Heart Valve Repair Instead Of Replacement

The most common heart operations are coronary artery bypass surgery and heart valve replacements. When there is a narrowing in the arteries of the heart, there is reduced blood supply, which leads to angina. If the artery gets blocked, it can cause a heart attack. Coronary artery bypass surgery is needed when medicines alone are not sufficient. Stents to coronary artery narrowing’s can be used but in some cases where there is diffuse disease or for technical issues, bypass surgery may be the only option.


The other common heart operation is heart valve surgery. The heart has four valves namely: aortic, mitral, pulmonary and tricuspid valves. These valves can be affected in different medical conditions such as rheumatic disease, infections or function abnormally due to degeneration and sometimes secondary to other problems in the heart. Although rheumatic disease was one of the common causes of valve problems in the past, it is on the decline. Infection of the heart valves is called endocarditis. Medicines can treat this condition but sometimes when the infection is aggressive, surgery will be needed. I.V drug abusers and patients with recurrent dental infections are prone to endocarditis. Sometimes the valves themselves are fine but cannot function properly due to other issues. An example of this is when someone has a heart attack, a part of the heart muscle can die and this part of the heart can dilate (commonly the ventricular chamber of the heart). Because the heart becomes distended, the valve cannot function normally and this causes the valve to leak. Sometimes, the structures supporting the valve, (chordae) which are thin strands break and this can cause valve to leak. Other conditions are due to degenerative disease or small defects in the valve tissue (mitral valve cleft or perforations).If there is a little amount of leak, the heart can tolerate this but if the leak is very big, patients will not tolerate it. Mitral valve is commonly the valve, which has this type of problem.

When the valve is not functioning normally, initially the body tries to cope with it but when this becomes severe, the body cannot tolerate it and in such conditions, they might need an operation. One option is to replace the valve using a metal or a tissue valve. Another option that is becoming more and more popular is valve repair. Here, the valve is repaired so that the patient’s own valve becomes normal and therefore there is no need to replace the valve with an artificial valve. Valve repair surgeries for mitral and tricuspid valves are becoming very common in the western world. Artificial materials like a ring and artificial chordae are sometimes used as a part of the repair.

Does this mean that all valves can be repaired and there is no need for valve replacement surgery? The answer is NO. Although repairing the valve is much better than replacement, it is not possible in every situation and every valve. In rheumatic heart disease, the valve tissues are very thickened and damaged. Besides the valve, the tissues around the valve are also damaged. Therefore in these patients, valve repair is not possible. Some units do valve repair for aortic valve problems particularly in the young patients. But of all the valves, mitral valve is most commonly repaired. This is for conditions I have described above. In addition to valve repair, patients might need coronary artery surgery as well at the same time.

One very important reason why repair is becoming more popular is the availability of intra operative echocardiogram (Transoesophageal echocardiogram or T.O.E). Here a small probe is put in the food pipe during the operation and this allows identifying the specific valve defect and also allows the surgeon to know if the repair is successful in the theatre before completion of surgery. T.O.E has revolutionised valve repair surgery.

The advantages of valve repair are that patient’s own natural tissues are preserved and there is no need for long term use of Warfarin (needed if a mechanical valve is used). Any artificial valve can fail after 10 – 20 years needing a second operation. This will not be the case after a successful repair.


Picture showing a leaking mitral valve due to ruptured chordae. Valve can be preserved by removing the abnormal part of the valve leaflet and repairing it.

Dr. Hemanth Kaukuntla
CARDIOTHORACI SURGEON
FRCS Glas, FRCS Ed, M.D, FRCS C-Th, UK.
Care Hospital, Banjara Hills. Hderabad. India.
Phone 099599979989

Sexual dysfunction

HealthWise After blue, pink pills for a colourful life

NOW HERE’S an argument that decisively supports keeping things simple. If you are a man with a flagging libido, all you need to do is pop the little blue pill — Viagra, for the ignorant and the colourblind — to bounce back into the action.

Women have no such option and here’s why Scientists claim sexual dysfunction in women is a multifaceted disorder that includes anatomical, psy- chological, physiological and social- interpersonal aspects. Simply put, whether women are in the mood for sex depends on how they look, how great they feel, how healthy they are and how much they like their partner. That’s too many hows, more so compared to what men want (usu ally just a big pair of knockers).

Early clinical trials using derivatives of sildenafil (Viagra), too, found no response in women, prompting scientists working on the pink pill for women to throw up their hands some years ago, saying female sexuality was too complex to be treated with medication alone.

Since then, patches for women that work by releasing the male hormone testosterone through the skin into the bloodstream have been made available, but have not quite caught people’s fancy For one, they are .

cumbersome: about the size of an egg, the patch has to to be stuck just below the navel and changed twice a week. Pills are any day simpler.

The good news for women in blue funk is that new studies in animals indi- cate that male impotence drugs may deserve a second look in women. Three drugs used to treat male impotence also appear to work in females, although a little differently, and could have the potential to treat the 40 per cent of women who report sexual dysfunction.

In one of the first studies of the effect of phosphodiesterase Type 5 inhibitors — sildenafil (Viagra) and vardenafil (Levitra) — on the arteries that supply blood to the penis, vagina and clitoris, Medical College of Georgia researchers showed the drugs relax the artery in male and female rats. The findings were presented in the scientific sessions of the Annual Meeting of the American Physiological Society this week in New Orleons.

They found one distinction: female rats responded better to sildenafil (Viagra), while males were most sensi tive to vardenafil (Levitra).

That apart, they also found that while the arteries from male rats displayed a relatively standard concentration-depend ent relaxation – the more drug they got, the more they relaxed — females arteries showed initial relax ation then oscillation between relaxation and contrac tion with sub sequent dos ing. Whoever said female sexu ality was complex, had it, well, bang on.

Sexual dysfunction in both men and women is usually caused by vascular problems because of diabetes, hypertension and high cholesterol, which is the reason why these medicines are meant to be had only on prescription. But when it comes to sex, people tend to throw caution to the winds. Take Viagra, for example. Around 60 per cent men who use it are believed to have no erectile problems. They just use it to add an extra zing to their sex life.

Whether it works, I wouldn’t know.

I’m a mere woman ruing the complexity of my gender.

LITTLE WONDER

Premature twins born little bigger than a human hand go home in the pink of health

BORN WEIGHING 599 gm and 694 gm, the Mehra (name chan ged) twins were bare ly larger than a human hand at birth on January 21. They weighed less than one-fourth of the normal birth weight of 3 kgs because they arrived unexpectedly, three months earlier than when they were supposed to, on April 30.

The babies were born after 25 weeks and four days of gestation. Full-term babies usually come after 38 to 40 weeks.

The twins — the older boy weighing 599 gm and girl, 694 gm — have not only survived but have left for their Vasant Kunj home from Delhi’s Fortis La Femme in the pink of health last week.

Their mother Natasha, 39, (name changed) is thrilled that her babies are feeding well, gaining weight (they now weigh 1.3 kg and 1.36 kg respectively) and crying loudly indicating healthy lungs. “I , had a difficult pregnancy and the twins were born in the second trimester. They were so tiny that I was scared to touch them,” she says.

Fighting infection was the biggest challenge senior neonatologist Dr Raghuram Mallaiah faced when the babies arrived in the neonatal ward. “They were about the size of a human hand.

Babies this small have no immunity, so to cut down risk of infection, we took them off the ventilator within 24 hours and put them on non-invasive ventilation,” he said. The twins were, however, given steroids to help their lungs develop naturally and antibiotics for two months to fight infection.

Their extreme prematurity prompted doctors to screen them extensively for development abnormalities. “Three ultrasounds showed everything was normal,” says Dr Mallaiah.

Though the twins are a week older than Baby Jagjit Kaur, India’s earliest recorded birth on June 13, 2008, at Ludhiana’s Satguru Pratap Singh Apollo Hospital, they weighed far less than Kaur, who weighed 850 gm at birth.

“It was a complicated pregnancy from the start but someone had to do it. Births in the 25th week are rare and there is a 50 per cent chance of losing the babies, but we did our best. Now both are as healthy as full-term babies,” said gynaecologist Tripat Chaudhary, who delivered them.

No baby born before 23 weeks has survived, according to the University of Iowa, which keeps a record of the world’s tiniest babies. The only miracle child was Amillia Tayor.
LITTLE WONDER
Amillia Taylor, now two, is the world’s tiniest and most premature living baby. She was born after 21 weeks and six days of gestation ¦ When she was born on October 24 in 2006 at Baptist Children’s Hospital in Miami, US, Amillia weighed just 283 gm and measured 240 cm, slightly longer than a ballpoint pen ¦ No baby born at less than 23 weeks was previously known to survive, reports the University of Iowa, which keeps a record of the world’s tiniest babies

NO MORE HEADACHES

Those arising out of neurological disorders are usually associated with symptoms like nausea, vomiting, blurred vision and fits. This type of headache may be a warning of increased intra cranial tension or intracranial tumours. Ophthalmic disorders like glaucoma and refractory errors may cause headaches. Dental caries and other disorders in the teeth may cause severe headache, which can mimic sinusitis. Migraines cause more trouble and are usually episodic associated with an aura. They are also one-sided.

Common cause

The commonest cause of headache, however, is Sinusitis. This may be associated with nasal obstruction, running nose, postnasal discharge, dry cough and other such factors. With the nose being subject to various environmental pollutants and infections, sinusitis has become an increasingly common problem.

Sinuses are normal spaces or cavities within our skull. Ventilation and drainage of their secretions is essential for proper functioning. Our nose acts as a common drainage point for all sinuses. When the sinus pathway is obstructed, secretions collect in sinuses leading to bacterial and fungal infections. The nasal obstruction may be caused by variations in the anatomy of the nose like deviation of the septum and formation of soft tissues like polyps.

Examination

Evaluation of patients with sinusitis requires a detailed examination. The advent of nasal endoscopes has revolutionised the treatment of sinusitis. This reveals the complex anatomy and the changes causing disease in the nose and sinuses. The patient can also see all this on the monitor. Blood tests, x-rays and a CT scan of the sinuses complement the endoscopy and play a vital role in evaluation.



The use of nasal endoscope has revolutionised treatment of sinusitis.

Patients are initially treated with appropriate antibiotic therapy. The use of nasal endoscopes has brought about a great change in the treatment of the disease and surgical aspects. The earlier surgical methods like puncturing and lavage, which did not establish adequate drainage, are all obsolete now.

The latest surgical procedure called Functional Endoscopic Sinus Surgery (FESS) uses the advanced nasal endoscope. This procedure precisely eliminates the blockage of natural pathways of the sinuses restoring the normal flow of secretions. It also has a cosmetic advantage in that it produces no external scar. The surgery can be performed as a day care procedure. Deviation of the septum, when present, is also corrected in the same sitting. There is no need for repetitions as in the older procedures.

Advanced surgical tools like Microdebrider help in adequate and efficient treatment making FESS a safe and advanced technique in the management of sinusitis. The use of Microdebrider provides good mucosal preservation, reduced complications like bleeding and hence good postoperative results. Microdebrider plays a vital role in polyp surgeries reducing the recurrence rate.

The nasal endoscope is also a great tool in performing other surgeries and its role in minimally invasive removal of orbital tumours and in neurosurgery has revolutionised these fields. With these advanced options available, sinusitis no longer needs to be a headache.

WE KNOW EARLY WARNINGS

THE tsunami that struck South Asia last December provided a salutary warning to all the countries around the Indian Ocean.

If only we had in place an effective early warning system, so many lives could have been saved. If we had been forewarned, I am sure people would not have suffered so much. Actually we were quite unprepared for the tragedy that struck us.

Similarly many medical tragedies can be prevented if we attune ourselves to the early warning signs that Nature gives us. Unfortunately, most of us are oblivious to these signs either due to ignorance or neglect. Among the tragedies that we can prevent or at least minimise are heart attacks, strokes and cancer.

Heart attack

A heart attack occurs because one of the coronary arteries (the blood vessels that carry blood to the heart muscles) gets blocked — whether by a sudden severe spasm or by a blood clot obstructing a narrowed vessel.

In an unfortunate few, the first indication that their arteries have narrowed is when they suffer a massive and fatal heart attack. Most people, however, get warning symptoms in the form of angina, which is the name for pain or discomfort originating from the heart muscle. This is usually felt as a tightening feeling in the centre of the chest, brought on by physical exertion, cold weather or severe emotion.

Angina is felt because the heart muscle gets less blood than it needs since enough blood is unable to reach it through the narrowed coronary artery.

Angina pain may not always be typical — some people describe it as heaviness in the chest, some feel the pain along the upper left arm or the throat but it is always an unusual symptom brought on by physical exertion or severe emotion.

If you experience such a symptom, there is no point in ignoring it or rubbing liniment in the belief that it is a muscle pain. See your doctor because central chest pain of this nature should be considered to originate from the heart unless proved otherwise.

Stroke

A stroke or a cerebrovascular accident (CVA) is a similar occurrence because the vessels supplying blood to the brain (cerebral arteries) are narrowed. A clot stuck in one of the important blood vessels can suddenly cut off blood flow to the brain.

Even if the area of the brain that has had its blood flow cut off suddenly is not large enough to cause death, strokes can damage the affected part of the brain resulting in paralysis, loss of memory, speech and other such problems.

Fortunately most people experience mini-strokes or Transient Ischaemic Attacks (TIAs) before they suffer a full-blown stroke. It is important that one knows the symptoms of a mini stroke so that it can be recognised for what it is — an early warning of imminent danger.

TIAs are felt as a momentary loss of brain function that lasts less than 24 hours — a slurring of speech. A feeling of paralysis in an arm or leg, an episode of blindness in one eye, numbness in a limb or loss of consciousness for a few minutes.

Risk factors

If you are at risk of a stroke — by virtue of age, smoking, high blood pressure, diabetes or if you have suffered a heart attack/stroke previously — then you should be aware of what a TIA feels like.

If you ever experience what feels like a mini stroke, see your doctor immediately and have a scan done so that effective preventive measures can be taken if it is proved that your cerebral arteries have narrowed.

Cancer is a group of diseases characterised by the abnormal rapid growth of cells and can affect various organs of the body. The symptoms can vary depending on the organ affected.

Symptoms

Any abnormal lump in the breast, testicle or surface of the body or a non-healing ulcer in the mouth, tongue or skin should be checked by the doctor. Do not hide the lump or ulcer hoping it will go away. If it is a cancer then it will grow and spread. Once a cancer has spread from the original site to other parts of the body, it is difficult to cure.

Unexplained weight loss is another symptom of cancer, which is often neglected. If you are not dieting, losing weight is a serious symptom as are tiredness and weakness.

Usually working too much, worrying too much or sleeping less than usual can explain being excessively tired. Not infrequently tiredness and malaise can also be caused by anaemia and blood loss resulting from a cancer in the bowel or stomach. Discuss any of these symptoms that you cannot readily explain with your doctor.

The important message is that we should recognise the warning signs and take preventive measures before we are struck down.

KNEE INJURIES

THE anterior crucaite ligament (ACL) is one of four ligaments that stabilise the knee. It runs within the joint cavity of the knee (intra-articular) from the top of the leg bone (tibia) to the thighbone (femur) in an outward direction. It prevents the leg bone from sliding off the thighbone during activities like running or climbing down stairs.

Bundle of collagen

The ACL is a bundle of collagen (connective tissue) about four cm long and one cm thick. It, perhaps, deserves to be termed as the most valuable piece of collagen in the human body as many a high-profile sportsperson's career can be jeopardised by injury to the ACL.

In the last 10 years, there has been tremendous growth of scientific literature on the management of this injury. It is common to sportspersons and in the West, women have a greater incidence than man. This has been attributed to the peculiar anatomy at the end of the thighbone. In India, there is an additional high incidence in men after accidents.

Although there are very few randomised trials concerning surgical management, there have been reasonable studies in the initial assessment, surgical techniques and rehabilitation. Public awareness of the impact of the injury has led many people to seek early surgical treatment.

This is called ACL reconstruction, as attempts to suture the torn ligament have been largely unsuccessful. In an ACL reconstruction, a piece of tissue from the neighbouring tendons and bone (graft) of the patient's own knee (auto graft) is borrowed and fixed with implants. The source of the graft is commonly the patellar (knee cap) or hamstring tendons.

Bone tunnels are drilled in the tibia and femur to site the graft; the graft is threaded through them and is fixed at both ends by some implant (metal or bio absorbable).

Surgical reconstruction is advised in young people who wish to remain active in sports and even in those in whom it is symptomatic even if they are not engaged in sports.

There is no strict age limit or any reason to withhold an ACL reconstruction in a symptomatic individual.

Accurate history

Even consultants miss many ACL injuries. An accurate history should be obtained from the patient. There will be a "popping" sound at the time of the injury.

Immediate swelling ensues after this injury (haemarthrosis or blood collection in the joint). A routine MRI study to support diagnosis in cases of suspected ACL injury is not justified.

MRI has been shown to be less sensitive and specific than an experienced examiner. A MRI is useful in chronic injuries to pick up associated resultant damage to the menisci (semi-lunar cartilages). Concomitant treatment of articular cartilage lesions can logically improve the long-term results after an ACL reconstruction.

Surgical techniques have been refined over the last 10 years. Most knee surgeons now use Arthroscopic or minimally invasive technique. There is some debate about the best source of the graft — patellar tendon or hamstring tendon.

Advances

There is no one answer to this and surgeons should decide on the basis of the patient's needs. Patients whose occupations involve kneeling are not suitable for patellar tendon graft, as there is an increased incidence of anterior knee pain.

New forms of fixing grafts have been developed. These include bio absorbable fixation devices and screws. Early ACL reconstruction is advisable to avoid likelihood of damage to the cartilages of knee and osteo-arthritis.

Ten years ago, it was common practice to splint the knee after an ACL reconstruction. It is now considered unwise to protect the knee and an early return to normal activities is advocated.

Regaining the straight position of the knee is the first goal and regain flexion is the next goal to be achieved progressively. The exercise regime is in an "accelerated" nature and not "aggressive" to avoid strain on the graft.

The physiotherapist needs to supervise the rehabilitation process only on an intermittent basis.

IF SHE DISCOVERS A BREAST LUMP?

The discovery of a breast lump usually causes anxiety bordering on panic among many women. Most rush to the nearest doctor and plunge into a morass of illogical investigations and treatment, including surgery. Needless to say, many a woman regrets th is headlong rush at a later point of time.

Incomplete assessment and treatment, a false perception of cancer risk, a lifelong commitment to intensive and needless breast cancer screening, emotional and economic exhaustion are but a few fall outs that result from all this.
Lack of awareness

There are other women who in contrast are blissfully oblivious to the presence of a breast lump. A lack of breast awareness is often engendered by cultural inhibition and a conviction that once breast feeding is complete, the breasts are of no importance. Yet others do note the presence of a lump but assume rightly or wrongly that it will "go away". Often it requires a friend or family member to coax these women into seeing a doctor.

It is important to note that breast lumps are a common problem and the majority are benign. Lumps are usually discovered by the woman herself and only occasionally by doctors. A woman who is breast-aware tends to discover them early and obviously a painful lump is noted early in contrast to a painless lump.

What should a woman do if she discovers a breast lump? It is important not to panic. Approach a healthcare provider without loss of time. It is prudent at this stage to ask for a referral to a breast specialist (invariably a surgeon). This trend has become established in the developed countries after research showed significant benefits in outcome when a woman with breast disease is treated by a breast specialist.
Thorough examination

Next the patient will be subjected to a thorough examination by the surgeon to determine whether the woman truly has a lump. Often prominent breast tissue is mistaken to be a "lump". Breast imaging follows: mammogram in women over 35 years and an ultrasound scan in younger women. This is followed in the same sitting, if warranted, by an image guided needle biopsy of various levels of sophistication. On no account should a woman agree to bypass these steps and go straight for an open surgical biopsy. This can lead to serious repercussions in breast cancer management.

After comprehensive evaluation, (which may take four to five days) the treatment options can be discussed. With the dramatic and ongoing advances in the field of breast diseases, the emphasis is on individualised treatment. This may be in the form of clinical surveillance, medication or surgery according to the need. By and large there is no need for "emergency" surgery and even for cancers, a delay of a few days or even one or two weeks is of no medical consequence.
Don’t be short changed ?

The late 20th century saw a paradigm shift in the management of breast diseases, both benign disease and cancer. This came about due to two powerful influences: the women’s movement and mounting research evidence on the best methods to treat breast disease.

The First European Breast Cancer Conference held in 1998 issued the famous Florence statement: that all women (at least in western Europe) should have access to multidisciplinary breast clinics and that all breast related health services should have mandatory quality assurance. An important ground level consequence is that national guidelines were created in countries like the U.S., Canada, New Zealand, Australia to improve breast cancer outcomes. The impact was a fall in breast cancer death rates in these countries.

A powerful message of these guidelines is that only surgeons with a special interest in breast disease should treat patients with breast cancer and breast disease. The benefits are greater accuracy of diagnosis, better quality of treatment and a reduction in morbidity and mortality.
Indian situation

By contrast India is seeing rising incidence of breast cancer, high incidence of advanced breast cancer and shameful death rates. Indeed there are no national guidelines on how services should be organised, delivered and monitored within our socio economic constraints.

It is up to Indian women’s groups to push the medical profession and the Government to look at breast disease as a national issue.

Our women must assert their rights to get the best possible treatment and refuse to be short-changed as their western counterparts did nearly 50 years ago.

Spiralling costs

The advances in breast cancer medicine and surgery have been progressing at a prodigious rate. The crunch is that the best methods of diagnosis and treatment come at a cost.

In a highly specialised and evolving field such as breast cancer treatment, even diagnosis is an expensive business. A few thousand rupees need to be set aside just for assessment of the cancer. If in addition, genetic tests are required, the bill for this alone is about Rs. 50,000. But this elaborate evaluation helps individualise breast cancer treatment and enhances efficacy of treatment. Surviving a few years more without cancer is the direct result of this individualisation. It is indeed a balance between money and life.
Financial implications

Treatment in the form of surgery, chemotherapy and radiotherapy follows and is financially crippling. Families need a few lakhs of rupees to get the best in terms of the latest chemotherapy drugs of added efficacy or the latest machines for better and safer delivery of radiation.

Today we have special drugs such as anti-breast cancer antibodies, which can be given to selected patients to control the cancer remarkably well. The cost of these injections is approximately Rs.1,00,000 per dose. These drugs need to be given every three weeks for close to a year. To meet the bills, families have been known to reduce themselves to penury. The tragedy is that many do not survive.

Whom does one blame for this financial juggernaut: The government, the private sector or the multinational companies? Or the patient for asking to live in peace for a few more years?
Why see a specialist

• It gives better local control of cancer.

• It improves the survival of the patient significantly.

• The patient has greater satisfaction with the treatment.

• The patients receive greater psychosocial support.

• The patients have improved quality of life after treatment.

• It is cost effective to be treated by breast specialists in the long run.
If you discover a lump

• Ask to be referred to a breast specialist.

• Undertake investigations as per specialist advice.

• Wait for the full evaluation.

• Heed the specialist’s advice.

• Do not seek multiple medical opinions, particularly from "non specialists".

• Be reassured that the majority of breast lumps are benign.

• Even if you have a cancer, do not lose heart. It can be controlled effectively.
Tips to contain costs

• Ask to be referred to a breast specialist early.

• Do not undertake investigations without professional guidance.

• Adhering to international treatment guidelines contains costs in the long run.

• Be part of a breast cancer support group, on going information helps contain costs.