Experience is the key

RAMAKANTA PANDA, who successfully carried out the complex redo bypass on Prime Minister Manmohan Singh, is the chief cardiovascular-thoracic surgeon and vice-chairman at the Asian Heart Institute (AHI), Mumbai, which he founded in 2002. The AHI is today the highest internationally accredited hospital in the country.

Panda has performed 700 redo bypass operations apart from more than 1,500 high-risk procedures, many of them in cases that were considered inoperable.

Excerpts from an interview he gave Frontline in New Delhi, soon after the surgery on the Prime Minister:

Why is redo coronary bypass considered difficult? Why is it not commonly done by heart surgeons?

Redo bypass is very complicated. The reason is, during the first surgery, when you open a persons heart for the first time, there are various anatomical layers inside the body to be bypassed. There is the [chest] bone and behind the bone there is a membrane that protects the heart, the pericardium. And then the heart is not sticking to anything and everything is visible. You cut it and you reach the heart in ten minutes time. In a routine case, if there is an emergency, you can reach the heart in even five minutes. Also, on the surface of the heart you can see all the arteries. So identifying the ones that you want to bypass is very easy.

But once you do any surgery, the heart sticks to everything around it. It sticks to the pericardium. It also sticks to the chest underneath. Because once you open it and do a bypass, by and large, you will not be able to completely close the pericardium around the heart. And many times you dont do that because sometimes it can constrict the heart and produce some other symptom. That is the reason why you dont completely cover it back with the pericardium; you do it only partially. This means the heart is right under the breastbone and is sticking. So the first risk when you open is that there is a chance you might cut the heart, whereas in a first-time operation there is enough tissue and there is also a gap. So the risk in this is extremely small, perhaps one in a million unless it is done by a brand new surgeon. If you cut it, it is instantaneous death. Secondly, since the heart is sticking to everything around, it takes very long to dissect the heart out anywhere from half an hour to two hours or even more. During that time too, you can injure the heart. Thirdly, because on the surface there are no landmarks left now, identifying the arteries is difficult. So you have to do quite a bit based on experience. There are also the older grafts that are sticking out. Many a times, loose cholesterol deposition is found in the earlier grafts. This can break from inside and go inside the heart and can cause damage to the heart, including an attack. Normally patients who have a second bypass usually have smaller arteries. So technically redo is more demanding.

What are the risks in such a procedure?

According to the data from our hospital, in regular surgery we have an overall 0.3 per cent mortality. For redo, for the last two years, we have not lost any patient; of course, redo we do roughly on 10 per cent of the cases, which is around 60-70 patients a year. And that is a big number. Not many surgeons do that. Part of the reason for our success rate is that luckily I was trained at a place that is considered the birth place of redo Cleveland Clinic [Ohio, United States] is the best place in the world for doing redo bypasses. I was there for a very long time. So I was fortunate to be trained with the best people. So I could pick up all the finer aspects. Then I improvised and developed on that.

So why is it that an institution as big as the All Indian Institute of Medical Sciences (AIIMS), which must have done thousands of bypass surgeries, not doing enough redos?

If you cant do redo properly, lot of patients die. The mortality rate is very high. But generally if you ask me, in India there are only a few surgeons, four or five, who do redo [coronary] bypass properly on a regular basis and have decent results. Almost any surgeon can do a redo [on heart] valve. It is not a big deal. There you are not looking at the surface of the heart; you are only cutting open the heart and going inside. Almost any surgeon who has done a hundred or so cases can do a redo valve. Redo bypass is technically very demanding both on the surgeons heart and on the body. People usually want to take the easy route.

Isnt cutting open the heart to access the valve more difficult and risky?

Here the blood supply is normal. Even if you cut the valve and take it out, the heart is protected. The heart is normal. So nothing happens. In coronary bypass, on the other hand, we deal with loss of blood supply to the heart. You make the slightest mistake, you damage the heart.

Is it because of the support equipment, supportive infrastructure and so on that many centres, including AIIMS, do not attempt beating heart (off-pump) surgery on a regular basis but prefer the convention

More than that, it is building up a team. The first thing is experience, second is how much challenge the team wants to take on and third it is building up a team. I shall tell you another thing. On a beating heart you require an excellent anaesthetist. In a conventional bypass, even if you dont have a very good anaesthetist, it is okay. Because on a heart-lung machine you are in a very controlled situation and the chances of error or something unusual happening are very low. On a beating heart, it is a far more uncontrolled situation and you have to be constantly on the look-out whether the heart is functioning normally.

In beating heart, when you stabilise the part that will be operated upon with the octopus device and if it is directly visible to you it should be easier, I guess. How do you reach and ope

That is difficult. You put some stitches to the pericardium and lift up the heart physically. This holds up the heart. You then operate.

Under what circumstances do you have to switch over to the conventional mode?

If the patient is not stable.What kind of instability?

The blood pressure goes down; the heart starts contracting less etc. Last year we had that instance only once. And that too not in an emergency like when you are doing bypass and suddenly the patient is not doing well and you have to switch over or something like that.

Does it happen often?

Out of the 1,250 cases last year we had to go for a heart-lung machine only thrice. That also not in any emergency. We electively plan out.

It is generally said that in beating heart, anastomosis [the surgical connection between blood vessels] is usually inefficient. Is that true?

It is all related to experience; if you have good experience, you dont have problems. If you dont have experience, then you end up not doing it properly and the anastomosis can be inefficient.

Because it is moving?Yes.

So how many years of experience gives you that kind of confidence to do that?

Not only the number of years, but also the number of surgical procedures that you do. And the third thing is the personal acumen with which you pick up those things. Honestly, I was one of the last surgeons to switch over to beating heart surgery. I switched over in 2001. Already people [in India] were doing beating heart for a couple of years before I started. I wanted to be sure that the results would be good before I switched over to that. But once I switched over, within six months I was doing all the cases. It was because of previous experience. I was already doing a huge number of [cardiac] cases and had good experience. It is almost eight years now since I have been doing beating heart. And we now have one of the largest numbers in the world. In beating heart, we rank among the top four or five in the world. I dont think there are many centres in the world that are doing more than us.

What is the basis of deciding whether a redo bypass would be a conventional on-pump one or on a beating heart one? What are the pros and cons of an off-pump redo?

In a conventional redo, the advantage is for the surgeon, not for the patient. You are doing it when the heart is completely arrested. So technically it is much easier for the surgeon. The disadvantages are, one, there is a higher chance of bleeding, and two, there usually is some deterioration of intellectual and cognitive functions. What happens is when you do using a heart-lung machine, a lot of small cholesterol deposits and clots, microclots, go to the brain. There is clear evidence that after on-pump surgery, the patients cognitive functions the higher intellectual functions, memory, etc. take a little beating. Off-pump surgery, on the other hand, is technically far more demanding. That is why it is bad for the surgeons heart and back but good for the patient.

Because of the heart-lung machine, the patients recovery is slow; whereas the overall sense of well-being, the way they recover, etc. are all much faster in patients after a beating heart surgery. They also feel less tired and the feeling of being sick is less. They recover in about two or three days. The other advantage is that bleeding will be less, which means less blood loss and fewer transfusion-related complications. The third thing is that cognitive functions are better protected. When the Prime Ministers health is involved, you better protect all his higher intellectual functions. And the stroke rate is also lower.