require hospitalization).
Angioplasty and Bypass Surgery there can be situations where both can be offered as treatment of coronary artery disease and of course Bypass Surgery can be applied and is the solution in any type of situation. Angioplasty means that the diseased area of coronary artery is repaired by dilating the diseased porition with a balloon catheter and these days to support the weak dilated wall of the artery a stent is put in place for better long term patency rates.
Bypass Surgery is where surgically the disease part is bypassed with a new route of blood supply via a graft taken from the human body only in the form of vein or an artery. These days we used more and more of arterial grafts either the Internal Mammary Artery that runs at the beck of sternum or radial artery, which runs in the arms.
Angioplasty is less invasive than surgery in terms of that it is done under local anaesthesia and there are no major incisions. Bypass Surgery has also become less invasive in terms that it is being done on beating heart and no longer the heart is arrested to carry out these grafts. So the stressful effect of heart lung machine on the body is gone now and recovery is much faster. Bypass surgery is beyond doubt the long term, time tested solution which improves quality of life, prevents sudden heart attacks and freedom from second procedure is great.
In case of Angioplasty with stents also improves quality of life but the other two factors do not hold good. If the stent fails or blocks again it will lead to a fresh heart attack and also the chances of blockages second time are more with stents where a second procedure may be required early. The earlier stents had high re-blockage rate but the new generation of medicated or drug coated stents have better durability and patency rates but still they have above 9% re-blockage rate during the first year only. The procedure is beneficial only in short-term basis, in terms of no major incision, less or shorter stay in hospital and no general anaesthesia but at the cost of durability.
Bypass surgery is a proven durable treatment for coronary artery disease but when a patient is detected to have this disease there are certain situations where both the treatments can be applied and there the dilemma starts. If you look at human psyche anybody and everybody in the world will want a less traumatic treatment where angioplasty comes in mind but at the same time no one wants to suffer again and again and one wants a long term solution to the disease or to that effect eradication of disease (which though is not possible) but something close to that is possible with bypass surgery. As new route of blood flow is create via grafts, which are disease free, bypassing the diseased part of artery, which means in an indirect sense removing the diseased path from the route of blood supply to the heart.
Whenever a particular form of treatment is adopted it is backed by lot of research first in animal models and then in human beings as clinical trials. Then only it is offered to public en mass. Even after the procedure is accepted it is constantly evaluated by further trials and also it is compared to the already existing procedures or other newer procedure so that the best form of therapy can be chosen for the patient population. In this direction lot of trials were conducted on cardiology front about 15 major ones and some were compared with surgical arm. Even with the advent of drug eluting stents, bypass surgery scored over angioplasty with stents in terms of better long term results i.e. event free years and less chances of second procedure. Patients in the angioplasty arm had more incidence of major adverse coronary events after the first procedure.
What are the issues here lets have a look ! Agreed any patient will choose a less invasive treatment out of two available treatments. But here is a catch; these two terms of treatments have to be equally effective in terms of their results. In case of angioplasty vs surgery key issues are:
1. Is angioplasty in multi-vessel disease evidence based?
2. Are the limitations of angioplasty known to the patient?
3. Is it economical in multi-vessel disease as compared to surgery?
There is another major flaw. The trials on which we base our treatment are conducted on western population, which is genetically different than Asian or Indian population. In the sense that in western population the size of coronary arteries is much bigger than the Asian population like it is 4-6mm as compared to 2-4mm in Asians. So treatment applied there cannot hold good here.
As such if we look at Angioplasty vs CABG the two forms of treatment are not equivalent in terms of:
1. Bypass Surgery not only tackles culprit lesion but also deals with future lesions as it is done distal to the diseased part.
2. In certain situations angioplasty carries very high mortality like Left Main Disease.
3. Even the repeat revascularization or second procedure requirement is higher with angioplasty in multi-vessel disease or left main disease. As per two latest trials even in western population Arterial Revascularization Therapy Study (ARTS), Stent or Surgery (SOS) trials the incidence of second procedure in angioplasty group is 3 times higher than patients treated with surgery. Also the risk of death in both the trials with surgery is very low 1.2% in ARTS trial and 0.8% in SOS trial.
4. The trials included only simpler form of disease like single or double vessel but the results are being applied to multi-vessel group. The need for re-intervention in ARTS trial was 30% as compared to 9% in surgical group.
5. Again in diabetes the bypass surgery scores over angioplasty in terms of long term benefits as in ARTS trial it was 43% in angioplasty as compared to 10% in surgery patients.
6. Surgery offers more complete revascularization with better durability especially arterial grafts.
7. Left main disease is a very serious situation, which requires urgent intervention and bypass surgery so far has been the best form of treatment.
8. Another major disadvantage with drug coated stents is what we call “Late Stent Thrombosis” or sudden occlusion of the stent after a year or so when the blood thinners or antiplatelets are withdrawn or reduced and infact FDA in USA has issued a warning to all these companies for this dreaded complication.

Other myths about angioplasty safety have also been proven wrong.
1. Risk of heart attack during angioplasty is 10%
2. Risk of restenosis with in first year is 10% to 30%.
3. There is no reduction in neurological complications with this.
4. Even in trials including drug coated stents multi-vessel disease, small vessels, long lesions, diabetes and restenosis patients have been excluded but in practice they are applied in even these subset of patients also.

Recently a lot of studies have come in the reputed International Journals, two of which I quote here which have proven beyond doubt that CABG or Bypass Surgery is much superior to angioplasty in multi-vessel and left main disease and these subset of patients should only be treated with surgery for long term benefits and economics.
1. One paper was published in Annals of Thoracic Surgery Dec. 2006 entitled, “Coronary Artery Bypass Grafting is still the best treatment for Multivessel and Left Main Disease… But patients need to Know” by Dr. David P Taggart from John Radcliffe Hospital, University of Oxford, United Kingdom.
2. Does off pump or minimal invasive coronary artery bypass reduce mortality, morbidity and resource utilization when compared with percutaneous coronary Intervention? A Meta analysis of randomized trials. …In Journal of Thoracic and Cardiovascular Surgery March 2007 by David Bainbridge & Colleagues from Canada.
Both these papers have detailed about pros and cons of two procedures. In Lancet in Jan. 2006, the headline cover stated, “In view of the survival benefits shown for CABG the real controversy is why patients with symptoms and anatomy known to benefit from surgery are still submitted to angioplasty”.
Again the dilemma is summarized by Dr. Califf, Head of Interventional Cardiology at Duke University, “Stenting or Surgery” in Journal of American College of Cardiology”. It is likely that most people undergoing Coronary Angioplasty are not told the entire story when a decision is made about undergoing angioplasty. He attributes this to conflicts of self-referral and financial incentives and concludes, “Without Surgical Opinion the patient is in no position to have a rational input into the decision.”
The great father of interventional cardiology, Andreas Gruntizg, who died prematurely in a plane crash at age of 46 stated in 1979, “We estimate that only about 10-15% of candidates for bypass, surgery have lesions suitable for angioplasty. A perspective randomized trial will be necessary to evaluate the usefulness in comparison with surgical and medical management”.
So to conclude stent or surgery is not/should not be a physician’s choice. It should depend on what disease demands keeping in view the long term benefits and the economics. Pros and Cons of both the procedures should be made aware to patient in detail. Durability of treatment rather than short stay should be the goal and important factor for deciding treatment.
In the end I think the best way to remove this dilemma is have multidisciplinary team consisting of a physician, a cardiologist and a cardiac surgeon to decide about the treatment plan for coronary artery disease in a particular patient on individualized basis.

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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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HYDERABAD: A Srinivas, 44, underwent a heart valve replacement surgery at a city hospital. Like all other patients undergoing surgery, he too needed blood. But being O-ve (Bombay phenotype), a very rare blood group, he could not get any donor after a relentless search. Left without any option, doctors put him on iron supplements for seven days following which they withdrew two units of blood (medically called auto transfusion), and performed the surgery.

People like Srinivas are universal donors but when it comes to receiving blood, they have to depend on O-ve (Bombay phenotype) donors only, specialists say. "Considering his heart condition, it was necessary to perform the surgery at the earliest. After exhausting all the options of getting blood from other sources, we decided to harvest blood drawn from the patient and use it for surgery," said Dr Amrendra Singh, cardiac surgeon, Kamineni hospital, L B Nagar, who performed the surgery along with his team. This was second such case in Dr Singh's 10-year career.

Srinivas underwent the surgery with doctors taking extra precaution to conserve the blood. His two units of precious blood were used for the operation and has been discharged from the hospital. According to specialists, O-ve blood group is rare and its Bombay phenotype subgroup is its very rare variant. It is found in four (persons) out of ten lakh population.

"People with this blood group should donate blood for emergency situations. While negative blood groups are always short in supply, it is worse when it comes to O-ve (Bombay phenotype). In emergency situations such as accidents, it can be life threatening," says a surgeon from Nizam's Institute of Medical Sciences. He added that auto transfusion is the only way for these patients but it works out only for elective surgeries and not emergencies.

Dr Ramesh Babu Byrapaneni, chief cardiologist and MD of Medwin hospital says that the hospital had done a similar case almost a decade ago. "We got a patient from the Jehovah's Witnesses (a quasi Christian Sect) which does not accept blood transfusion at all. For this patient, we had to go for auto transfusion," said Dr Ramesh. Further, Dr Ravi N Bathina, cardiologist at Care hospital added that it is a safe procedure and common in countries like US. Dr Ravi, who has worked in the US said that he did not come across such a case in his practice in India.

According to officials at NTR Blood Bank, it takes months and sometimes years to get this blood group. Last year, NTR blood bank could arrange four units of this blood group after much effort

MI – DVR(Minimally Invasive Double valve Repair)

Rajendra Vasaiya, Mch, Vihar Shah-MD(anesthesiologist)
Sunil vyas,M.Sc,PGDPT (perfusion technologist)

BACKGROUND: Minimally invasive double valve surgery is relatively lesser known in this part of the globe.. Here we are reporting a case of double valve surgery using minimally invasive approach.


METHODS: A 31yrs old female with post CMV(12yrs back), post MTP(22-days back) status with Hb%=7.3gm was admitted for DVR Gradient across aortic valve=55mm Hg with grade II -AR and MVA=0.8 cm. She had past H/O MTP twice due to her cardiac condition. . A 4 inch size skin incision is made. Sternum is cut with oscillating saw up to the 3rd ICS. Adhesion due to previous surgery were removed, adhesion from Aorta,,PA,&RA are also removed very carefully. Cannulation was carried .through femoral artery and two stage venous cannula in to RA Venous cannula was delivered out from the future drains tube site just below xyphoid. 1st cardioplegia was delivered antigrade in to the aortic root, rest were delivered directly in to the ostea . .Fusion between RCC & NCC up to the mid point was released, partial fusion between RCC & LCC also released. Annulus found to be dilated which was tackle later on after mitral valve correction. Mitral valve was approach through aortic aortic opening, LA was also incise. Complete MV was not seen even through this incision due to previous CMV. Through aortic opening and LA MV and its subvalver apparatus were inspected and decided to go for MV commisurotomy and release of chordal and papillary fusion.Valve is check for any leakage . Now aortic annular dilatation is dealt with reduction annuloplasty using 4-0 teflon pledgated prolien suture.t.
Immediate and late post operative period was smooth and uneventful. Ventilator was removed 3hrs after surgery.On day one blood loss was 120ML.Two units of blood was required post operatively.PCM was given as pain killer.Pnt was shifted to the ward on2nd POD ,and was discharged on 4th POD

REASULT: DVR can be carried out without much of the difficulty using minimally invasive approach. .In this particular patient post operative blood loss was significantly low. Requirement of post operative analgesia is also less. It gives patient a sense of INTACT CHEST.

CONCLUSION: Minimally invasive double valve surgery can be carried out without much difficulty with numerous advantages.

JOURNEY THROUGH MIDCAB (1997 to 2009)
TYRO TO VIRTUOSO (STUDY OF 159 MIDCAB)

BACKGROUND: - MIDCAB CABG in triple vessel disease is remained dream to many Cardiac surgeons. Difficulties and short comes exist. How to overcome and accomplish a complete and satisfactory revascularization is the most important goal of a Bypass surgery. Technical difficulties and its solution are described.

METHOD: - Since 1997, we started sternal sparing MIDCAB CABG. Till 2009 we have done 159 patients.70 patients were operated for SVD (58 CABG, 12 redo CADG), 32 cases for DVD (29 CABG, 3 redo CABG), 57 cases of TVD (55 CABG, 2 redo CABG). For initial two yrs. it was limited to SVD, mostly CTO of LAD. 1st case of redo CABG was carried out in 1999. Gradually field was expanded to DVD and since last 4 yrs. TVD cases are also incorporated. It also includes 10 cases of endarterectomy. One case with CMV and CABG. Patients’ age range between 32 – 92 yrs. LVEF = 25% (10 – 55%), 3 patients with EF of 10% were offered CABG with stem cells implantation. As much as 4 vessels were grafted. Patients overweight have no contra indication. Additional plural adhesion is also not a contra indication. Among TVD 20% had varying degree of left main disease (50 – 96%). 1 patient weighing 114 kg was also operated.

RESULT: - There was 1 mortality in a redo CABG group. The patient died on 6th POD due to VTVF. One case of TVD shows ST- elevation for 24 hrs, post operatively which subsided later on (peri operative MI). 1 patient required re-exploration due to bleeding from mammary bed. Average requirement of BT was 1.5 bottles per patient. Transfusion requirement usually depends upon pre operative HB level. Average hospital stay was 4 days (36 hrs to 6th POD). No major wound complication is seen. Average incision size is 3.5 inches (2.5- 4.2 in.). Conversion to mid sternotomy was required in 1 patient.

CONCLUSION: - Sternal sparing MIDCAB can be carried out in all but cardiogenic shock group of patients. We found it is particularly advantageous to old debilitating patient more so with farer sex group of patient. It can b learnt only by self indulgence. This method is not described anywhere in known literature. It is little time consuming and requires great deal of skill and patience on part of operator.