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Preparations for the Heart Surgery?

One individual’s experience before surgery can be altogether different from another’s yet we follow similar planning for most regular procedures.
This is because there are many varieties of heart surgery.
Most people start their journey by contacting specialist doctors and get examined (by a cardiologist) who after a precise diagnosis guides them to the cardiac surgeon. The surgeon plans the operation according to his understanding of the disease and in discussion with the cardiologist.
The patient and their relatives are counselled about the plan of treatment so that they have understood both the disease and the plan of treatment. Most people start preparing themselves very well mentally for the procedure. Then they start to plan their Hospital admission, travel and finances.
On arrival at the hospital, they will be guided to the care of the consultant in charge of the treatment by coordinators. After the consultant re-examines the patient, he/she will be admitted the previous evening for the proposed operation.

Doctors and nurses will re-examine you, take blood and urine samples and other investigations as advised by the consultant. Your consent for all procedures is once more taken and documented. The anesthesiologist will also examine your fitness for the procedure. You may need to have body hair removed by some means to help to operate unhindered. You will be given a special scrubbing solution to have a bath with, so as to reduce the chances of infection.

An intravenous (IV) line will be put into a vein in your arm to give you liquids and medicines. Just before the surgery, you’ll be moved to the operating room. You’ll be given medicines so you are relaxed and stress-free when going to the operation theatre.

The operation will be done after you have been made to go into a deep sleep so that you do not feel any pain. After the planned procedure has been completed you will be brought into the ICU where you will recover from the operation. On waking up you will find many tubes and wires attached to you, there will be sounds of computers and other machines beeping, doctors and nurses talking. This is normal. You may not be able to move or speak for some time, because of the medicines. We will wait for your complete recovery before allowing you to move and then removing the ventilator machine. Now you will be able to speak. 3 to 6 hours after removing the ventilator, you will not be given anything to eat or drink. Only when your recovery is complete will you be transferred to the wards.

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What are the Types of Cardiac Surgery?

There is more to heart surgery than only open-heart surgery.

Open-Heart Surgery:

Open-heart surgery is one in which a specialist surgeon opens the chest to reach the heart. In order to To keep the patient alive during the time we are working on the heart, the blood circulation to the body is taken care of by a heart-lung machine. The heart-lung machine oxygenates and pumps the blood back to the body. It is only when we open the heart, that we can see and correct abnormalities in the structure of the heart. In general abnormalities are like holes, blocks, valve malfunction and abnormal interconnections.

Closed Heart surgery:

Closed-heart surgery is surgery in which a specialist surgeon opens the chest to reach the heart or great vessels and then operates on these structures from outside,  without stopping or opening the heart. Examples are PDA ligation, Coarctation repair and BT shunt.

Heart Valve Repair or Replacement:

Some people are born with heart valves that do not open adequately and some that do not close well. Some develop disease that damages the valve leaflets later in life. In the past these valves were being replaced even in the USA. Now techniques to repair most of these valves are available in India also. There are advantages of repair over replacement and vice versa.

CABG:

Coronary artery bypass grafting surgery is done for patients who have blocks in the blood vessels (coronary artery) supplying blood to the heart muscle. To do this, the chest of these patients is opened and the block is identified. Then a suitable artery from inside the chest wall or a vein from the leg is taken to carry blood from the Aorta to the heart muscle, beyond the block. This bypasses the block and brings required blood to the muscle. This prevents heart muscle dying from the lack of oxygen, which is commonly known as a heart attack.

Heart Transplant:

When a person has a severe form of heart disease that cannot be treated either with medicines or surgery, he may need to have the entire heart replaced with a new one. The donor for heart transplant is a person who has had a severe illness or accident and whose brain is damaged irreversibly, also known as brain-death. This healthy heart is harvested (with consent from the close relatives) and surgically transplanted into the recipient in place of (after removing) the diseased heart. This heart functions normally and helps the recipient recover. Yet to protect the transplanted heart we need to keep the patient on medicines for life.

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What are the Risks of Heart Surgery?

Open heart surgery in children and what to expect.

Despite the fact that its outcomes are frequently amazing, heart surgery has its risks. The events that can affect the patient include:

The causes for concern when we take a person for open heart surgery are because untoward events can happen, even when we are very careful. What are these situations we need to be aware of?

  1. Reaction to medicines used in Anesthesia.
  2. Bleeding after the operation.
  3. Infection, of the surgical sites.
  4. Reactions to the any of the medicines used during surgery.
  5. Arrhythmias (abnormal rhythm of the beating heart).
  6. Affections to the brain, kidney or liver function.
  7. Damage to blood vessels and
  8. Damage to the lungs.

With growing expertise in our specialty of pediatric cardiac surgery, we are seeing more safety. The better long term results and lower costs than ever before are also because of expertise and establishment of safe principles.

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Ventricular septal defect ( VSD )

The  VSD is a defect in the septum that separates left and right ventricles. Blood from the left ventricle, which is at high pressure flows across the VSD, Right ventricle and then into the pulmonary artery. This results in blood reaching the lungs at high pressure. Over a period of time, the blood vessels of the lungs undergo changes and this is called pulmonary hypertension. It is to avoid this that we close the VSD.

How does it look when a surgeon opens the chest?

We see the heart situated between the diaphragm and the collar bones, and between the lungs on either side. The right border of the heart is formed by the right Atrium. The right ventricle forms the front of the heart. The left ventricle lies under the left half of the chest and the left atrium lies behind all these chambers.

To do open-heart surgery, we connect the major veins and arteries, and thereby the patient to the heart-lung machine which takes blood out of the venous system and give it back to the aorta. This is CPB, it ensures a supply of oxygenated blood to the whole body and hence keeps the patient alive, therefore, once we know that heart-lung machine is able to maintain the patient’s cardiac output, we stop the heart by giving potassium-rich solution into the blood vessels supplying the heart muscles. This is known as cardioplegia.

Open Heart Surgery

To close this VSD, we enter through the right Atrium surgically and place a patch on this defect and attach it using stitches. When we look through the oval orifice of the Tricuspid valve we are able to locate the defect in the interventricular septum, the VSD. Through which we can see the inside of the left ventricle. This is the ventricular septal defect that has got to be closed. It is closed by placing a patch and stitching along the edges with suture material, working in the motionless heart. This is VSD closure.

The heart is then closed, all the inside air is taken out and blood is returned to the heart. It is allowed to start beating and once the heart and lung function comes back to normal, we wean the patient off the heart-lung machine and remove the tubes inserted earlier. When the child is safe, we close the chest and shift them to the ICU for care under trained doctors and nurses.

During this entire time, the patient is under anaesthesia and is not aware of any of this activity.

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Atrial Septal Defect ( ASD)

There are multiple defects that can happen in of the heart of the child while developing inside its mother’s womb. The most common is the atrial septal defect. It is A Hole In The Wall that separates the two Atria, viz. the right and left upper Chambers of the heart.

Blood from the left atrium thereby flows across the ASD, into the right heart and goes to the lungs. When this condition persists, the increased flow of blood to the lungs causes changes to the blood vessels in the lungs. This can result in permanent damage to the lungs known as Pulmonary hypertension. This is one of the commonest reasons for closing the ASD.

What do we do?

To close the ASD, we enter through the right Atrium surgically (Open Heart Surgery) Under vision we place a patch on this defect and fix it using stitches. And this is called atrial septal defect closure.

So, How does it look when a surgeon opens the chest? Surgery being very clean, there is nothing here that surprises us, because our cardiologists can actually see using modern technology how the inside anatomy of the heart looks. We see the heart between the diaphragm and the collar bones. The right atrium forms the right border of the heart. the right ventricle is the front of the heart. the left ventricle lies under the left  half of the chest and the left atrium lies behind all these chambers.

To do surgery, we connect the major veins and arteries, (and thereby the patient) to the heart lung machine which takes blood out of venous system (now the heart is empty) and give it back to the aorta which supplies the whole body and keeps the patient alive. Once we know that heart lung machine is able to maintain the patient’s cardiac output and keeps the patient alive, we stop the heart by giving potassium rich solution,known as cardioplegia, into the blood vessels supplying the heart muscles. Then we open the right Atrium and see within it the atrial septal defect. Once visualized, we can close the ASD in the motionless heart.

The heart is then closed, all the air inside is taken out and replaced by blood that is returned to the heart. The heart starts to beat once the muscles get normal blood,  and once the heart and lung function comes back to normal, we wean the patient off the heart lung machine and remove the tubes inserted earlier. During this entire time the patient is under anesthesia and is not aware of any of this activity.

Recent advances

Almost every country in the world has the facility to do this kind of open-heart operation. Whether in the USA, Europe, India, or anywhere else, it is associated with minimum risk to life of the patient. Many centers are now able to close ASDs using devices without surgery in all but the smallest children.

In some hospitals we are able to do this operation through small cuts, or the side of the chest using advanced instruments and techniques.

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