medifocus january 2008
TRANSCRIPT
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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
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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
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Vol. 6, Issue 2 January - March 2008
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
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Vol. 6, Issue 2 January - March 2008
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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Vol. 6, Issue 2 January - March 2008
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
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Vol. 6, Issue 2 January - March 2008
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)
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Vol. 6, Issue 2 January - March 2008
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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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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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.
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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
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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
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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
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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.
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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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Vol. 6, Issue 2 January - March 2008
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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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
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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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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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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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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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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
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PROCESSDRIVEN
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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