Medifocus January 2008

8/8/2019 Medifocus January 2008

1/61

Volume: 6 Issue: 2 January March 08

Cardiology

Special

Suspensionof

privilegesimp

roves

physicianadh

erence

tohandhygiene

Choice of Heart Valve

Chest Pain in Children

Wolff-Parkinson-White Syndrome

CABG in Patients with Co Morbidities

A New Challenge for Surgeons

Timing of Surgery in Valvular Heart Diseases

Management of Unstable Angina and NSTEMI


2/61

Vol. 6, Issue 2 January - March 2008

Vol. 6 Issue 2 Jan - March 2008

Owned,Edited,PrintedandPublishedby

Dr.VinayAggarwalforandonbehalfof

PushpanjaliMedicalPublicationsPvt.Ltd.,

A-14,Pushpanjali,VikasMargExtn.,

Delhi-110092

PrintedatKumarOffsetPrinter,381,Patparganj

IndustrialArea,Delhi-110092

AlldisputestobesettledinDelhiCourtsonly.

All rights reserved.

Noresponsibilityistakenforreturning

unsolicitedmanuscriptsunlessaself-addressed

stampedenvelopeisenclosed.

ViewsexpressedinarticlesinPushpanjali

Medi-Focusdonotnecessarilyreflectthoseof

theeditorialboard.

Editor-in-Chief Dr. Vinay Aggarwal

SectionalEditors Dr. Ganesh Mani

Dr. D. Singhania

EditorialBoard

Dr. Ashok Grover

Dr. Hariharan Dr. Madhumita Puri

Dr. Sharda Jain Dr. Parkash Gera

Dr. Rajiv Gupta Dr. S. Arul Rhaj

Dr. Deepak Pande Dr. Yogesh Jhamb

Dr. Vineet Jain Dr. Neeraj Jain

Dr. B.K. Gupta Mr. S.K. Singhal

Dr. Atul Jain Mr. Atul Gandotra

Photographer Mr. Mukesh Kapoor

DesignandLayout Ms.Tabassum

FOREWORD

CONTENTS

1. CABGinpatientswithco -m orbidities 7

-Anewchallengeforsurgeons

2. ChoiceofHeartValve 11

3. TimingofSurgeryinValvular 17

HeartDiseases

4. AParadigmShiftinHealthcareDelivery 27

5. Increasingphysiciancompliance 30

withhandhygiene

6. RoleandImportanceofBiochemical 31 MarkersinClinicalCardiology

7. ManagementofCardiacPatientduring 35

NonCardiacSurgery

8. ChestPaininChildren 43

9. ManagementofUnstableAngina 45

andNSTEMI

10. Wolff-Parkinson-WhiteSyndrome 49

11. AlcoholAblationoftheSeptum 54

12. PushpanjaliHealthcareEvents 56

andInitiatives

13. Guidelinesforsubmissionof 59

Manuscripts

Cardiovasculardiseasesare a major cause of death

and disability. Dealing with such problems in our

day-to-daypractice assumesvital importancewhen

wetakeintoaccountthesuddennesswithwhichthey

mayappear.Arrythmiasaretheforemostculpritsin

thisregard.

In this issue, a cause of arrhythmia, the WPW

syndrome,hasbeendealtwithindetailtofacilitateearly

detectionandtimelytreatment.Itishopedthataclearerunderstanding

ofthemechanismwillhelpavoidthefrequentpanicandemergency

situationsthisdisorderisknowntocreateingeneralpractice.Recent

advancesincardiacelectrophysiologyhaveaidedlongtermreliefand

safetybytimelyabalationbyradiofrequencywaves.WPWsyndrome

isoneofthosesubsetswhereabalationcanbeconductedwithgood

results,thoughtherearesomeaccessorypathwayswhicharetechnicallymoredemanding.

Chestpainisanothercommoncomplaintfacedineverydaypractice

and because of the growing menace of coronary artery disease; it

hasbecomeacauseofworryandconcernforpeople.Thisissuealso

featuresanotherimportant topic, thatis, of chest painin childhood

and its management. Management of Acute Coronary Syndromes is

changingveryfastandearlyinterventionsaregraduallyreplacingthe

conservativemanagement.Whatisthebeststrategyinthesesituations

isdiscussedinthisissueinlength.

Inadults,chestpainleadstoevaluationforcoronaryarterydiseaseand

veryusefultoolinthisevaluationistheassessmentofcardiacenzymes.

Cardiacenzymesinthemyocytesandanyinjurytocardiacmuscleleadtotheirreleaseinbloodtherebyincreasingtheirlevels.Today,various

kitsareavailablefortherapidtestingofsubstancesliketroponinswhich

haschangedtheevaluationofchestpaindramatically.Thesehavebeen

detailedinthepresentissueandaguideregardingtheiravailabilityand

utilitypresented.

Tilltherecentpast,thecardiomyopathies,especiallythehypertrophic

obstructed cardiomyopathy, wastreatedonlywith medications,with

poor results in those withsevere obstruction. The alcohol abalation

technique,afairlyrecentintroductionintothetreatmentportfolio,works

byangiographicallyidentifyingthebloodsupplytothehypertrophied

septumafterwhichthehypertrophiedmuscleisdestroyedbyinjecting

alcohol in thatblood vessel. Thisaction decreases themuscle mass

leading toa decreasein obstruction bythat muscle. Thistechnique,hailedinrecentyears,isdescribedcompletelyinthisissue.

Yetanothercauseforconcernisthecardiacpatientwhoisrequiredto

undergonon cardiacsurgeries.Thus,guidelinesfor themanagement

ofperioperativecomplicationstakingintoaccounttheneedtoavoid

unnecessarytestingassumesignificanceforpatientswhoareinthehigh

andthelowriskcategories.ThearticletitledManagementofCardiac

PatientduringNonCardiacSurgerydealswiththisissueextensively.

Thepresentissuecoverspracticeorientedproblemsanditshopedthat

readerswillfinditinterestinganduseful.

Dr. Dhirendra Singhania

SectionalEditor


3/61


2

Best Practices In Health Care

Ganesh K Mani* and Manju Mani**

Best Practices is indeed a management idea which

incorporatesappropriate processes, checks andmonitoring by

whichadesiredoutcomecanbedeliveredefficientlywithfewer

problemsandunforeseencomplications.

Historicallyandeventoday,thepracticeofmedicineiscagedin

watertightcompartmentsofhealthcaredeliverynamely,Primary,

Secondary and Tertiary healthcare! It is about time we got

togethertooffertothesocietyweserve,amodernandseamless

systemthatisacontinuum-fromthePrimarytothetertiary,and

notasfragments.TheneedofthehourisCare Beyond Cure.

Thus, healthcare is the collective responsibility of all care

providers and providing continuous status health reports a

necessary obligation. Connectivity provided by Information

Technology(IT) offers thenecessary matrix forthe continued

closeinteractionbetweenthepatient,physiciansandinstitutions.PatientscouldhaveEMRs(electronicmedicalrecords)insteadof

thehistoricalpaperfiles.Computerscouldbethekeystoneof

healthcaredelivery.Imagineadoctorseeingthepatientforthe

firsttimewithadetailedhealthrecordalreadyonthecomputer.

Demographic data,family history, biomarkers, information on

other relevantmedical event arealreadyon thescreen of the

computer even as the patient and doctor interact about the

presentailment.Thisinformationcouldbegatedthroughhealth

exchanges to maintain confidentiality and privacy. Electronic

medicalrecordsisthefuturisticwaytogoandverysoonpatient

referrals,crossconsultationsandpromptexpertopinions(even

withreimbursements)wouldbecomethestandardoursociety

will demand fromthe custodians of healthcare. Telemedicine

willreinforceDoctor-Patientinteractionirrespectiveofdistances.

Time,moneyandthepromptnessofcommencementorchange

oftreatmentwillthusbeimmediatelybethewinners.

A Paradigm Shift in Thinking

The medical profession should consider the change from

EpisodicCaretoLifetimeCare.Otherthanthedoctorswhoare

indirectpatientcontact;thischangewillhavetobeborneby

theproviders(Hospitals,clinics) andthepayers(Government,

HealthInsurance,ThirdPartyinsurancecompanies)aswell.The

abovecanbeinstitutedbytheADKARModel.

A:Awarenessthatthechangeisrequired

D:Desiretosupportandparticipateinthechange

K:Knowledgeofhowtochange

A:Abilitytoimplementnewskillsandbehavior

R:Reinforcementtosustainthechanges

To implement this change, the medical fraternity should laydownpoliciesafterstudyingthemacroandmicroenvironment.

A study carried out at the IBM Institute of Business Value

Healthcare2015winwinorlose-losehasreleasedareportthat

Healthcaresystemsinitspresentformwillbecomeunsustainable

bytheyear2015!Ithaspresentedthecurrentchallengesfaced

bytheHealthcareIndustry(perhapsweshouldthinkofsome

wordotherthanIndustry!)

Rising healthcarecosts dueto sophisticationin technology,

newer innovations and rapidly advancing pharmaceutical

drugs.

Poorandinconsistenthealthcaredelivery

Globalization

Consumerism

Demographicshiftsaslifeexpectancyincreases

Newerdiseaseentities

Healthcare systems not addressing this new environment

with collapse and will require immediate and major forced

restructuring. Thiswould be a Lose-Losescenario forall the

stakeholdersnamelypatient,providerandpayer.

Key Drivers of Improved Health Care Delivery

1. Focus on Value:Consumer,providersandpayerswillagree

upon the definition and measures of healthcare value by

accreditationandthendecidingthelevelofreimbursementby

theTPAs.

2. Develop Better Consumers: Increasethe awarenessin the

patientsofthediseaseandqualityoftreatmentoffered.Thusthe

patientisabletoastutelyselectthehealthcareservices.

3. Continuity of Care:Consumers,payersandprovidersensure

qualityofcareelectronicmedicalrecords

4. Connectivity by Cell Phones (SMS) and Interactive Websites

willreducethelongwaitingperiodintheOPDsandthusreduce

lossofrevenuebyabsenteeismatwork.The3Asaccessibility,

affordabilityandacceptabilitywillbecomethenewparameters

ofqualityhealthcare.

Forhealthcareto becost-effectiveinformation sharingis the

key.Allstakeholdersshouldcreate,storeandshareinformation

securelyandseamlesslytomeetthedemandsofincreasingcost

accruedbytheagingpopulationandchronicdiseases.Electronic

MedicalRecordswillhelpInstitutionsandtheGovernmentto

plantoEnterpriseResourcePlanning(ERP),MarketingOperation

Management(MOM)andHumanResourceManagement(HRM).

Informationfromthisdatawillformthebasisforbestpractices

required for organizations to become sustainable in a global

competitiveenvironment.

Best practices cannot be successful only by a few islands of

excellenceinorganizations.Thekeytocontinuebestpractices

is to view the patient not as merely a disease entity but a

wholesomelivingbeingwhoisprobablygoingtohavealifetimeofperiods ofillhealth and wellbeing. Thisshouldbe the

combined responsibilityof themedical fraternity operatingat

primary,secondaryandtertiarylevels.Thepatientwhoenters

a tertiary hospital should not be left to fend for themselves

afterthepresentevent orillhealth period isover. Instead a

lifetimeperiodofmonitoringbythemedicalprofessionshould

beprovided.TheFamilyPhysicianaswellastheorganization

providingthetertiarycareshouldinteractactivelyandprovide

thepatientthecaredeserved.

Biomarkers have been recognized as providing important

informationtomanagementofindividuals.Besides,theknown

biomarkers like Blood Natriuretic peptide, C-reactive protein,

Lipid profiles, HbAC etc, and genetic markers of patterns in

chromosomes provideadvanceinformation ofevents likely to

happen. Genotypeand Phenotypestudies wouldgive insight

intofuturepossibilitiesofcertaindiseasepatterns.

Information Technologyhas progressed leaps andboundsand

hasalmostcompletelychangedthewaymanyindustrieswork

withexponentialadvantages.ShouldwenotincorporateITinto

healthcareandstrivetomakeitaseamlesscareprovideratall

levelswithpatientpriorityandtotaltransparencyastheultimate

goal?

Wecouldtogetherchangethewaywepracticemedicine.Best

practicesguaranteenotonlythetreatmentofthesick,butalso

the apparently healthy thus making Healthcare and Wellcare

continuous,comprehensiveandseamless.

ThetimetobeginthechangeisNOW!!

EDITORS SPEAK

*Chairman, **Executive Director, Delhi Heart & Lung Institute, New Delhi


4/61


LIST OF CONSULTANTS

CONSULTANT RESIDENCE CHAMBER MOBILE DAY/TIMING E-Mail Address

MEDICAL DIRECTOR

Dr.VinayAggarwal 22374612 22371818 9811050403 [email protected].

MEDICAL SUPERINTENDENT

Dr.H.S.Nagi 95120-4125563 9818599722 9.00am-5.00pm(Daily) [email protected]

PHYSICIAN

Dr.ParkashGera 22375440,22371284 22075641 9810000944 11.30am-1.00pm(Daily)

Dr.NavinAtal 42408075 22140637 9810115132 8.00pm-9.00pm(Daily) [email protected]

PHYSICIAN-CHEST SPL.

Dr.AshokGrover 22541854 22411236 9810121609 4.00pm-5.30pm(Daily) [email protected]

PHYSICIAN & NON INASIVECARDIOLOGIST

Dr.MukeshAjmera 22374502 9811008306 11.00am-1230pm(Daily) [email protected]

GYNAECOLOGIST

Dr.ShardaJain 22238838-22238847 22414049-22453724 9312644808 8.00am-9.00am(Daily) [email protected]

Dr.KanikaGupta 22149718,22169718 9810183236 10.00am-12.00noon(Tue,Wed,Fri)

Dr.BakulArora 22750757,22750551 9810089120 7.00pm-8.00pm(Mon,Fri) [email protected]

Dr.AnitaJain 95120-4112881,2640397 22582002 9810262229 1.00pm-2.00pm(Daily) [email protected]

Dr.RekhaSarin 65261328 659014833 9818088114 9.00am-11.00am(Mon,Thur,Sat)

SURGEON

Dr.YogeshJhamb 22378281 9811168281 11.30am-1.30pm(Daily) [email protected]

CHILD SPECIALIST

Dr.DeepakPande 22243742,42182025 22432218 9810366571 11.30am-1.00pm(Daily) [email protected]

Dr.VineetJain 95120-4112881,2640397 22582002 9810121098 10.00am-12.00noon(Daily) [email protected]

Dr.AlokGupta 65374625 9910227227 9312248808 5.00pm-6.00pm(Mon,Wed,Fri) [email protected]

PAEDIATRIC SURGEON

Dr.AnuragKrishna 24112687,24114887 9810060565 1.00pm-2.00pm(Sat) [email protected]

ORTHOPAEDIC SURGEON

Dr.B.K.Malik 9811703004 6.00pm-8.00pm(Daily) [email protected]

Dr.GirishChhabra 95120-2628200,2625200 22507728 9810025926 9.30am-12.30pm(Tue,Thu,Sat) [email protected]

Dr.P.K.Dhar 22244801 9810038879 10.30am-12.00noon(Daily)

Dr. Ashish Sao 9312010421 9.30am-12.30pm(Mon,Wed,Fri)

Dr.R.K.Sachdeva 22162135 22094892 9811073613 5.00pm-6.00pm(Daily)

Dr.AlokSharma 9312070380 6.00pm-8.00pm(Daily)

ANAESTHETIST

Dr.RajeshDhall 22167122 9810110405 OnCall(Tue,Thu,Fri,Sun) [email protected]

Dr.SwarajGarg 22543003 22548796,22519888 9811441064 OnCall(Mon,Wed) [email protected]

Dr.RakeshAtray 22152245,22157745 9810272563 OnCall(Sat)

ENT SURGEON

Dr.AtulJain 22376205 22545000 9811120545 12.00noon-1.30pm(Daily) [email protected]

Dr.AnuragJain 22720901 9810249015 8.30pm-9.30pm(Daily) [email protected]

Dr.VyomeshBansal 9310077990 6.00pm-8.00pm(Tue,Thus,Sat)GASTROENTEROLOGIST

Dr.NeerajJain 22371024 22545000 9810166989 4.00pm-6.00pm(Daily) [email protected]

ONCOLOGIST

Dr.SudersanDe 26252065 9810227340 OnCallbyappointment [email protected]

ONCO SURGEON

Dr.UmangMittal 95121-2668149 95121-2652347 9313926194 Oncall [email protected]

EYE SPECIALIST

Dr.L.D.Sota 26016636 9312876694 10.00am-1.00pm(Daily,exceptWed) [email protected]

4.00pm-7.00pm(Wed)

Dr.P.C.Bhatia 26515263,26863998 9810064554 OnCall [email protected]

URO-SURGEON

Dr.C.M.Goel 95120-2630717 951202630365 9811047047 1.00pm-2.00pm(Mon,Thu) [email protected]

PATHOLOGIST

Dr.VandanaArora 22246806 9811009938 9.00am-4.00pm(Daily) [email protected] 22096401 9312319887 OnCall


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CONSULTANT RESIDENCE CHAMBER MOBILE DAY/TIMING E-MAILADDRESSS

MICROBIOLOGIST

Dr.NarinderSaini 22376289 22381445 9810252127 8.00am-9.00am(Daily) [email protected]

RADIOLOGIST

Dr.MukeshKoshal 22546704 9810062179 12.00noon-1.30pm(Daily) [email protected]

NEUROLOGIST

Dr.B.K.Gupta 22371675,22371033 9811084263 OnCall [email protected] 22540271,22526601 30946399 9810061981 OnCall [email protected]. Aditya 9810556353 9.00am-11.00am(Tue,Thur,Sat)

NEURO SURGEON

Dr.VikasGupta 9810661522 7.00pm-8.00pm(Tue,Fri)

Dr. J. Kumar 9810273684 OnCall

NEPHROLOGIST

Dr.NeeruAggarwal 95120-2724591 95120-2780736 9810266275 1.00pm-2.00pm(MontoFri) [email protected]

9.00amto10.00am(Sat)

PSYCHIATRIST

Dr.RamanJeetJaswal 22526533 9810526533 OnCall

Dr.VikasMohanSharma 22623183 9810412911 6.00pm-8.00pm(Fri) [email protected]

PSYCHOSEXUAL DISORDERS

Dr.(Col.)V.K.Wadia 55469686 26140058 9891192777 6.00pm-8.00pm(Fri) [email protected]

PSYCHOLOGIST

Dr.R.K.Srivastava OnCall

CARDIOLOGIST

Dr.DhirendraSinghania 9871650111 6.00pm-8.00pm(Mon-Sat.) [email protected]

ENDOCRINOLOGIST

Dr.S.K.Wangnoo 22618242,22621357 95120-2921446 9810113922 OnCall [email protected]

DENTIST

Dr.GeetaPaul 9811415489 9810292498 10.00am-2.00pm(Daily)

5.00pm-8.00pm

PHYSIOTHERAPIST

Dr.Md.MajidKhan 9873207660 9.00am-1.00pm(Daily) [email protected]

HOMOEOPATHIC PHYSICIAN

Dr.M.M.Aggarwal 22434770 22094879 22513835

PLASTIC SURGEON

Dr.R.K.Sandhir 95120-2458588 22592073,22169732 9810033525 OnCall [email protected]

Dr.ManojBansal 22155057 22097417,22093107 9810003628 12.00am-1.00pm(Mon,Tue) [email protected] 11.00am-1.00pm(Tue,Wed,Fri,Sat)

SKIN SPECIALIST

Dr.V.K.Upadhyaya 22152084 22091758 9810033882 Oncall [email protected]

Dr.MukeshGirdhar 95120-2625544 22372484 9810078198 Oncall [email protected] 9891063467 10.00am-11.00am(Mon-Fri) [email protected]

DIETICIAN

Mrs.ArchnaGupta 9313759050 10.00am-12.00pm(Daily)

CHEST SURGEON

Dr.R.C.Jain 26803436,26808035 9811106203 Oncall [email protected]

RHEUMATOLOGIST

Dr.AnishAggarwal 95120-2753546 9810073795 4.00pm-7.00pm(Fri) [email protected]

COURTESY CONSULTANTS

Dr.PoonamGupta 22095708 22161397 9811744426Dr.S.P.Singh 22152036 9811152254

Dr.JyotiAggarwal 22238871 9910081484 [email protected] 9810123067Dr.MadhuAhuja 22516733 22541842 9810067539

Dr.DeepakSarin 65901485 22147652 9811022434

FAMILY PHYSICIANS

Dr.V.K.Malhotra 22157127 9313100602 OnCallDr.AjayAggarwal 9810130292 OnCall [email protected]

Dr.AjayArora 22156672 22510904 9810049714 OnCall [email protected]

Dr.VipinJain 22372065 22412008 9811047912 OnCall [email protected] 22372727 22372728 9811319070 OnCall

Dr.HariHaran 22549804 22540624 9810197049 OnCall [email protected]

Dr.AtulAggarwal 22459608 9811137098 [email protected] 9312504480 [email protected]

Dr.V.P.S.Chawla 9811305435

Dr.SangeetaGupta 9810395657Dr.AshwaniGoyal 22112343 9811112688 [email protected]

Dr.A.K.Jain 9871803070

Dr.RakeshGupta 22155979,55298198Dr.B.B.Wadhwa 22596043,22589072 9810885555


6/61


EMPANELLED ORGANISATIONS

1) GeninsIndiaLtd

2) UnitedHealthcarePvt.Ltd

3) MDIndiaPvt.Ltd

4) MedicareServiceClub5) ParkMediclaimConsultantsPvt.Ltd

6) ParamountHealthcareManagement

7) AlankitCapsec.Pvt.Ltd.

8) VipulMedCorp.Pvt.Ltd

9) E-meditekSolutionsLtd

10) TTKHealthcareServicesPvt.Ltd.

11) HeritaggeHealthClub

12) MediAssistLicensedTPA

13) MedSaveIndiaPvt.Ltd

14) FamilyHealthPlanLtd

15) RakshaTPA

16) EastWestAssist

17) BSESYamuna/Rajdhani/IPGCL(Genco)PowerLtd

18) BajajAllianzLifeInsuranceCo.Ltd.

19) GoodHealthPlanLtd.-

20) PawanHansHelicoptersLtd

21) HeritageHealthServicesPvt.Ltd

22) BajajAllianzLifeInsuranceCo.Ltd.

23) HygeniceCare(OPD)

24) CentralElectronicsLimited(OPD)

25) MotherDairy

26) NationalTextileCorporation(NTC)

27) NationalBuildingConstructionCorporation

Ltd.

28) Dabur&Excelcia

29) ArankariPlacementServicesPvt.Ltd.

30) MicromaticMachineToolsPvt.Ltd.

31) GopalIndustriesPvt.Ltd.

32) NationalIndustrialDevelopmentCorporation

Ltd.

33) MarutiUdyogLtd.

34) NationalProjectsConstructionCorporation

Ltd.

35) BharatHeavyElectricalsLtd.(BHEL)

36) NationalAgriculturalCooperativeMarketing

FederationofIndiaLtd.(NAFED)

37) UniversalMedi-AidServicesLtd.

38) HealthIndiaPvt.Ltd.39) MetLifeIndiaInsuranceCo.Pvt.Ltd.

40) MedicareServicesPvt.Ltd.

41) M/sVenusMedicareServices

42) MedicareFoundationPvt.Ltd.

43) IndiaTradePromotionOrganization

44) HealthIndia(BAISPL)

45)WHO

46) SafewayMediclaimServicesPvt.Ltd

47) ConsortiumforEducationalCommunication

48) NationalSmallIndustriesCorporationLtd.

49) MeconLtd.

50) FocusHealthcare

51) E-Medlife

LIST OF CONSULTANTS

CONSULTANT DAY / TIMINGS E-MAIL ADDRESS

PHONE NO

PHYSICIAN

Dr.RubyBa nsal 9.00am- 11.00am rsb_ban [email protected]

R) 2614076 (Daily)

M) 9891376756

CHILD SPECIALIST

Dr.(Mrs.)VPDobhal 9.00pm-10.00am [email protected]

M) 9811161590 (Daily)

SURGEON

Dr.VijayS.Pandey 11.00am-1.00pm [email protected]

R) 95 120-26 28254 (Mon,Thur)

M) 9818492809

ENDOCRINOLOGIST

Dr.S.K.Wangnoo 7 .00pm- 9.00pm s ubh ashwa [email protected] om

R) 22618242 (Mon,Wed)

22621357

M) 9810113922

CARDIOLOGIST

Dr.Dhirender 7.00pm-9.00pm [email protected]

Singhania (Mon,Sat)

M) 9871650111

ORTHOPAEDIC SURGEON

Dr.AshishSao 6.30pm-8.30pm

M) 9 312010421 (Tue,Thur,Sat)

DERMATOLOGIST

Dr.RituGupta 7.30pm-9.00pm [email protected]

R) 22371114 (Wed,Fri)

M) 9891063467

ENT

Dr.SaketAggarwal 11.00am-1.00pm [email protected]

M) 9811231599 (Mon,Thurs)

PHYSIOTHERAPIST

Dr.Md.MajidKhan 1 .00pm- 4.00pm maj_phys io@yah oo.c om

M) 9873207660 (Daily)

Dr.SonikaSaraswat 8.00am-3.00pm [email protected]

M) 9899649920 (Daily)

HOMOEOPATHIC

Dr.PriyaKapor 10.00am-12.00noon [email protected]

M)9312770969 (Daily)


7/61


8/61


CABG In Patients with Co MorbiditiesA New Challenge for Surgeons

J R Kunwar, Anil Gara, M. Mubeen, J. Pillai, B Dalmia, Ganesh K Mani

Manju Mani Subhasish Bhowmik, G K Singh, K Srinivas, Amit Jain, Anju Mehta andPrashant Borathakur,

Introduction

CABG once considered a panacea for triple

vessel coronary artery disease in the eighties

and early nineties, was challenged by a less

invasiveprocedureof multivessel PTCA using

DrugElutingStents.ThemainreasonforCABG

falling into disfavor was the relatively higher

morbidityascomparedtoPTCA.

Whereas surgeons toiled to better their own

techniqueand patient management strategies,

many patients referred by the physicians

for CABG were the ones that could not be

revascularized by PTCA and therefore had

relatively higher risk subsets. Furthermore,

surgeons hadtoundertakesurgery onpatients

withmultipleco-morbidconditions,whoused

toberefusedCABGintheyesteryears.

The present scenario

Surgeonstodaydonothavetheoptiontodeny

CABGtohighriskpatientsaspatientpreference

andreferralsbycardiologistshaveresultedinthe

largeproportionoflowriskpatientsoptingfor

PTCA(notwithstandingthemuchhighercost).

Thus,patientsreferredforCABGtodayarethose

withmanyconcomitantco-morbidconditions.

Asaresult,todaythesurgeonisforcedtooperate

onpatientswhoarefarfrombeingidealsurgical

candidates.Contraindicationshavebecomethe

newindications!

Luckily for surgeons, it is universally being

recognized that the adverse outcomes of

patients with co-morbidities is more due to

extracorporeal circulation rather than CABG

perse.Canavoidingextracorporealcirculation

canceltheimpactofco-morbidities?Thatsthe

challenge!

Morbidity after cardiac surgeryApproximately 30% is directly related to

anesthesiaand/orsurgery

Approximately 60% is related to co-

morbid preoperativestatus andthe effect of

extracorporealcirculationonthesefactors

Approximately10%aresurprises.

Preoperative co-morbidity is detrimental

to outcome even after uneventful cardiac

surgery, but some of the adverse outcomes

of co-morbidity are really due to systemic

inflammatoryresponse.Itisveryrarecurrently

thatmorbidity after CABGis dueto defective

technique!

What is co-morbidity?Co-morbidityconditions

include preoperative states of the patient

which get modified favorably or unfavorably

after CABG. Generallyif theprimarycauseof

morbidity is myocardial ischemia or failure,

thenCABGwouldpossiblycancelthemorbidity

andresultin favorableoutcome.Surprisingly,

themoretheischemia,thebetterthebenefit.If,

however, theprimarycauseis notmyocardial

ischemiaorfailure,thensurgerymayaggravate

the morbidity and may result in unfavorableoutcome.Thismaybecomefurtherconfounded

bythesystemicinflammatoryresponsedueto

extracorporealcirculation.

Morbidity is unwelcome by patient, family

and physician!Patientswithnonfataloutcomes

following operations for ischemic heart

diseasemakeup morethan95 percentof the

pool of patients undergoing operation. Of

approximately 300,000 patients undergoing

CABGannually,between50and75percenthave

an uncomplicated postoperative course. The

complications occurring in surviving patientsrange from serious organ system dysfunction

to minor limitation or dissatisfaction with

lifestyle,but account fora significant fraction

ofthecosts.

Asmuchas 40percentof the yearly hospital

costsforCABGareconsumedby10to15percent

ofthepatientswhohaveseriouscomplications

afteroperation.ThisisanexampleoftheParetos

principlethatsuggeststhatreducingmorbidity

canreducecostssignificantly.

Co-Morbidity Factors

Non-CardiacRiskFactors

1. Advancedage

2. Chronicobstructivelungdisease

3. Advancedrenaldysfunction

4. Redostatus

5. RiskofCVA

6. Hematologicalabnormalities

7. Endocrinedisordersincludingdiabetes

8. Morbidobesity

CardiacRiskFactors

1. RecentMI(


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8

5. LMD>0.75>0.75RCAdis.

6. Completeheartblock

7. Concomitantaorticstenosis

8. Concomitantcongenitalheartdisease

Cardiac Surgery Experience (1984-2007)

Theprincipalauthorstartedpracticeofcardiacsurgeryin1984

atRailwayhospital, Perumbur,shiftingto Batra hospital,New

Delhiin1989andthentoIndraprasthaApollohospitals,New

Delhiin 1996,andfinallytoDelhiHeartandLungInstitutein

2004.Duringthisperiodatotalnumberof15123CABGswere

performed, initially on CPB (CCAB) and since the beginning

of 2000, the strategy of the team has been off pump CABG

(OPCAB).

A total of 4932 patients (2432 at DHLI) have been operated

with thistechnique of beating heart surgery, using epicardial

stabilisationwiththeMedtronicOctopussystem(OPCAB).

AimTheaimofthisstudywastoidentifythemodifiableco-morbid

riskfactorswhichcanaffecttheresultsofCABGunfavorably.

Patients and Methods

Patients:Forthisretrospectivestudy,twogroupswereconstituted:

GroupA(n=580)consistedofpatientswhounderwentCABG

on beating heart (OPCAB) during January to December 2007;

andGroupB(n=550)whichwasahistoricalgroupofpatients

whounderwentconventionalCABG(CCAB)duringJanuaryto

December1999.All patientsunderwentpreoperativecoronary

angiography and 2D echocardiography with color Doppler.

CarotidDopplerwasalsoperformedtoruleoutanysignificant

carotidarterydisease.

Surgical technique: All surgical procedures were performed

bythesamesurgicalteam.Mediansternotomywasthecardiac

approachinallpatients.Theleftinternalmammaryarterywas

harvestedinpedicleformafteropeningtheleftpleura.Saphenous

veins were harvestedusing opentechnique and divided only

at the timeof grafting.Left radial artery washarvested using

harmonicscalpelinGroupA,andpreviouslywithelectrocautery

inGroupB.Heparin400IU/kgwasadministeredtobothgroups

intravenouslytoachieveanactivatedclottingtime(ACT)above

400.

Group A: CABGwasperformedusingbeatinghearttechniquewithoutCPBsupport.Cardiacstabilizationwasachievedwith

avacuumstabilizersystem(OctopusIII,MedtronicInc,USA).

Tractionsutureswereappliedtothepericardiummargininthe

leftsideforexposureoftheleftanteriordescending(LAD)artery.

Elevationoftheheartfortheexposureofthelateralandposterior

wallvesselswasobtainedwiththehelpofretrocardiacsponges.

Visualizationin theperformingof thedistalanastomoseswas

enhancedbyusingamisterblowerdevice(Clearview,Medtronic

Inc,USA).Intraluminalshunts(Clearview,MedtronicInc,USA)

wereroutinelyusedforgraftingofallcoronarybranches.Alldistal

anastomoseswereperformedwitha7-0polypropylenerunning

suture.Thefirstgraftedvesselwastheleftanteriordescending

artery,followedbyposteriordescendingarteryandfinallyobtuse

marginalbranches.Proximalanastomoseswereconstructedusing

apartialoccludingaorticclampand6-0polypropylenesutures.

A cellsaver system wasused intraoperativelyto preservethe

shedmediastinalbloodduringCABG.

Group B: ConventionalCPBwas institutedbycannulatingthe

ascendingaortaandsinglevenous(RA)cannulation.Myocardial

protection was achieved by using cold blood antegrade

cardioplegia.Distalanastomoseswereperformedonstillheart.

Cardioplegia was continued through aortic root and as graft

cardioplegia. After completion of the distal anastomoses, the

aorticcrossclampwasremovedandtheproximalanastomoses

wasperformedwithpartialclamp.CPB wasgraduallyweaned

off.

Inboththegroupsheparinwasfullyreversedwithprotamine

aftercompletionoftheprocedureandconventionalclosurewas

doneafterhaemostasis.

Results

PatientPopulationandIn-hospitalresults:Baselinecharacteristics

werewellbalancedacrossthetwogroups(Table1).

Currently, patients with moreadvanced age (>75 years), and

patients with advanced renal failure and chronic pulmonary

diseases are being operated upon. Preoperative cardiac co-

morbidfactorsareshowninTable2.

Therewere more high risk patientsin group A as compared

to group B; we areacceptingsignificantlymore patientswith

Table 1 : Preoperative Criteria: Non-Cardiac Morbidity

Group A Group B

(OPCAB) (CCAB)

Age> 7 5 years 52 07

Female sex 106 97

Lung disease 31 10

Renal failure 78 52

CA breast 02 02

Hemophilia 01 00

Pagets disease 01 00

Pancreatitis 02 00

Myasthenia Gravis 01 00

Portal hypertension 02 01

Ulcerative Colitis 02 01

Restrictive lung disease 07 03

PVD 09 07

Parkinsonism 03 01

CLL 02 00

SLE/RA 02 00

Table 2 : Preoperative Criteria: Cardiac Morbidity

Group A Group B

(OPCAB) (CCAB)

Cardiogenic Shock 42 08

Without IABP 02 05

With IABP 40 03

Recent MI 24 hrs) 40 21

LVEF < 0.25 104 79

LMCA>75% 12 10

Five or more grafts 12 18

Severe MR 19 10


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acuteMI,incardiogenicshockandpreoperativeIABPsupport.

Similarly,morepatientsingroupAhadsevereLVdysfunction

(LVEF 12 hours 17 110

> 24 hours 02 24

Acute Renal Failure

Conservative Mx 104 79

Requiring HD (new) 03 07

CRF -continuing HD po stop 09 06

Neurologic complication

Minor 01 10

Major 01 03

Average rcu stay> 48 hours 21 108

Hospital stay> 7 days 11 42

Table 5 : Cardiac outcome at 1 month

Event Group A Group B

(OPCAB) (CCAB)

Mortality 3 (0.5%) 9 (1.6%)

MI 3 (0.5%) 7 (1.5%)

Repeat procedure 2 (0.4%) 15 (2.7%)

Survival free of cardiovascular 464 (80%) 382 (69%)

event

NYHA class I or II 516 (89%) 473 (86%)

Table 3 : Operative Criteria Group A Group B

(OPCAB) (CCAB)

No. of grafts (average) 3.8 3.9

> 2 arterial grafts (LIMA + LRA) 81% 70%

Re-operative bleeding 17 23

No homologous transfusion at all 77 17

Elective concomitant MVR 02 10

Peri operative infarct 00 03

Moderate-heavy inotropic support 19 69

New IABP insertion 05 12

Hospital deaths (within 24 hrs) 00 03


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0

PossiblereasonsforimprovedresultsinOPCAB:

1. Chronologicallaterpointinlearningcurve.

2. Simultaneousimprovementinexpertiseinanaesthesia

3. Myocardial metabolism is maintained in Aerobic mode

(whichgenerates18timesmoreATP!)

4. Significant increased transfusion requirements in CCAB

(GroupB)

1. Activationofleucocytes,plateletsanddamagedRBCs

2. Consumptionofcoagulationfactors

3. RecentconsumptionofGpIIb/IIIainhibitors,antiplatelets

-greaterriskofsurgicallyinducedhemorrhagebytrauma

ofECC.

Demonstrated benefits of OPCAB: Several studies conducted

during1997-2007haveeffectivelyshownthebenefitsofavoiding

CPB-

Reduceduseofbloodproducts Lessmyocardialdamage

Reducedmorbidityandmortality

Shorterlengthofstay

Lesspostoperativestroke

LessinstanceofAtrialFibrillation

Lesschestdrainage

Fewerneurocognitivedisorders

SeveralstudieshavealsoindicatedOPCABcostsless

thantraditionalCPB

In group A, CPB was totally avoided, this has resulted in

reducedCK-MBrelease,reduceduseofbloodproducts,reduced

ventilatorytimeandshorterICUstay.Inotropicrequirementwas

alsolower in group A, probably dueto lower subendocardial

damageandpreservationofleftventricularfunction.

Preoperativehemorrhagiccomplicationsandtheneedforblood

transfusionsarestilloneofthemajorproblemsinthistypeof

surgery.Theteamhaslearnttomanagetheproblemofbleeding

with the use ofa cell saversystem. Thishasbeeneffectively

usedingroupA,wheretheshedmediastinalbloodwascollected

duringCABG,cleanedandtheredbloodcellstransfused.

ConclusionCABG on beating heart is a safe method to perform while

preventingsubendocardialdamageinthesehighrisksubgroup

patients.ThechallengeofCABGinthepresenceofmultipleco-

morbidfactorscanbeeffectivelydealtwiththepresentapproach

of off-pump CABG combined with short anesthesia and fast

trackinginICU.


12/61


M. Mubeen

J R Kunwar

Anil Gara

J. Pillai

B Dalmia

Ganesh K Mani

Department of

Cardiothoracic &

Vascular Surgery

Delhi Heart &

Lung Institute

New Delhi

Choice of Heart Valve Prosthesis

M. Mubeen, J R Kunwar, Anil Gara, J. Pillai, B Dalmia, Ganesh K Mani

It has been 47 years since Starr and Edward

described a successful prosthetic valve

replacement procedure. Some patients who

underwentvalvereplacementwiththeoriginal

Starr-Edwardsprosthesisinthe1960sarestill

alive.Sincethentillnow,morethan80models

ofprostheseshavebeendevelopedforpatients

requiringvalvereplacement.

Types of Prosthesis available: Availableheart valve prosthesis can be grouped into

two major categories: mechanical valves

and bioprostheses. Mechanical valves have

the advantage of structural stability but the

disadvantage of requiring anticoagulation.

Bioprosthesesvalvehavetheadvantageofnot

requiringanticoagulationandthedisadvantage

ofbeingsubjecttotime-relatedstructuralvalve

failure.

I. Mechanical valves

Ball valves: The original Starr-Edward

prosthesis compriseda silastic ball which

seatedinthesewingringwhenclosedand

movedforwardintothecagewhenopen(fig1). The original design has gone through

several modifications butthe basicdesign

remains similar tothe original.More than

2,00,000valveshavebeenimplanted.

Disc valves:TheBjork-Shileyprosthesisis

comprisedofasinglegraphitedisccoated

with pyrolite carbon which tilts between

twostrutsofthehousingwhichismadeof

stainlesssteelortitanium(fig1).Theoriginal

designwasmodifiedintheearly1980sto

increasetheangleofopeningandtochange

the disc to a convexo-concave shape (cc

model).Thisdesignchangeinconjunction

withchangesinthemanufacturingprocess

led to some models of this generation of

the prostheses being prone to fracture of

one of the retaining struts, allowing the

disc to escape with catastrophic results.

Although these structural defects were

correctedandmodifiedversionsofthevalve

were subsequently implanted for several

years, the Bjork-Shiley valve is no longer

manufactured. More than 3,60,000 Bjork-Shiley prostheses have been implanted.

Other manufacturers continue to produce

single disc prosthesesfor example, the

Medtronic-HallandtheAortechUltracor.

Bileaflet valves: Bileafletvalveshavetwo

semicircularleafletswhichopenandclose

creating one central and two peripheral

orifices.TheStJudemedicalvalve(fig1)was

introducedin1977,andmorethan6,00,000

have been implanted. This and similar

valvesproducedbyothermanufacturersare

nowthemostcommonlyimplantedtypeof

mechanicalprosthesisintheworld.

II. Biological prostheses

All mechanical prostheses have an absolute

requirement for anticoagulant treatment. The

potential advantage of avoiding the hazards

of anticoagulation has led to the search for

a valve replacement of suitable biological

material which would not require long term

anticoagulanttreatment.Anumberofdifferent

approaches to the problem of finding a

suitable biological valve have been made.An

autologous or autogeneous valve is fashioned

from the patients own tissue such as fascialataorpericardium.Anautograftvalveisone

translocatedfromonepositiontoanother-for

example, when the patients own pulmonary

valveisusedtoreplaceadiseasedaorticvalve.A

homograft (or allograft) valve isonetransplanted

fromahumandonor.A heterograft (or xenograft)

valveis onetransplantedfromanotherspecies

suchasapig,ormanufacturedfromtissuesuch

asbovinepericardium.

Autologous valves: In the 1970s, valves

werefashionedfreehandfromthepatients

own fascia lata in the operating theatre.

Theprocedurewastechnicallydemanding,

thevalveshadverylimiteddurability,andFig 1. Types of valve prosthesis


13/61


2

this approach has been abandoned. More recently frame

mountedvalvesconstructedfromthepatientspericardium

in the operatingroom using a commerciallyproduced kit

havebeendeveloped-forexample,theCarpentier-Edwards

Perimountpericardialprosthesis.

Autograft valves: Described by Donald Ross in 1967, theprocedure involves replacing the patients diseased aortic

valve with their own pulmonary valve which is in turn

replacedbyahomograft.Theprocedureisofparticularvalue

inchildrenasthetranslocatedpulmonarytrunkgrowswith

thechild.Mostproblemsinlaterlifehavebeenrelatedto

failureofthepulmonaryhomograft.Theprocedurerequires

a double valve replacement at operation with attendant

increasedsurgicalrisk.

Homograft valves: Homografts from human cadavers

(alsoknownasallografts)havebeenusedinsomecentres

for aortic valve replacement for over 30 years. They are

sterilised using an antibiotic solution and either stored

in fixative or cryopreserved. Viable homografts are also

successfullyharvestedfrombraindeadorgandonorsorfrom

theexplantedheartofahearttransplantpatient.

Porcine heterograft (or xenograft) valves: Porcine valves

are treated with glutaraldehyde which both sterilises the

valve tissue and renders it biologically acceptable to the

recipient-forexample,theHancockIIPorcine(Medtronic)

andthe Biocor Porcine(St JudeMedical)prostheses. Most

bioprosthesisaremountedonstentsattachedtoasewingring

(fig1),butmorerecently,stentlessvalveswhicharesewnfree

handhavebecomeavailable.Stentlessvalveshaveagreater

effectiveorificeareacomparedwithstentedvalves,butare

technicallymoredifficulttoimplant.

Bovinepericardial valves: Thesevalvesarefashionedfrom

bovine pericardium mounted on a stented frame. The

Ionescue-Shiley pericardial valve proved lessdurablethan

porcine valves and has been withdrawn. The Carpentier-

Edwards pericardial valve is fabricated by anchoring the

pericardialtissuebehindthestentsratherthanusingstitches

throughthetissue,asprovedtobeaweaknessintheIonescue-

Shileyvalve,butlongtermdurabilityremainstobeproven.

Studies Evaluating Different Types of Mechanical

Prostheses

Moststudiesof resultsof mechanicalvalve replacement have

beenobservational studiesof theresultsof valvereplacement

withonetypeofprosthesis.Mosthaveshownexcellentlongtermresultsforprosthesissurvival,withnodifferencein durability

betweentypesofprosthesis.1,2Therehavebeenfewrandomised

controlled trials comparing outcomes after mechanical valve

replacement.Thromboembolismhasbeenreportedasoccurring

at a higher rate following Starr-Edward replacement than

Bjork-Shiley. Bileaflet prostheses such as the St Jude valve

appear tohave thelowestrisk ofthromboembolism.3Ratesof

thromboembolismarehigherfollowingmitralvalvereplacement

thanfollowingaorticvalvereplacement.4

Studies Evaluating Different Types of Biological

Prostheses

Aswith mechanicalvalveprostheses,most studieshave been

observational, reporting results with one type of prosthesis.

Several studies haveidentified porcine valvefailureseven or

moreyearsafterimplantation,particularlyinyoungerpatients.

Onestudycomparedresults withstentless porcineprostheses

withstentedprosthesesintheaorticpositioninanon-randomised

case-controlled study of patients undergoing aortic valve

replacement,andshowedapparentlyenhanceddurabilityofthe

stentlessprosthesis.5Advocatesofthestentlessprosthesispoint

toitssuperiorhemodynamicswithaneffectivevalveareasome

10percentlargerthanastentedprosthesisofequivalentsize.6

Howrelevantthisisinclinicalpracticewhenthevastmajorityof

patientsundergoingaorticvalvereplacementforcalcificaortic

stenosisareintheir60s,70sor80s isdoubtful.Toanswerthe

questionofwhetherstentlessprosthesesgivesuperiorlongterm

resultsproperly,arandomisedcontrolledtrialisneeded.

Studies Comparing Mechanical with Biological

Prostheses

Therehavebeentwolargerandomisedtrialscomparingresultsof mechanical valve with porcine valve replacement, the

EdinburghHeartValvetrial(1975-1979)andtheVeteransAffairs

Co-operativestudyonvalvularheartdisease(1979-1982).Both

trials comparedthe Bjork-Shiley tilting discmechanical valve

with first generation porcine heterograft (Hancock) valve. In

theVeteransAffairs trial, 15-year survivalrates weresuperior

for patients with mechanical valves (34%) compared with

thosewith bioprosthesis (21%) inthe aortic position, but no

significantdifferenceforthosewhohadundergonemitralvalve

replacement(fig2).7 Inthe Edinburghtrial,20-yearfollowup

showednosignificantdifferenceinsurvivalforboththegroups.

Asexpected,bleedingratesweresignificantlyhigherforpatients

withmechanicalvalvesand structural valve degeneration and

re-operationswerehigherinpatientswithbioprosthesesinboth

trials.(fig3)8

Choice of Valve Prosthesis for the Individual Patient

Insynthesisingthe resultsfrom these trials andobservational

studies, how should we advise individual patients on what

typeofprosthesisismostsuitableforthem?Formostpatients

undergoingmitralvalvereplacementwhoareinatrialfibrillation

and already on anticoagulant treatment, the advice is easy.

Bioprosthetic valves confer no advantage as the patient will

continueanticoagulanttreatment.Mechanicalprostheses have

betterdurability:modernbileafletvalveshavegoodlongterm

durabilityandcansafelybemanagedwithlowintensitywarfarin,andappeartobetheoptimalchoice.Evenfortheminorityof

patientsrequiringmitralvalvereplacementwhoremaininsinus

rhythmunlesselderlyoratriskfromanticoagulanttreatment,the

enhanceddurabilityofmechanicalprosthesesandthelikelihood

ofatrialfibrillationdevelopingwiththepassageoftimewould

makeamechanicalprosthesisthebetterchoice.Inreplacingthe

valvethesurgeonshouldtrytoconservethesubvalvarapparatus

asthishelpspreserveleftventricularfunctionandappearsto

improvelongtermresults.

For patients undergoing aortic valve replacement, choice of

prosthesisiseasierfortheelderlypatient.Bioprostheticvalves

degenerate moreslowlyin elderly patients thanin theyoung

and the risks of anticoagulation may be higher in the veryelderly.Ifanelderlypatientwouldnotbeexpectedtolivefor


14/61


morethan10yearsfollowingaorticvalvereplacement,thena

bioprosthesis would be the bestchoice, as the patient would

avoidtherisksofanticoagulanttreatment.Thisstrategycarries

theriskthatsomepatientswilloutlivetheirprosthesisandfacetheneedforrepeatsurgeryintheir80swithincreasedmortality

andmorbidityfollowingreoperationatthisage.Itisdifficultto

chooseanarbitraryageatwhichthisstrategycouldbeadopted;

theAmericanHeartAssociation/AmericanCollegeofCardiology

(AHA/ACC)taskforcerecommendsbioprosthesesforthoseover

65undergoingaorticvalvereplacement.9

For younger patients undergoing aortic valve replacement a

modern bileaflet mechanical valve would seem the optimal

choice. Those wishing to, orneeding to, avoid anticoagulant

treatment could have a bioprosthesis. Aortic homografts may

be more durable than porcine bioprostheses, particularly in

youngerpatients,andseemtoproducethebestresultswitha

short harvest and implantation time when the homograft isobtainedfrom a brain deadorgandonor ora heart transplant

recipient. In one large series involving 618 patients, freedom

fromreoperationforvalvefailureat10yearswas81percentand

at20yearswasonly35percent.Homograftsfromdonorsolder

than65yearsofage,orwherethedonorwasmorethan10years

olderthantherecipient,hadpoorerresults.Itwasalsofound

thatusingthehomografttoreplacethevalveandtheaorticroot

withreimplantationofthecoronaryarteriesproducedbetterlong

termresultsthanusingthehomograftforasubcoronaryvalve

replacement. Repeat surgeryfor valvefailurein patientswith

reimplanted coronaries is, however, much more demanding.

Patients with renal failure, or with hypercalcaemia, have

accelerateddegenerationofbioprosthesisandshouldnotreceive

abioprosthesis.TheAHA/ACCtaskforcerecommendationsareshownintable1.9

Despite various randomized trials showing apparent slight

advantage for patients receiving mechanicalvalves, the trend

world-wide has been away from mechanical prostheses and

towardsbiologicalvalvesformultiplereasons.

Currentbioprosthesesappeartohavelowerratesofstructural

valvedeteriorationthanthoseusedduringthesestudiesthat

involved first generation bioprostheses. Re-operation rates

forpatientsover65 years of ageare particularly lowwith

modernstentedbioprostheses.

Therisksof re-operationhavecontinuedtodecreasesince

thesetrialswerecompleted,particularlytheriskofafirstre-

operation.

Youngpatientsundergoingvalvesurgeryareoftenreluctant

toaccept anticoagulanttherapyand theactivityconstraint

associatedwiththem.

There are some nonrandomized but relatively largecomparativetrialsthathaveshownapparentsurvivalbenefit

forpatientsreceivingbioprostheses.

Women of Childbearing Age

Foryoungwomenofchildbearingage,whereverpossiblesevere

valvarlesionslikelytocauseproblemsduringpregnancyshould

becorrectedbeforepregnancybytreatmentswhichavoidvalve

replacement-balloon valvuloplasty for mitral stenosis, mitral

valve repair for mitral valve prolapse. If valve replacement

isrequired the choice oftype ofprosthetic valveis difficult.

Implantationofabioprostheticvalveinthemitralpositionwill

conferthenearcertaintythatthevalvewilldegenerateinthe

patientslifetimeandrequirereplacement,andthepatientwillfacesignificantriskofmortalityandmorbidityatreoperation.

Fig 2. The veterans affairs co-operative study Fig 3. Edinburgh trial


15/61


Table 2 : Recommendations for anticogulation during pregnancy in patients with mechanical prosthetic valves: weeks 135

Indication Class

1. The decision whether to use heparin during the rst trimester or to continue oral anticoagulation I

throughout pregnancy should be made after full discussion with the patient and her partner; if she chooses

to change to heparin for the rst trimester, she should be made aware that heparin is less safe for her,

with a higher risk of both thrombosis and bleeding, and that any risk to the mother also jeopardises the baby

2. High risk women (a history of thromboembolism or an older generation mechanical prosthesis in the mitral I

position) who choose not to take warfarin during the rst trimester should receive continuous unfractionated

heparin intravenously in a dose to prolong the midinterval (6 hours after dosing) aPTT to 23 times control.

Transition to warfarin can occur thereafter

3. In patients receiving warfarin, INR should be maintained between 2.03.0 with the lowest possible dose of IIa

warfarin, and low dose aspirin should be added

4. Women at low risk (no history of thromboembolism, newer low prole prosthesis) may be managed with adjusted IIb

dose subcutaneous heparin (17 50020 000 U twice daily) to prolong the mid interval (6 hours after dosing)

aPTT to 23 times control.

Class I. There is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class IIa. Weight of evidence/opinion is in favour of usefulness/efcacy.

Class IIb. Usefulness/efcacy is less well established by evidence/opinion.

From the European Society of Cardiology guidelines for prevention of thromboembolic events in valvular heart disease.

This is likely to occur when the patients children are still

young.Pregnancymayacceleratetherateofbioprostheticvalve

degeneration.

Implantation of a mechanical valve will necessitate warfarin

treatmentwithanattendantriskoffetallossormalformationand

amaternalriskofvalvethrombosisandperipartumhemorrhage.

Warfarincrossestheplacentaandisassociatedwithanincreased

incidence of spontaneous abortion, stillbirth, prematurity,

Table 1 : Summary of class I and II AHA/ACC recommendations for choice of prosthetic valve

Recommendations for valve replacement with a mechanical prosthesis Class

1. Patients with expected long life spans I

2. Patients with a mechanical prosthetic valve already in place in a different position than I

the valve to be replaced

3. Patients in renal failure. on haemodialysis, or with hypercalcaemia II

4. Patients requiring warfarin treatment because of risk factors* for thromboembolism IIa

5. Patients 70 years needing MVR who do not have risk factors for thromboembolism* lIa

5. Valve rereplacement for thrombosed mechanical valve lIb

Class I. There is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class II. There is conicting evidence and/or a disagreement of opinion about the usefulness/efcacy of a procedure or treatment.

Class lIa. Weight of evidence/opinion is in favour of usefulness/efcacy.

Class lIb. Usefulness/efcacy is less well established by evidence/opinion.

*Risk factors: atrial brillation, severe left ventricular dysfunction, previous thromboembolism, and hypercoagulable condition.


16/61


References

1. Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart

valves.NEnglJMed1996;335:40716.

2. Groves P. Surgery of valve disease: late results and late

complications.Heart2001;86:71521.

3. Boon NA, Bloomfield P. Medical management of valvarheartdisease.Heart2002;87:395400

4. Gohlke-BarwolfC.Anticoagulationinvalvarheartdisease:

newaspectsandmanagementduringnon-cardiacsurgery.

Heart2000;84:56772.

5. David TE, Puschmann R, Ivanov J, et al. Aortic valve

replacement withstentless and stented porcine valves: a

case-matchstudy.JThoracCardiovascSurg1998;116:236

41.

6. BurdonTA,MillerDC,OyerPE,etal.Durabilityofporcine

valves fifteen years in a representative North American

patientpopulation.JThoracCardiovascSurg1992;103:238

51

7. HammermeisterK,SethiGK,HendersonWG,etal.Outcomes

15yearsaftervalvereplacementwithamechanicalversus

a bioprosthetic valve: finalreportof the Veterans Affairsrandomizedtrial.JAmCollCardiol2000;36:11528

8. BloomfieldP,WheatleyDJ,Prescott RJ,et al.Twelve-year

comparisonofaBjork-Shileymechanicalheartvalvewith

porcinebioprostheses.NEnglJMed1991;324:5739.

9. BonowRO,CarabelloB,DeLeonAC,etal.ACC/AHApractice

guidelines.Guidelinesforthemanagementofpatientswith

valvularheartdisease.Circulation2006;114:84-231.

10. Vitale N,De FeoM, DeSanto LS, etal. Dose-dependent

fetalcomplications of warfarin in pregnant women with

mechanicalheartvalves.JAmCollCardiol1999;33:1637

41.

andembryopathy.The riskofwarfarinembryopathy hasbeen

estimated at between 410 percent and appears to be dose

dependent.InarecentobservationalstudyfromItaly,Vitaleand

colleaguesreportedanoverallriskoffetalcomplicationsasbeing

fourtimeshigherinwomenrequiringanaveragedailydoseof>

5mgwarfarincomparedwiththoserequiring5mgdaily.These

authors therefore recommended for patients requiring low

dosesofwarfarinastrategyofmaintainingwarfarinthroughout

pregnancyandanelectivecaesareanat38weeks.10

Heparindoesnotcrosstheplacentalbarrierandforthisreason

has been considered to be safer for the fetus. However, the

risk of thromboembolic complications including fatal valve

thrombosis inpatients treatedwith subcutaneousheparinhas

beenobserved in somestudiesto be between 1224percent.

TheEuropeanSocietyof Cardiology guidelinesforprevention

of thomboembolic events in valvar heart disease therefore

recommend that womenat high risk because of a history of

previousthromboembolismoranoldergenerationprosthesisin

themitralpositionwhochosenottotakewarfarinduringthe

firsttrimestershouldreceivecontinuousunfractionatedheparin

intravenously throughout the first trimester. Low molecular

weightheparinhasbeensafelyusedfordeepveinthrombosis

inpregnancy,isobviouslyfarmoreconvenientthancontinuous

unfractionatedheparin,buthasyettobefullyevaluatedduring

pregnancyinpatientswithmechanicalprostheticvalves.

Thebest managementstrategy forwomenof childbearing age

requiring valve replacement remains unclear. Both they and

theirspousesmustbefullyinformedoftherisksofeachstrategy

beforeundergoingvalvereplacementsurgery.


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18/61


M. Mubeen

J R Kunwar

Anil Gara

J. Pillai

B Dalmia

Ganesh K ManiDepartment of

Cardiothoracic &

Vascular Surgery

DelhiHeart&

LungInstitute

NewDelhi

Timing of Surgery in Valvular Heart Diseases

M. Mubeen, J R Kunwar, Anil Gara, J. Pillai, B Dalmia and Ganesh K Mani

Introduction

For most hemodynamically relevant heart

valve lesions, surgical therapy remains the

treatment of choice. During the past two

decades, major advances have occurred in

diagnostic techniques, the understanding of

naturalhistory,andinterventionalandsurgical

procedures for patients with valvular heart

disease. The information base from which to

makeclinicalmanagementdecisionshasgreatly

expandedinrecentyears,yetinmanysituations,

management issues remain controversial or

uncertain.

Inthisarticleasummaryofthetimingofsurgery

for patients with following conditions: mitral

stenosis (MS), chronic mitral regurgitation

(non-ischemic), aortic stenosis and chronic

aorticregurgitationispresented.

Mitral Stenosis

The predominant cause of MS is rheumatic

carditis. Isolated MS occurs in 40 percent of

all patients presenting with rheumatic heart

diseaseandahistoryofrheumaticfevercanbe

elicited in ~60 percent of patients presenting

withpureMS.

Thenormalmitralvalveareais4.0to5.0cm2.

Narrowingofthevalveareato1.5cm2usuallydoesnot

producesymptomsatrest.However,ifthereis

an increase in transmitral flow or a decrease

inthe diastolic filling period, therewill bea

rise in left atrial pressure and development

of symptoms. Thus, the first symptoms of

dyspneainpatientswithmildMSareusually

precipitated by exercise, emotional stress,

infection,pregnancy,oratrialfibrillationwitharapidventricularresponse

Natural history

MSisacontinuous,progressive,lifelongdisease,

usuallyconsistingofaslow,stablecourseinthe

early years and progressive acceleration later

inlife.Thereisalonglatentperiodof20to40

yearsfromtheoccurrenceofrheumaticfeverto

onset of symptoms. Once symptoms develop,

there is another period of almost a decade

before symptoms become disabling. Overall,

the10-yearsurvivalofuntreatedpatientswith

MSis50percentto60percent,dependingon

symptomsatpresentation.Intheasymptomatic

orminimallysymptomatic patient, survivalis

>80%at10years,with60percentofpatients

demonstrating no progression of symptoms.

However, once significant limiting symptoms

occur,thereisadismal10-yearsurvivalrateof0

percentto15percent,andwhenthereissevere

pulmonaryhypertension, mean survival drops

to1.5cm2and

meangradient1.5 1.0-1.5


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8

PatientswithNYHAfunctionalClassIIsymptomsandmoderate

orseverestenosis(mitralvalvearea1.5cm2ormeangradient5

mmHg)maybeconsideredformitralballoonvalvotomyifthey

havesuitablemitralvalvemorphology.(Fig1)

Patients withNYHA functionalClass IIIor IV symptoms and

evidenceofsevereMShaveapoorprognosisifleftuntreated,

and intervention with either balloon valvotomy or surgery

shouldbeconsidered.(Fig2)

Chronic Mitral Regurgitation

Mitralregurgitation(MR)causedbyananatomicabnormalityof

theleafletsandchordaeistermedprimaryregurgitation,while

mitral regurgitation caused by a process primarily affecting

the left ventricle is termed secondary mitral regurgitation.

Examplesof primarymitralregurgitationincludemyxomatous

mitralvalvediseasewhichresultsinmitralregurgitationcaused

by leaflet prolapse and/or chordal rupture, rheumatic diseasewhich typicallycausesincreasedleafletstiffness withchordal

shorteningandfusion,andendocarditiswithleafletdeformation

and destruction. Examples of secondary mitral regurgitation

include ischemic disease that affects the function of the

papillary muscles and underlying left ventricular wall, and

dilatedcardiomyopathythataltersthenormalanglebetweenthe

papillarymusclesandmitralannulus.

Natural history

Inpatientswithprimarymitralregurgitation,theremaybean

interval of several years between the diagnosis of significant

mitral regurgitation and onset of symptoms, with a rate of

symptom onsetof 24percent per year. However, the rate of

symptomonsetdependsontheetiologyofmitralvalvedisease

andtheseverityofregurgitation.Inadditiontodevelopmentof

symptoms,thetwomajorconcernsinpatientswithasymptomatic

primarymitralvalvediseasearetheriskofsuddendeathand

theriskofirreversibleleftventriculardysfunction.Theriskof

suddendeathisestimatedtobe10to100timesthenormal,with

anabsoluteriskofsuddendeathof12.5percentoversixyears.Riskfactorsforsuddendeathinpatientswithmitralregurgitation

q

qq

q

q

PASP>50mmHg?q

q

AF =atrialfibrillation;CXR=chestX-ray;echo=echocardiography;LA=leftatrial;MR=mitralregurgitation;2D=2-dimensional.

q

MitralStenosis

History, physical exam CXR, ECG, 2D echo/Doppler

qq

Symptoms ?

Symptomatic

(see Figures 2 and 3)

Asymptomatic

Mildstenosis

MVA>1.5cm2

Mildstenosisor

severestenosis*

MVA60mmHg

or PAWP 25 mm Hg

q qqNo

Yes

qqYesNo

Exerciseq

q

qqNo Yes

ClassI

q

Consider

PMBW

ExcludeLFclot,

3+to4+MRClassI

Yes

ClassIIb

q

qqNewonsetAF?

q

No

q

Fig 1. Management strategy for patients with mitral stenosis11


20/61


q

SymptomaticMitralStenosis

NYHAFunctionalClassII

History physical exam,CXR, ECG, 2D echo/Doppler

qq

Moderateorsevere

stenosis MVA 1.5 cm2Mildstenosis

MVA>1.5cm2

PASP>60mmHg

PAWP 25 mm Hg

MVG>15mmHg

qqYes

Exercise

qValvemorphology

favorableforPMBV?

qqNo Yes

q

q

qqNoYes

Class IIb

q

6month

follow-up

q

Yearlyfollow-up

Fig 2. Management strategy for patients with mitral stenosis and mild symptoms11

q

q

Valvemorphology

favorableforPMBV?

q

qqNo Yes

q

No

q

Class I

q

ConsiderPMBV

ExcludeLAclot,

3+to4+MRConsider

commissurotomyor

MVR

ServerePH

PAP>60mmHg

Class IIa

q

q

q

6month

follow-up

CXR=chestX-ray;ECG=electrocardiogram;LA=leftatrial;MR=mitralregurgitation;

MVG=meanmitralvalvepressuregradient;PAP=pulmonaryarterypressure;2D=2dimensional

areleftventricularsystolicdysfunction,leafletredundancy,and

severemitralregurgitation.2

Evaluation and management of the asymptomatic patient :

InevaluatingthepatientwithchronicMR,acarefulhistoryis

invaluable.AnECGandachestx-rayareusefulinestablishing

rhythmandheartsize,respectively.Aninitialechocardiogram,

including Doppler provides a baseline estimation of LV and

left atrial volume, an estimation of LV ejection fraction, and

approximationoftheseverityofregurgitation.

Asymptomatic patients withmild MR and no evidenceof LV

enlargement or dysfunction or pulmonary hypertension can

befolloweduponayearlybasiswithinstructionstoalertthe

physicianifsymptomsdevelopintheinterim.Inpatientswith

moderateMR,clinicalevaluationsshouldbeperformedannually,

andechocardiographyisnotnecessarymorethanonceayear.

AsymptomaticpatientswithsevereMR shouldbefollowedup

with a history, physical examination, and echocardiography

every 6 to 12 months to assess symptoms or transition to

asymptomaticLVdysfunction.

Severalstudieshaveindicatedthatpreoperativeejectionfraction

isan importantpredictor ofpostoperativesurvival inpatients

withchronicMR.Postoperativesurvivalisreducedinpatients

with a preoperative ejection fraction


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20

q

SymptomaticMitralStenosis

NYHAFunctionalClassIII-IV

History, physical exam, CXR, ECG, 2D echo/Doppler

qq

Moderateorsevere

stenosis MVA 1.5 cm2Mildstenosis

MVA>1.5cm2

PASP>60mmHg

PAWP 25 mm Hg

MVG>15mmHg

qqNo

Exercise

q

qqNo Yes Class IIb

q

q

Lookfor

other

etiologies

Fig 3. Management strategy for patients with mitral stenosis and moderate to severe symptoms 11

q

q

Valvemorphology

favorableforPMBV?q

Yes

Class Iq

MitralvalverepairorMVR

ConsiderPMBVq

q

CXR =chestX-ray;ECG=electrocardiogram;echo=echocardiography;

LA=leftatrial;MR =mitralregurgitation;MVG=meanmitralvalvepressuregradient;MVR=mitralvalvereplacement;NYHA=NewYorkHeartAssociation;2D=2-dimensional

q

High-risksurgical

candidate?q

qNo Yes

q

Class I

Class IIa

q

ExcludeLAclot,

3+to4+MR

ofthemitral apparatus, and MVR with removal ofthemitral

apparatus.

Inmostcases,mitralvalverepairistheoperationofchoicewhen

thevalveissuitableforrepairandappropriatesurgicalskilland

expertise areavailable. Thisprocedure preserves thepatients

native valve without a prosthesis, avoiding the risk of long-

termanticoagulation(exceptinpatientsinatrialfibrillation)or

prostheticvalvefailurelateaftersurgery.Inaddition,preservation

ofthemitralapparatusleadstobetterpostoperativeLVfunction

andsurvivalthanincaseswhentheapparatusisremoved.The advantage of MVR with preservation of the chordal

apparatus is that this operation ensures postoperative mitral

valve competence, preserves LV function, and enhances

postoperative survival compared with MVR, in which the

apparatusisdisrupted.

MVR in which the mitral valve apparatus is resected should

almost never be performed. It should be reserved for those

circumstancesinwhichthenativevalveandapparatusareso

distortedbythepreoperativepathology(eg,rheumaticdisease)

thatthemitralapparatuscannotbesaved.

Symptomatic patients with normal LV function:Patientswith

severe MR and symptoms of congestive heart failure despite

normal LV function on echocardiography (ejection fraction

>0.60andend-systolicdimension45mm).

Determiningthesurgicalcandidacyofthesymptomaticpatient

withMRandfar-advancedLVdysfunctionisacommonclinical

dilemma. If mitral valve repair appears likely, surgeryshould

stillbecontemplated,providedejectionfractionis>0.30.Even

thoughsuchapatientislikelytohavepersistentLVdysfunction,


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2

ChronicSevereMitralRegurgitation

Clinical evaluation + Echo

Yes

MVrepairlikely?*

q

Clinicalevalevery6

mosEchoevery6mos

q

Fig 4. Management strategy for patients with chronic severe mitral regurgitation11

q

No

MVrepairMedical Thrarapy

q

AF = atrial fibrillation; Echo = echocardiography; EF = ejection fraction; ESD = end-systolic dimension;HT = hypertension; MV = mitral valve; MVR = mitral valve replacement.

q

Symptoms?q

q

NormalLVfunction

EF>0.60ESD0.30

ESD 55 mm

q q

EF55mm

Class I Class I

MVrepair

ItnotpossibleMVRClass IIa q

Chordialreservationlikely?

No

q Class IIa Yes

q q

q q

q

Yes*q Class IIa q

q

surgery is likely to improve symptoms and prevent further

deteriorationofLVfunction.

Asymptomatic patients with normal LV function: Repair

of a severely regurgitant valve may be contemplated in an

asymptomatic patient with normal LV function to preserve

LVsizeandfunctionandpreventthesequelaeofchronicMR.

Althoughtherearenodatathatrecommendsthisapproachto

all patients, some experienced centers prefer this as there is

evidenceofahighlikelihoodofsuccessfulrepair.Thisapproach

is often recommended in hemodynamically stable patients

withnewlyacquiredsevereMR,asmightoccurwithruptured

chordae.Surgeryisalsorecommendedinasymptomaticpatients

withchronicMRwithrecentonsetofepisodicorchronicatrial

fibrillationinwhomthereisahighlikelihoodofsuccessfulvalverepair.

Aortic Stenosis

Aortic Stenosis (AS) may be caused by rheumatic disease, a

congenital bicuspid valve or degenerative calcification of a

trileafletvalve.

Theaorticvalveareamustbereducedtoonefourthitsnormal

sizebeforesignificantchangesinthecirculationoccur.Because

thenormaladultvalveorificeis3.0to4.0cm2,anarea>0.75

to1.0cm2isusuallynotconsideredassevere.Inlargepatients,

avalveareaof1.0cm2maybeseverelystenotic,whereasavalve

areaof0.7cm2maybeadequateforasmallerpatient.

Somepatients withsevereAS remain asymptomatic, whereas

others with only moderate stenosis develop symptoms.

Therapeutic decisions, particularly those related to corrective

surgery,arebasedlargelyonthepresenceorabsenceofsymptoms.

Thus,theabsolutevalvearea(ortransvalvularpressuregradient)

isnot usually the primary determinantof the need for aortic

valvereplacement.

Natural history

ThenaturalhistoryofASintheadultconsistsofaprolonged

latent period in whichmorbidityand mortality are verylow.

Therateofprogressionofthestenoticlesionhasbeenestimated

in a variety of hemodynamic studies performed largely in

patientswithmoderateAS.CardiaccatheterizationandDoppler

echocardiographicstudiesindicatethatsomepatientsexhibita

decreaseinvalveareaof0.1to0.3cm2peryear;theaveragerate

ofchangeis0.12cm2peryear.Thesystolicpressuregradient

acrossthevalvemayincreasebyasmuchas10to15mmHgper

year.However,morethanhalfofthereportedpatientsshowed

littleornoprogressionovera3-to9-yearperiod.

Grading the Degree of Stenosis

Mild Moderate Severe

AS AS AS

Jet Velocity (m/sec) 4.0

Mean Gradient (mm Hg) 40

Valve area (cm2) >1.5 1.0-1.5


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22

SevereAorticStenosis

Vmaxgreaterthan4m/s

AVAlessthan1.0cm2

Meangradient>40mmHg

Fig 5. Management strategy for patients with servere aortic stenosis11

Less than 0.50

q

AVA =aorticvalvearea;BP=bloodpressure;CABG=coronaryarterybypasssurgery;LV=leftventricular;Vmax=maximalvelocityacrossaorticvalvebyDopplerechocardiography

qSymptoms?

q

Yes

q

Class I

No

qYes

q

q

q

q

Equivocal

q

Class I

q

q

Yes

Class IIb

q

Exercisetest

No

Normal LVejection

fractionq

q

Normalq

Class I

q

q

Severevalvecalcification,

rapidprogression,and/or

expecteddelaysinsurgery

Class IIb

q

q

Clinicalfollow-up,patient

education,riskfactor

modification,annualecho

q

q

Reevaluation

q

Undergoing

CABGorother

heartsurgery?

AorticValveReplacement

Eventually,symptomsofangina,syncope,orheartfailuredevelop

afteralonglatentperiod,andtheoutlookchangesdramatically.

Afteronsetofsymptoms,averagesurvivalis


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2

Indications for Aortic Valve Replacement

Inthevastmajorityofadults,AVRistheonlyeffectivetreatment

forsevereAS.

Symptomatic patients:Patientswithangina,dyspnea,orsyncope

exhibitsymptomaticimprovementand anincrease insurvival

afterAVR.OutcomeissimilarinpatientswithnormalLVfunction

and those with moderate depression of contractile function.

Thedepressedejectionfractioninmanypatientsinthislatter

groupiscausedbyexcessiveafterload(afterloadmismatch),and

LVfunctionimprovesafterAVRinsuchpatients.Therefore,in

theabsenceof seriousco-morbid conditions,AVRisindicated

invirtuallyallsymptomaticpatientswithsevereAS.However,

patientswithsevereLVdysfunction,particularlythosewithlow

gradient AS, represent a difficult management decision. AVR

shouldnotbeperformedinsuchpatientswhentheydonothave

anatomically severestenosis. Inpatients withsevere AS,even

thosewithalowtransvalvularpressuregradient,AVRresultsin

hemodynamicimprovementandbetterfunctionalstatus.

Asymptomatic patients: Managementdecisionsinasymptomatic

patientsare morecontroversial.The combinedrisk ofsurgery

and late complications of prosthesis generally exceed the

possibilityofpreventingsuddendeathandprolongingsurvival

inallasymptomaticpatients.Despitetheseconsiderations,some

differenceofopinionpersistsregardingindicationsforAVRin

asymptomatic patients. It is reasonableto attempt to identify

patientswho may beat especially high risk ofsudden death

without surgery, although data supporting this approach are

limited.Patientsinthissubgroupincludethosewithanabnormal

responsetoexercise(eg,hypotension),LVsystolicdysfunction

ormarked/excessiveLVhypertrophy,orevidenceofsevereAS.

However,itshouldberecognizedthatsuchhigh-riskpatientsarerarelyasymptomatic.

Patients undergoing coronary artery bypass surgery: Patients

withmoderate-severeAS,withorwithoutsymptoms,undergoing

coronaryarterybypasssurgeryshouldundergoAVRatthetime

of revascularization. Similarly, patients with moderate-severe

ASundergoingsurgery onother valves (such asmitral valve

repair) ortheaortic root should also undergoAVR aspartof

thesurgicalprocedure.However,controversypersistsregarding

indicationsforconcomitantAVRatthetimeofcoronaryartery

bypasssurgeryinpatientswithmilderformsofaorticstenosis.

Chronic Aortic Regurgitation

Chronic Aortic Regurgitation (AR) represents a condition of

combinedvolumeoverloadandpressureoverload.Asthedisease

progresses, recruitment of preload reserve and compensatory

hypertrophy permit the ventricleto maintain normal ejection

performance despite the elevated afterload. The majority of

patients remain asymptomatic throughout this compensated

phase,whichmaylastfordecades.

LV systolic dysfunction (defined as an ejection fraction

below normal at rest) is initially a reversible phenomenon

predominantlyrelatedtoafterloadexcess,andfullrecoveryofLV

sizeandfunctionispossiblewithAVR.Withtime,duringwhich

the ventricle develops progressive chamber enlargement anda morespherical geometry, depressed myocardialcontractility

predominatesoverexcessiveloadingasthecauseofprogressive

systolicdysfunction.Thiscanprogresstotheextentthatthefull

benefitof surgicalcorrectionof theregurgitantlesioninterms

ofrecoveryofLVfunctionandimprovedsurvivalcannolonger

beachieved.7

AlargenumberofstudieshaveidentifiedLVsystolicfunction

and end-systolic size as the most important determinants of

survivaland postoperativeLV functionin patientsundergoing

AVRforchronicAR. 8

Natural history

Asymptomatic patients with normal left ventricular function:

The rate of progression to symptoms and/or LV systolic

dysfunctionis4.3percentperyearandanaveragemortalityrate

of25%peryear.10

Symptomatic patients: There areno recent large-scale studies

ofthenaturalhistoryofsymptomaticpatientswithchronicAR,becausetheonsetofanginaorsignificantdyspneaisusuallyan

indicationforvalvereplacement.

Diagnosis and Initial Evaluation of the Asymptomatic Patient

The diagnosis ofchronic severe AR can usually be made on

thebasisofphysicalexamination.Thechestx-rayandECGare

helpfulinevaluatingoverallheartsizeandrhythm,evidenceof

LVhypertrophy,andevidenceofconductiondisorders.

Echocardiography is indicated to confirm the diagnosis of AR;

assessthecauseofARaswellasvalvemorphology;providea

semiquantitativeestimateofseverityofregurgitation;assessLV

dimension, mass, andsystolic function;and assessaorticroot

size.

Indications for Cardiac Catheterization

Cardiaccatheterizationisnotrequiredinpatientswithchronic

AR unless there are questions about the severity of AR,

hemodynamicabnormalities,orLVsystolicdysfunctiondespite

physicalexaminationandnoninvasivetestingorunlessAVRis

contemplatedandthereisaneedtoassesscoronaryanatomy.

Indications for Aortic Valve Replacement

InpatientswithpurechronicAR,AVRshouldbeconsideredonly

ifARissevere.PatientswithonlymildARarenotcandidatesfor

valvereplacement,andiftheyhavesymptomsorLVdysfunction,

othercausesshouldbeconsidered,suchasCAD,hypertension,

Grading the Degree of Stenosis

Mild Moderate Severe

MR MR MR

Regurgitantvolume(ml/beat) 60

Regurgitantfraction(%) 50

Regurgitantorificearea(cm2) 0.10 0.10-0.29 >0.30


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irreversiblemyocardialchanges.AVRshouldbemorestrongly

considered in patients with NYHA functional Class II and

III symptoms, especially if (1) symptoms and evidence of

LV dysfunction are of recent onset, and (2) intensive short-

term therapy with vasodilators, diuretics, and/or intravenous

positiveinotropicagentsresultsinsubstantialimprovementinhemodynamicsor systolicfunction.However,evenin patients

withNYHAfunctionalClassIVsymptomsandejectionfraction

75mmorend-systolic

dimension>55mm),evenifejectionfractionisnormal.Such

patientsappeartorepresentahigh-riskgroupwithanincreasedincidence of sudden death, and thus far the results of valve

replacementhavebeenexcellent.

Womentendtodevelopsymptomsand/orLVdysfunctionwith

lessLVdilatationthanmen;thisappearstoberelatedtobody

size,asthesedifferencesarenotapparentwhenLVdimensions

arecorrectedforbodysurfacearea.Hence,LVdimensionsalone

maybe misleadingin smallpatients ofeithergender, andthe

threshold values of end-diastolic and end-systolic dimension

recommendedforAVRinasymptomaticpatients(75mmand55

mm,respectively)mayneedtobereducedforsuchpatients.

References

1. RoweJC,BlandEF,WhitePD.Thecourseofmitralstenosiswithout

surgery:10-20yearperspective.AnnInterMed1960;52:741-9.

2. Rosen SE, Borer JS, Hochreiter C et al. Natural history of

asymptomatic/ minimally symptomatic patients with severe

mitralregurgitationandnormalRV&LVperformance.AmJCard

1994;74:374-8.3. Enrique-SararoM, TajikAJ etal. Echocardiographic prediction

ofsurvival after surgical correction of organic MR.Circulation

1994;90:830-7.

4. FlemmingMA,OralH,StarlingMR.Echocardiographicmarkers

formitralvalvesurgerytopreserveLVperformanceinMR.Am

HeartJ2000;140:476-82.

5. FaggianoP, AurigemmaGP,et al.Progressionof valvular aortic

stenosisinadults,literaturereviewandclinicalimplications.Am

HeartJ1996;132:408-17.

6. RosenhakR,BinderT,PorentaG,etal.Predictorsofoutcomein

severeasymptomaticaorticstenosis.NEJM2000;343:611-17.

7. Borer JS, Herrold EM, Hochreiter C, et al. Natural history of

LV performance at rest and during exercise after aortic valve

replacementfor aorticregurgitation.Circulation1991;84:III133-

9.8. CohnPF,GorlinR,CohnLH,etal.LVEFasaprognosticguidein

surgicaltreatmentofcoronaryandvalvularheartdiseases.AmJ

Card1974;34:136-41.

9. GreresJ,RahimtoolaSH,etal.Preoperativecriteriapredictiveof

latesurvivalfollowingvalvereplacementforsevereAR.AmHeart

J1981;101:300-8.

10. IshiiK,HirotaY,KitaY,etal.Naturalhistoryandleftventricular

responseinchronicAR.AmJCardiol1996;78:357-61.

11. Bonow RO, Carabello B,DeLeonAC, et al.ACC/AHA practice

guidelines. Guidelines for the management of patients with

valvularheartdisease.Circulation2006;114:84-231


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2

Ganesh K Mani

Chairman

DelhiHeart&

LungInstitute

NewDelhi

A Paradigm Shift in Healthcare Delivery

Ganesh K Mani

Historically, medicine has passed on from

generationtogenerationthroughtheteachings

of physicians whose forte was clinical

experience. These physicians soon achieved

leadership positions in the fraternity and

youngerdoctorslookeduptothemforguidance

and governance. The experienced physicians

who could deliver and reproduce excellent

outcomes enjoyed the exalted status of

PhysicianKings!Duetotheircapacitytodraw

anincreasingnumberofpatientstheybecame

valuable to the institutions they worked in.

Unfortunately, when these Physician Kingsleft or passed away, the institutions suffered

economically. Perhapsthe reasonforthiswas

thatthebestpracticesinitiatedandpropagated

bythemwerenotfollowed.Sadly,theprotocols

ofstandardsofcareremainedinthehandsof

thesePhysicianKings!

Over the years it was realized that these

best practices could be attributed not to the

physiciansthemselvesbuttoprocessesthatthey

meticulously followed to achieve an optimal

standard of care. The institutions realizing

this secret started highlighting the processes

andunderstoodthatifreplicatedcompetently,

other physicians toocould achieve excellenceinpractice.Thusevolvedtheparadigmshiftin

healthcarefromonethatwasphysiciancentered

to a process based one. Some Physicians

challengedthistransformationandotherswere

reluctanttochange,whilestillothersclungto

theego-baggageheyhadinheritedfromtheir

past.

Interestingly, when Indian Physicians went

overseas,theyseamlesslyadoptedpeerreviewed

protocolswhichensuredBestPractices!Indian

Healthcare institutions continued to meander

in troubledwaters of importedprotocolbases

processesunassistedbytheircompatriots.

Best Practices - Redefined

A Best Practice is nowdefined as a service

function or process that has been fine-tuned,

improved andimplemented to produce world

classcustomer(patient)careleadingtoimproved

customer loyalty (Recall).

Institutional best practices are those that can

bereproducedanynumberoftimesunaffected

bythepresenceorabsenceoftheoriginalCare

provider.

Thus, when the mantle of best practices

in healthcare delivery was gradually being

transferredfromPhysiciantoProcess,itbecame

imperative that these processes were peer-

reviewedandaccreditedtomakethemfunction

onauto-pilot.

Physicians bring in best practices, then why

process?

As clinical volume increases, quality of care

may be threatened if the same is dependent

onlyonthePhysiciansindividualskills.

Toillustrate,taketheexampleofadoctorwho

needstoperformeightmajorsurgicaloperations

inaday.Itisnotdifficulttounderstandthatthe

standardofcareintheeighthoperationofthe

daywouldbefarinferiortothefirstoperation.

Thisiswhereprocessstepsin!Protocolbased

management by trained personnel would

assurethesamestandardevenasthenumbersincrease.

Structure and function

There have been three components of a

successfulprocess:

a)Infrastructure

b)Personnel

c)Economics(withoutcompromisingsafety).

Allthreecomponentsneedtobeupdatedand

validated from time totime bysystemic peer

reviews.

Developing a Culture not merely Strategy

Itwouldbenaveforinstitutionstositbackafter

setting up processes and recruiting talentedPhysicians,thinkingthateverythingelsewould

beautomaticinhealthcaredelivery.Thelink

betweenthephysicianandprocessindelivering

thecareenvisagedisbythethirdP=Passion.

Itispassionthatmakespeopleimplementthe

process better resulting in improved clinical

and economic outcomes. Passion is not a

commoditythatcanbeoutsourced.Itisindeed

a wayof lifethat leaders caninstill,nurture

anddevelopamongthepersonnel.

Passion amongst personnel is discovered by

closely watching people, identifying their

aptitudes and attitudes and by providing

incentsintheformofappreciation,rewardsandpromotions.

Below

Average

Excellent

Good

Average

1234567

No.ofpatients

PROCESSDRIVEN

IndividualApproach

Q

u

a

l

i

t

y

c

a

r

e


29/61


28

Therightmixwouldbeto:

a) Increaseaccountability

b) Developpatientcentriccosteffectiveaccreditedprocesses

c) Reinstate Ethics, Accountability and Transparency using

InformationTechnology

sothatthepracticeofMedicineisrestoredtoitsoriginalstatus

ofbeingaNobleProfessionandnotanindifferentcostcentric

industry.

Information Technology (IT)

IT helps increase standardization of Infrastructure, physician

and process link, document data and thereby to bridge the

knowledge-performancegap.

It also assists in reducing systems errors, facilitates cost

containmentandmonitorsqualityofcare. Electronicmedical

recordsaremoredependableandinformationcanbetransferred

andsharedwithoutanylimitationofdistance.

An attempt in this direction is presently being envisaged at

Pushpanjali Crosslay Hospital bringing this combination of

talented Physicians, Peer reviewed and validated protocols

overseen by Information Technology intothe livesof people!

This is indeed the paradigm shift that PCH visualizes as a

benchmarkforthefuture.

Objectives of Best Practices

Witisproperandcommendablewhenitenlightenstheintellectbygoodsense,conveyed

injocularexpression;whenitinfringesneitheronreligion,charity,andjustice,noron

peace;whenitmaintainsgoodhumor,sweetensconversation,andmakestheendear-

mentsofsocietymorecaptivating;whenitexposeswhatisvileandbasetocontempt;

whenitreclaimsthevicious,andlaughsthemintovirtue;whenitanswerswhatisbelow

refutation;whenitrepliestoobloquy;whenitcounterbalancesthefashionoferrorand

vice,playingoffthei

Documents

Medifocus January 2008