BANGALORE: Endoscopic surgery for the heart has been common practice at Apollo, Bangalore for the last three years now. In the middle of this year, Mrs B, a 44 year old lady of English ancestry having lived in Africa, called on us. Her problems were indeed unique and she had the following history to give.
She was born to white settlers in Africa. As a young girl she was diagnosed with Rheumatic Heart Disease (RHD). For several years, as she grew into her teens, she remained asymptomatic as is the natural history of RHD. In 1989, in her twenties, she was diagnosed with tight mitral stenosis requiring some form of intervention. She was sent to England for surgical management and the surgeons at a well known hospital in London took one look at her and decided she needed a valve replacement. However her associated medical condition made the whole procedure highly risky.
In this condition the cells are shaped like a crescent or sickle. They don't last as long as normal, round red blood cells, which leads to anemia. The sickle cells also get stuck in blood vessels, blocking blood flow. This can cause pain and organ damage.
She had inherited sickle cell disease, a condition quite prevalent in Africa and had multiple transfusions to treat her anemia. Implanting a mechanical valve requiring long term anticoagulation in this setting could have had serious implications in her. The surgeons in London did exactly what was appropriate. They went in, inspected the valve and decided that an open mitral valvotomy was feasible and did exactly that. This procedure lasted her a good twenty years and here she was with us with a tight mitral stenosis and no chance of saving her native valve anymore.
The challenges that stood in front of us were many. The heart was in a good shape and replacing the mitral valve appeared to be simple. However this was a redo operation, since the first operation had been done through a midline Sternotomy, dense adhesions are the rule. Going in through the same route meant dissecting the heart out; in someone with sickle cell disease this could mean uncontrollable hemolysis and death. There was one more problem far bigger, that was diagnosed while here. She was cold antibody positive. This meant that her blood would clot if her body temperature fell below a certain point. Cold agglutinins are usually immunoglobulin (Ig) M antibodies (less commonly, IgA or IgG) that may result in hemolytic anemia due to complement-mediated RBC destruction in the reticuloendothelial system. These antibodies induce hemagglutination mainly at lower temperatures but not at 37°C and were therefore termed cold agglutinins.
The cardiac team at Apollo decided that the best option for her was totally endoscopic mitral valve replacement. This meant, no need to dissect out the heart, least exposure, quicker recovery with less stress and no need for blood transfusion. Thrown into the bag was a redo operation with practically no scar.
Close monitoring during the operation to maintain normal blood gases, acid base balance, body temperature and hemoglobin levels were critical to outcome. As expected the operation went without a hitch and was performed using a single video camera and specialised single shafted instruments. A day later the patient was in the ward and four days later was ready to fly. Endoscopic surgery is like a miracle. It’s often hard to identify if surgery has indeed been performed.
Patients are so fit and fine a week later in the outpatient, they are often mistaken for hospital visitors.
In conclusion, new technology is available to surgeons, and therefore to patients, that can significantly reduce the pain and recovery time for selected patients undergoing heart surgery. There are new approaches to old surgery, and there are completely new operations, that have the potential to improve the outcomes of thousands of patients every year.
How is it performed?
The port access surgery technique allows surgeons to use one to four small (5- 10 mm) incisions or "ports" in the chest wall between the ribs. An endoscope or thoracoscope (thin video instrument that has a small camera at the tip) and surgical instruments are placed through the incisions. The scope transmits a picture of the internal organs on a video monitor so the surgeon can get a closer view of the surgical area while performing the procedure.
In keyhole mitral valve surgery, the sternum remains intact. A Small incision is made on the side of the chest and the entire operation is performed through ports or 'keyholes' using highly specialised equipment.