India's National Magazine
From the publishers of THE HINDU

Vol. 16 :: No. 06 :: Mar. 13 - 26, 1999

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MEDICINE

Surgical achievements

The Madras Medical Mission in Chennai puts to use two unique surgical techniques, one to reduce enlarged atria and replace the valves and the other to correct a congenital heart defect.

ASHA KRISHNAKUMAR

IN what is stated to be a unique surgical procedure, two women received a fresh lease of life at the Chennai-based Madras Medical Mission in February. The operation, called auto transplantation of the heart, which involves triple valve replacement and reduction of the enlarged atria (upper chambers of the heart), was performed by MMM's Medical Director K.M. Cherian on two women - a 27-year-old Tanzanian and a 42-year-old Sri Lankan. Progressive rheumatic heart disease, a condition that causes atrial fibrillation or trembling leading to changes in the heart beat rhythm, had affected their heart valves. To rectify the condition, the valves had to be replaced and the size of the atria reduced.

The procedure involves removing the heart from the chest cavity, placing it in a receptacle of ice, reducing the enlarged atria, replacing the faulty valves with mechanical ones and restoring the heart to the cavity. It is known as "bench surgery" as the heart is kept on a table when various operations are performed on it. Technically, the procedure is akin to heart transplantation. During the four-hour operation, the brain and other organs are on a heart-lung machine.

Auto transplantation has been performed twice before - by Dr. Denton Cooley in 1985 and Dr. Randas J. Batista in 1990. While Dr. Cooley used the technique to remove a tumour in the spinal chord which intruded into one of the heart chambers, Dr.Batista performed auto transplantation and mitral valve replacement on a patient with a giant atrium. Dr. Cherian has used the method for the first time to correct the size of the enlarged upper chambers and to replace all three valves.

In the case of the Sri Lankan, the enlarged upper chambers were reduced in size and the aortic, mitral and tricuspid valves replaced. In the case of the Tanzanian, the left atrium was reduced, the aortic and mitral valves were replaced and the tricuspid valve repaired. Both women are well and have returned to their respective countries.

Dr. Cherian said that in both cases heart transplantation would have been the ideal method, and simpler too, but difficulties involved in getting a donor heart made him opt for auto transplantation. The cost of the procedure (apart from a fee of Rs.50,000 for replacing each valve) is the same as that of an open heart surgery.

BY SPECIAL ARRANGEMENT
Auto transplantation involves removing the heart from the chest cavity, placing it in a receptacle of ice, reducing the enlarged atria, replacing the faulty valves and restoring the heart to the cavity.

IN another landmark event at the MMM, a congenital heart defect was corrected recently. Two sisters from Bangladesh, Murshad, 5, and Razia, 9, who suffered from Long QT Syndrome (LQTS), became the youngest in Asia to undergo this operation. Dr. Maully Shah and Dr. N. Shivaprakash performed the Automatic Implantable Cardiac Defibrillator (AICD) operation under the guidance of Dr. Cherian.

The Long QT Syndrome is an abnormality of the heart's electrical system, caused by defects in the muscle cell structures called ion channels. LQTS is indicated by a faster heart rhythm (arrhythmia), which leads to a precipitous fall in the flow of blood to the brain resulting in sudden loss of consciousness (syncope) and sometimes even death. QT is the interval between a contraction and an expansion of the heart.

The syndrome, mostly inherited but also acquired, typically manifests itself during the pre-teens. In some cases it is associated with congenital deafness and is said to be a common cause for sudden deaths of children and young adults. In the United States, LQTS is estimated to cause the death of between 3,000 and 4,000 children every year. Although the syndrome was discovered 40 years ago, research on it began only in the last five years.

The primary treatment for LQTS is the use of beta-blockers. In patients who do not respond to this, a pacemaker or an automatic defibrillator is inserted or cervico-thoracic symathectomy (a surgical procedure to cut a certain nerve in the neck region) is resorted to.

Murshad and Razia, children of middle class parents who have already lost two children to LQTS, were congenitally deaf and suffered from arrhythmic heart rates, fainting spells and seizures. During each such spell, cardiac pulmonary resuscitation had to be performed on them. The AICD procedure was adopted as they did not respond to beta-blockers.

The AICD implant monitors the heart beat rate. The onset of an arrhythmic attack automatically produces the electric shock required (as during cardiac arrests) to normalise the heart rhythm. The AICD device runs on a battery that lasts five to 10 years, depending on the number of arrhythmic attacks. If the battery is used up, another implantation has to be done. According to Dr. Cherian, with progress in genetic research on chromosomal abnormalities there is hope for a sure cure for the syndrome in the next 10 years.

Each AICD device costs Rs.8 lakhs to Rs.10 lakhs. As the family of Murshad and Razia could not afford it, the leading producer of this device, Medtronix, provided one free of cost and the MMM paid for the other.