Cardiovascular and Thoracic Surgery
The Department of Cardiovascular and Thoracic Surgery comprises surgeons with decades of collective experience behind them. With more than 13,000+ open heart surgeries under our belt, we are the leading cardiovascular surgical programme in the region. Here, coronary artery bypass surgery is routinely performed, both on and off pump, with great success. The team also has extensive experience with minimally invasive procedures such as the MIDCAB (minimally invasive direct coronary artery bypass), valve repairs, valve sparing aortic root replacement and many others.
Our expertise also includes paediatric surgeries for congenital heart diseases such as repairs of ASD (atrial septal defect), VSD (ventricular septal defect) and TOF (tetralogy of fallot) and correction of TAPVR (total anomalous pulmonary venous return).
In fact, our hospital was the first in the region to perform complex surgery on a six-day-old infant with congenital heart disease.
Your heart is in safe hands!
Coronary Artery Disease (CAD) or Ischemic Heart Disease (IHD)
CAD occurs when the arteries supplying blood to the heart get hardened and are narrowed. This is caused by the buildup (on the inner walls) of cholesterol and other material known as plaque. As plaque grows the flow of blood is inhibited which in turn means the heart and the rest of the body doesn’t get the blood it requires to function or survive. Over time this leads to angina (chest pain) and eventually to heart attacks. The majority of heart attacks occur when a blood clot cuts off the blood supply to the heart thereby causing permanent damage to it. CAD can also cause heart failure and arrhythmias.
There are a host of treatments for CAD, some of which are surgical. We at Sri Ramakrishna Hospital have extensive experience in both.
In the heart, blood flows or is pumped in only a single direction. The direction of the flow of blood is regulated or controlled by heart valves. (among other things). These open and close with every heartbeat, ensuring blood does not flow backward. There are four of these valves in total – tricuspid, pulmonary, mitral and aortic. When there is a defect in the valve blood flow is affected and this can have serious ramifications.
There are two kinds of problems which disrupt blood flow – regurgitation and stenosis. Regurgitation is also known as incompetence or insufficiency. When a valve cannot close correctly, blood moves backward instead of ahead. This means that the body cannot receive the oxygenated blood it requires. To make up for this, the heart works harder but over time it suffers. It will swell (become dilated) and its ability to pump will be reduced.
Stenosis is a narrowing of the opening. Basically the leaflets of the valve does not open wide enough therefore restricting the amount of blood flowing forward. It occurs when the leaflets fuse together or stiffen. This again puts pressure on the heart to pump harder.
Valve disease may be treated through medication but if the condition is severe it requires surgery. We at Sri Ramakrishna Hospital have an excellent track record when it comes to valve repair. Read more about the procedure here.
This is a syndrome which affects the connective tissue, Marfan syndrome affects various parts of the body such as the heart, lungs, blood vessels, bones, tendons, cartilage, eyes, nervous system and skin. It is caused by a genetic defect and is mostly inherited. It can be inherited from a single parent and there is a 50% chance that those who have Marfan syndrome will pass it on to their children. About a quarter of cases though are due to unknown causes. Typically it manifests itself and is noticeable with age and time as symptoms can vary in degree and nature.
In approximately 90% of patients there are changes to the heart and blood vessels. Due to the walls of the blood vessels becoming weak, they dilate or stretch. This in turn affects the aorta. The stretching of the aorta walls increases risk of an aneurysm, dissection or rupture. This is a medical emergency.
The heart valves can suffer from Marfan syndrome. It can lead to the leaflets losing strength thereby resulting in an inability to close properly. Blood leaks backwards as described in valve diseases. Heart muscle may enlarge over time and this can lead to heart failure over time. Arrhythmias may occur as well. The aortic root may dilate which can lead to a leak. This condition may have to be corrected through a procedure called valve-sparing aortic root replacement.
A healthy artery wall is thick and muscular which allows it to withstand pressure.
But, on occasion, a weak spot may develop. The pressure of the blood within the artery pushes it outwards into a bulge or balloon-like shape. This is called an aneurysm.
While they may occur in any blood vessel, they are most common in the aorta and these are called aortic aneurysms. It may occur in the abdomen or the chest cavity with the former being more common. They increase the risk of plaque formation and blood clots (which can cause strokes). If an aneurysm bursts it is a medical emergency. Aortic aneurysms are treated surgically through open heart surgery using the on-pump coronary artery bypass procedure.
Congenital Heart Diseases (CHD)
Nothing is more heartbreaking than watching an infant born into this world with congenital problems. Congenital heart diseases (CHD) are unfortunately not uncommon and these are some of the more common cardiac conditions. You can read more about the surgical procedures we at Sri Ramakrishna Hospital use to treat them here.
Atrial Septal Defect (ASD)
The wall between the left and right atria is known as the atrial septum. When there is a hole in this wall, it is called an ‘Atrial Septal Defect’ or ASD for short. When an ASD is present blood with oxygen and without can mix and this in turn can have long-term health implications such as arrhythmias.
This defect can be corrected using minimally invasive techniques or open heart surgery.
Ventricular Septal Defect (VSD)
The wall separating the left and right ventricles is known as the ventricular septum. A hole in this wall is called a ‘ventricular septal defect’ or VSD. This allows oxygenated blood to mix with the blood being carried back to the lungs. In time this can lead to heart problems such as heart failure, endocarditis and irregular heartbeats.
Tetralogy of Fallot (TOF)
TOF is a congenital heart defect. It involves four defects of the heart which results in the baby turning a bluish colour (called cyanosis).
The condition requires open-heart surgery which is carried out between the age of 6 months and 2 years.
Total Anomalous Pulmonary Venous Return (TAPVR)
TAPVR is a condition wherein the pulmonary veins carry oxygen-rich blood to the right side of the heart from the lungs. In healthy people it goes to the left side.
It has to be corrected with open-heart surgery either immediately after birth or within the first six months of the life.
Treatments & Procedures
Off pump and On pump coronary artery bypass surgery
When a coronary artery is blocked (partially or completely), it can cause Ischemic Heart Disease (IHD), Coronary Artery Disease (CAD) as manifested by chest pain (angina). In such a situation it is necessary to carry out a coronary artery bypass surgery. Most people have heard of ‘a bypass’ but aren’t too sure what it is.
In short, surgeons use a vein or artery from another part of the body to create a ‘bypass’ so that the blood may flow to the blocked coronary artery. The patient is put under general anaesthesia and the surgeons begin by making an incision in the middle of the chest. The breastbone is separated in order to create an opening through which the heart region may be accessed.
At this point, most patients are put on a bypass pump or heart-lung bypass machine. This is known as an on-pump coronary artery bypass. Essentially, all the work of the heart and lungs is then done by the machine, for the duration of the procedure. It adds oxygen to the blood before circulation to the body and then removes carbon dioxide from the blood as it returns.
The surgeon then takes a vein or artery from another part of the body. This is fashioned into a bypass wherein one end is connected to the coronary artery while the other connects to the aorta. This allows blood to flow around the blocked section so normal circulation is restored. Some of the common veins and arteries used as a graft in the procedure are the saphenous vein (from the leg), the radial artery (from the wrist) and the internal mammary artery or IMA (which lies in the chest and is already connected to a branch of the aorta).
When the procedure is complete, the breastbone is closed with steel wires (which will remain in the body) and the chest with stitches.
In some cases a patient may not be put on a bypass machine. In these instances, the procedure is done while the heart is still beating. This procedure is known as an off-pump coronary artery bypass (OPCAB). This is a far more complex and technically challenging procedure. But, the benefits to the patient can be quicker recovery, fewer blood transfusions, a shorter stay in hospital and even fewer complications in terms of the response of the immune system.
At Sri Ramakrishna Hospital, our surgeons are well equipped with the technical expertise to perform both procedures and a vast number of patients have benefitted from our expertise.
Minimally Invasive Coronary Artery Bypass Surgery(MIDCAB)
Just like off-pump coronary artery bypass surgery, minimally invasive direct coronary artery bypass (MIDCAB) surgery is performed on a beating heart i.e. no heart-lung bypass machine is used. The typical coronary bypass requires a large, ten to twelve inch incision on the chest in order to separate the breastbone. MIDCAB on the other hand employs either one incision of three to five inches between the the ribs or many small incisions. During the process, the heart is still beating so it is slowed using medication and stabilised using a special system.
An incision is made on the left side of the chest, between the ribs. Then muscle tissue is spread apart and a piece of the costal cartilage (front part of the rib) is removed. This allows the surgeon to access and ‘prepare’ an artery on the chest wall. One which is situated next to the blocked artery. Then the surgeon connects the prepared artery to the blocked artery.
This process can only be used on a maximum of two coronary arteries and even then, only if they are situated in a way as to make it possible. For more blocked arteries the conventional methods are recommended.
Minimally invasive direct coronary artery bypass has many advantages. Given the smaller incisions, the patient’s recovery time is much faster. Patients are discharged in as little as two or three days. As the heart is not fully exposed, the danger of infection is lower.
There is less bleeding and less trauma to the body and less damage to the blood cells (a possible effect of the use of a heart-lung machine). MIDCAB is available to a wider number of patients such as those who are too ill or whose hearts are too weak to undergo conventional surgery.
Aortic valve repair is usually recommended on defects in the valve which is requrgitant (leaking). It can be repaired by reshaping the ‘leaflets’ thereby allowing the valve to open and close better. It can be performed by using a minimally invasive surgical technique. It is a particularly complex procedure which requires highly skilled and experienced surgeons.
Sometimes in the case of an enlarged aorta, it may need to be replaced. During this the aortic valve may be replaced. If the leaflets of the valve has tears or holes in it, they may be patched by the surgeon using tissue patches.
For patients with a leaking or narrowed mitral valve, mitral valve repair is the recommended procedure. It is said to be a better option than replacement given the long-term prognosis. Surgeons may perform a triangular resection in the case of a posterior leaflet prolapse. In the case of an anterior leaflet prolapse of the mitral valve, the procedure is more complex. Surgeons either use ‘goretex’ chords or do what is called a ‘chordal transfer’ (where healthy chords are transferred to the location from another part of the valve).
Here at Sri Ramakrishna Hospital, our surgeons perform these procedures with great skill and dexterity. The prognosis is excellent for the patient with greater late (and early) survival, improved lifestyles and better preservation of heart function.
The aorta is composed of the ascending aorta (the section which arises from the heart), the aortic arch (the section bending over the heart), descending thoracic aorta (the section moving down the chest region) and abdominal aorta (the part beginning at the diaphragm). Sometimes the ascending aorta has defects or is diseased and the Bentall procedure is used to correct them.
At Sri Ramakrishna Hospital, we have great expertise in performing the Bentall procedure. In it, the patient is placed under general anaesthesia and the heart is put on a heart-lung bypass machine. The section of the aorta which is diseased or defective is removed. The diseased aortic valves are also excised. The aortic root (base of the aorta) and valve are replaced. Then the coronary arteries (branching out from the ascending aorta) are re-implanted.
Conceived by Tirone David, the valve sparing root replacement procedure allows a patient to keep the aortic valve.
A surgical treatment for aortic root aneurysms, the aneurysm is repaired while simultaneously preserving the patient’s own aortic valve. The valve itself might be repaired and re-implanted but its preservation is of great benefit to the patient in the long run by enabling the patient to avoid a lifetime of anti-coagulation therapy(among other things).
A procedure conducted on heart-lung bypass, it takes great skill and precision to carry out the valve sparing aortic root replacement.
Closure of ASD and VSD and Intra Cardiac repair for TOF and TAPVR:
With advances in modern medicine and surgical techniques, infants born with congenital heart diseases (CHD) now have a strong chance to live long and fulfilling lives. We at Sri Ramakrishna Hospital have the technology and expertise to surgically treat a number of conditions thereby ensuring that these children have the best shot at leading a normal life.
Atrial Septal Defect (ASD) repairs:
Atrial septal defect or ASD can be corrected using minimally invasive techniques or open heart surgery. In the former, a wire is inserted into a blood vessel leading to the heart. Using this two ‘clamshell’ devices are used to close the whole. In open-heart surgery the atrial septum is closed either with stitches or a patch.
Ventricular Septal Defect (VSD) repair:
Typically most small VSDs close of their own accord by the age of 1. Those which do remain need to be closed. Some which are larger or situated in more sensitive areas and require open-heart surgery. They are typically closed using a patch.
Repair of Tetralogy of Fallot (TOF):
To correct TOF open heart surgery is carried out. During the surgery, the ventricular septal defect is closed with a patch. The pulmonary valve is opened and the thickened muscle bundles are excised. A patch is placed on the right ventricle and the main pulmonary artery in order to improve the blood flow to the lungs. Sometimes a shunt procedure might be required at first. This increases blood flow to the lungs and complete correction can be done at a later stage.
Total Anomalous Pulmonary Venous Return (TAPVR) correction:
TAPVR has to be corrected within the first six months of the infant’s life. During the procedure, pulmonary veins will be routed to the left side of the heart, restoring the normal anatomy. Any abnormal connections are then closed off.
Complete A-V Canal defect correction:
In this defect there is an ASD with a VSD. There is only a single Atrio Ventricular Valve. The correction of the defect involves closure of the ASD and the VSD and the division of the single AV valuve into Right and Left components. Sri Ramakrishna Hospital is one of the very few Centres in the country which routinely does a single stage correction of this complex malformation.
Arterial switch operation:
This complex surgery which is done in new born babies is done for a condition called as Transposition of Great Arteries. In this condition the pulmonary artery instead of arising from the right side arises from the left side of the heart and the aorta instead of arising from the left side originates form the right side. By this complex procedure namely Arterial Switch Operation the position of these both blood vessels are interchanged therby restoring the normal anatomy.
This procedure is performed when there is a complex deformity of the heart and requires a single chamber palliation. At SRH surgeons perform this complex surgeries in children who have complex anatomical malformation which are not totally correctable.