Miraculous Surgery by Indian Doctor in patient with Coarctation of Aorta

Published in Panorama


Chennai-based Kerala doctor performs a miracle



35 year old Abdul Kareem, a telephone booth operator from Kozhikode, has been given a new lease of life, following a complicated and highly risky, fourth-time heart surgery in Chennai. Fourth time surgery for ascending arch aneurysm with leaking aortic value for Coarctation of Aorta is not reported in world medical literature so far, and this is the first such surgery in the world, claims Kerala-born, Chennai based, Dr V V Bashi, renowned surgeon and chairman of MIOT Hospitals, Chennai.

Abdul who was born with this condition, Coarctation of Aorta, was operated upon for it for the first time in 1984 when this condition was diagnosed at the Chitra Tirunal Hospital, Trivandrum when he was 14 years old. This is most often a congenital disorder, a condition wherein the aorta, the main tube that takes blood out of the heart, is blocked somewhere along its path. If not corrected, it can lead to high blood pressure and heart failure, explains Dr. Bashi.

The graft which was done in 1984 developed a block three years later and Abdul was once again operated upon in 1987, at Christian Medical College (CMC) Hospital, Vellore. However, that was not the end of Abdul’s woes. In 1990, he developed an aneurysm or bulge in the area of the operated site. He was rushed from Calicut to CMC in a serious condition as he began vomiting blood, since blood had leaked into his lungs.

As Providence would have it, Dr.Bashi was on a visit to CMC at that time. An emergency operation was performed on him by Dr.Bashi, to remove the aneurysm and to divert the blood from the aorta to the lower limbs of his body. A graft was placed from ascending aorta to the abdominal aorta. However, in December 2004, fourteen years after the third surgery to his chest region, Abdul once again got admitted to hospital, complaining of breathlessness and tiredness. This time also, he had developed a large aneurysm in the origin of the Aorta, a very unusual site of occurrence, according to Dr.Bashi. Further, Abdul also presented with leaking of the aortic valve.

Surgery was the only way to save Abdul’s life since had it been left undone, he would have collapsed suddenly due to rupture of aneurysm.

A large aneurysm at the root of the aorta, at the site of its ascending arch, is a life threatening condition which, if not operated upon, can rupture, leading to the patient’s death in under three minutes! Dr.Bashi explains, “In addition to this threat, we had the leaking valves which had to be corrected; else he would have heart failure! These were two issues that we had to address. But since he had already undergone three previous surgeries, doing a fourth one was difficult, tricky and risky because it involved cutting open the chest with the aneurysm being right behind the breast bone! So, while cutting open the chest itself, you can kill the patient since the risk of opening the aneurysm is very high. Hence, for the patient’s safety, we had to connect him to the heart-lung machine by making holes in the arteries to the lower limbs. We also had to cool the patient to about 15 degrees centigrade before opening up his chest. These measures had to be taken to protect his brain and life, should we accidentally6 open the aneurysm while opening his chest!”

Needless to say, the surgery was an extensive one since it involved navigating carefully through plenty of adhesions which had accumulated from previous surgeries. The aneurysm was removed and the ascending arch of his aorta was replaced with a tube graft and a synthetic aortic valve stitched on.

Dr.Bashi fields some questions on the conditions Coarctation of the Aorta, aneurysms and the surgery he performed on Abdul with the likely outcome for him in years to come.

What exactly is Coarctation of the Aorta, what is its incidence and who are the people prone to it?
Dr.Bashi: it is usually a congenital disorder, that is, existing from birth itself and it may affect 1/10,000 children. In rare instances, it can occur secondary to infection. The condition is slightly higher in males than females. The aorta is the major artery or blood vessel that arises from the heart and takes blood to the rest of the body. It branches to the brain, upper limbs and then it comes down and supplies the lower part of the body, the spinal cord, liver, kidneys, intestine and finally to the legs. In this condition coarctation, after the blood is supplied to the upper part of the body, there is a block in the blood supply going to the lower part. If this is not corrected with surgery, it can lead to high blood pressure and heart failure as the person grows up.

What are the symptoms of this condition?
Dr.Bashi: The condition can very often get missed because it may present with no symptoms at all unless the child grows up to adolescence or even early adulthood. However, if the condition is very severe, a child, even an infant, may show up symptoms of breathlessness and heart failure. In less severe cases the individual may have symptoms secondary to hypertension – like dizziness, headache, fainting, breathlessness and palpitation. As these individuals grow into adulthood, around 20 – 25 years, the upper part of their body will be more strong than their lower part and this feature will be apparent in them.

How does one diagnose the condition since there may be no symptoms at all?
Dr.Bashi: One of the simplest modes of diagnosis is by taking the brachial and femoral pulses at the same time in a new born child, as part of routine check up. Coarctation of Aorta is characterized by a feature whereby there will be a difference in pulse between the upper region and lower region of the body. The lower limb or femoral (pulse read from the groin area) pulse will either be slower than the pulse read from the radial artery in the arm, or be totally absent. This is almost always a conclusive diagnosis of the condition. However, to confirm diagnosis completely, Chest X ray, MRI and CT scans may be necessary. That is why, one of the important aspects of school health programmes is to pick up this condition in early childhood by checking simultaneous brachial and femoral pulse.

Refering to Abdul’s condition, how come he developed aneurysm last year again after you yourself had performed surgery on him in 1990?
Dr.Bashi: There was a weakness of his aorta now, in 2004 when he came to us. It was very surprising for us because it is a very rare condition and normally a weak aorta is a birth defect but sometimes, it can happen as a person advances in life. In Abdul’s case, he probably developed a weak aorta later, that is, after 1990 because there was no weakness then, when I performed surgery on him.

How is the present surgery you performed on him, different to what you did in 1990?
Dr.Bashi: In 1990, he came in for emergency procedure for an aneurysm that had developed in a previously operated site. This time, the aneurysm was at the root of the aorta. Not only were the aneurysms located in different areas of the aorta, but the mode of surgery itself was different on the two occasions. In 1990, though it was a serious condition in which he was brought and therefore we didn’t have time to plan the surgery methodically, it was easier than the present surgery for the simple reason that it was a first time aneurysm-removal surgery on him. But now, in Jan 2005 when I performed the surgery on him, he was being operated upon for the 4th time. So technically it was more difficult and challenging because the risk of surgery was very high. I’ve not seen reports of this type of operation done for this particular condition called Coarctation of the Aorta with aneurysm as a fourth time surgery, anywhere in medical literature in the world. Though of course, these types of operations are done for others conditions

Apart from the usual risks associated with any kind of surgery - that of anesthesia, bleeding and infection – there was more complicated risk here, from the surgery itself which can be life threatening.

What are the chances of Abdul not having any cardiac problems in the future?
Dr.Bashi: I don’t expect any problem because most of Abdul’s aorta is now synthetic; only a very small part of the original is left behind. At least for the next 15-20 years, he should have no problems.

What about the synthetic aorta? Is it bio-compatible?
Dr.Bashi. Yes. This synthetic aorta is made of Dacron, a non absorbable material which is bio friendly and not rejected by the body. The only thing is he has to be careful not to get infected, that is not get any deep seated infection. Any blood stream infection can make the graft infection, though this is very rare, the long term risk of such infection being 1% - 2% only. In case he does come down with some infection, he should take prompt medication with antibiotics as prescribed under medical supervision.

To what extent can Abdul lead a normal life in terms of activities, exercises and diet?
Dr.Bashi: He can lead a normal life like anybody else. In fact, he is married and even has a child and his wife is pregnant with their second child. He can continue doing all normal activities but avoid very strenuous ones. He can do cycling, swimming and even life moderate weight, climb stairs but refrain from doing competitive exercises.

Aneurysms can occur in other conditions also, where people do not suffer from coarctation of the aorta as in the case of Abdul, yes?
Dr.Bashi: Yes. Aneurysm of the aorta is basically a dilation somewhere in the aorta which if it ruptures, can lead to the patient’s death in 3 minutes. It is like a time bomb, a tsunami in the aorta! Even if such a patient with aneurysm is in the hospital and it ruptures, we cannot do anything for him to save his life because death is almost instantaneous. In fact such a rupture is one of the risks of surgery itself but we take all precautions for doing the surgery so long as the patient does not come in some kind of emergency condition.

So aneurysm is a surgically treatable condition, yes?
Dr.Bashi: Very much so. In fact, this is the message I want to drive home to people. In 2002 we performed a complex aneurysm surgery here at Miot Hospital on a 67 year old patient. This again was a surgery done first time in the world because this man had a lot of complications and little hope of survival. He had 90% narrowing of the left main coronary artery and aneurysm of the arch and descending aorta. We successfully did four bypass surgery and one for aneurysm as well. Aneurysm surgery which until quite recently was considered a life-threatening operation in our country, can now be done with good results with acceptable mortality and affordable cost. Earlier, such a surgery was considered risky because not many hospitals in India were doing it and people would have to travel abroad to have it done at a cost of $80,000 - $100,000. But now, we are getting cases from various parts of India and even from Oman. Following surgery, these people continue to lead a good quality of life.

The best outgoing MBBS student from Medical College, Kottayam, Dr.Bashi completed his MS, General Surgery from Trivandrum Medical College with distinction. Following his post graduation, he did his training in cardio thoraric surgery from CMC, Vellore. While he held various senior positions in various hospitals in Tamil Nadu, he furthered his skills and expertise in Coronary Artery Bypass Grafting (CABG) in Adelaide, Australia. One of the pioneers in Beating Heart Surgery in India, Dr.Bashi has to his credit, over 1000 CABG on beating heart with one of the highest success rates in the world – 99.5%. He has also performed many complex surgeries including valve repairs & replacements, correction of congenital abnormalities, vascular and pulmonary operations, over 5000 coronary bypass surgeries and more than 150 complex aneurysm surgeries.

Dr.Bashi is a member of several prestigious associations across the world in cardia specialty. He was awarded membership of the American Society of Thoracic Surgeons in 1998.