A remarkable turnaround

A team of world-class physicians make an incredible recovery possible for Union Minister Murasoli Maran who battled with a rare type of heart ailment for over a month at Apollo Hospitals, Chennai.

UNION Commerce and Industry Minister Murasoli Maran was discharged from the Apollo Hospitals, Chennai, on November 30 after successful treatment for a rare type of cardiac condition, "hypertrophic obstructive cardiomyopathy". Said a cheerful Maran while leaving the hospital after a 34-day-stay: "I have got my life back. I am really proud of this world-class institution." Timely intervention by a team of world-class medical specialists and physicians, quick and well-informed decisions made by family memb ers and, above all, Maran's will to fight made this remarkable recovery possible.

Maran, admitted to the hospital on October 28 with acute migraine and breathlessness, benefited from the timely emergency injection given at home by his daughter, a doctor, as soon as his distress was noted. In hospital, the Minister was given intensive treatment and administered de-hydro crojotemin injection for the "acute episode of migraine." He continued to suffer breathlessness and his condition worsened as the "hypertrophic obstructive cardiomyopathy", from wh-ich he has been suffering since 1989 without major complications, showed up suddenly and led to "diastolic left ventricular dysfunction", a genetic problem that impairs the pumping function of the heart. This problem manifested itself as an increase in the muscle mass (it was three times th at in a normal heart) of the left chamber of the heart, obstructing blood flow. This reduced pumping capacity and led to a mitral valve leak.

The panel of doctors attending on Maran decided to alter the line of medical management to improve the basic cardiac condition and suggested a special type of pacing - "sequential pacing". This was done on November 6, and Maran responded well to the temp orary pacemaker.

Though he appeared to recover immediately, his condition worsened the next day as he developed severe pulmonary oedema (collection of fluid in the lungs). With the lungs burdened with almost 20 litres of fluid, he was unable to breathe. His vital paramet ers went beyond control and the kidneys were on the verge of a shut-down. He was then put on a ventilator.

Two specialists from New Delhi - from the All India Institute of Medical Sciences (AIIMS), and the Indraprastha Apollo Hospitals - joined the medical team. Four more specialists from Apollo Hospitals, Hyderabad, arrived later that day. There were two opt ions. Open-heart surgery or the revolutionary "alcohol ablation of the septum of the left chamber of the heart", a procedure to shrink the increased muscle mass. Senior consultant cardiologist Dr. P. Ramachandran, who had done seven septal ablation proce dures, suggested the "alcohol ablation", an accepted modern management method for "chronic obstructive cardiomyopathy".

Describing the situation as of November 7, Apollo Hospitals chairman Dr. Prathap C. Reddy said that the massive pulmonary oedema led to a critical drop in all vital parameters, including "a renal shutdown". With such a lung condition Maran was in no stat e to undergo surgery. The panel of doctors decided on ablation and his family's consent was taken. According to Dr. Ramachandran, who performed the ablation procedure using a catheter, it was a "last, desperate measure". There were immediate results in t he form of "increase in oxygen saturation and urine output".

The ablation procedure was done at 1 a.m. on November 8 by introducing a balloon into the septal artery (which had expanded from the normal 10 mm to 27 mm), and 1.5 ml of absolute alcohol was injected in the affected area to produce a "controlled infarct ion of the intra-ventricular septum", to kill the extra muscle mass and shrink it. This led to a "dramatic improvement", and according to Dr. Prathap C. Reddy, there was a "turn in Maran's condition". Blood pressure returned to normal and oxygen saturati on rose from 70 to 98 per cent. More important, the patient's renal functioning was activated. However, Maran remained on the ventilator and pulmonary oedema persisted.

Pioneers in the field of interventional cardiology from the United States and the United Kingdom flew into Chennai to review the line of treatment. Dr. Ulrich Sigwart, an interventional cardiologist from the Royal Brompton Hospital, London, who invented the ablation procedure, arrived on November 9. Appreciating the line of treatment, he felt that the ablation procedure, performed perhaps in the best possible manner, had a significant beneficial effect on Maran's condition.

Dr. Horst Kuhn of Stadtlschen Kliniken, Germany, another interventional cardiologist, was the next international expert to arrive. Responding to the persisting lung congestion on account of diastolic dysfunction, he suggested another ablation procedure, and injected 2.75 ml of absolute alcohol in small doses into the septal arteries on November 11. Noting that there was a marked improvement in blood flow from the heart and in the lung condition, Dr. Horst Kuhn said that administering septal ablation on a critically ill patient was a rarity, and of the total ablation procedures done globally, only 3 per cent was done on the critically ill. He also said that the success rate of the procedure was 90 per cent.

Soon the obstruction in the left ventricle totally cleared, and the mitral valve leak stopped. Doctors implanted a dual-chamber permanent pacemaker in Maran.

The panel of doctors included cardiologists Drs. P. Ramachandran, I. Sathyamurthy, K. Subramanyam and Mathew Samuel Kalarickal, anaesthetist I.S. Naidu, and cardio thoracic surgeon M.R. Girinath of Apollo Hospitals; visiting cardiologists Drs. K.K. Talwa r of the AIIMS, Jaishankar of the Nizam Institute of Medical Sciences (NIMS), Hyderabad, and Sreenivasa Rao and Narasimhan of CARE Hospital, Hyderabad; and Maran's personal cardiologist Dr. S. Thanickachalam, Dean of Faculties, Sri Ramachandra Medical Co llege, Chennai, and his personal physician Dr. Gopal. Using the hospital's telemedicine facility, the doctors and hospital authorities remained in touch with experts around the world.

Even while Maran was on and off the ventilator till November 28, he showed steady progress. He came out of the Intensive Care unit on November 25 and was taken off all life-supporting systems on November 28, before being discharged on November 30. The do ctors have advised a certain line of treatment and two weeks' rest for the 66-year-old Minister before he resumes work.

According to Dr. Prathap C. Reddy, Maran needs no further medical or surgical intervention as he has received "total treatment". He needs to be under observation for some time. "Septal ablation had offset the need for an open heart surgery to loosen his heart muscles," he said.

According to Dr. Thanickachalam, Maran has had obstructive cardiomyopathy since 1989 and has been getting himself examined whenever he went abroad. Experts in the U.S. and the U.K. had suggested the ablation procedure for him in case of an emergency.