For valve expert, Dr Srinivas Prasad, it was a formidable challenge.
The case that had been turned away not only by India’s best, but by some of the world’s finest doctors — labeling it a “red flag” best left to destiny — came before him and his team at Fortis Hospital in Bannerghatta, Bengaluru.
Dr Srinivas’s effort not only paid off in saving the woman’s life, but became India’s first reported case of a twisted aorta and a failed valve replacement being successfully treated with Hybrid TAVR (Transcatheter Aortic Valve Replacement).
“I had no hope left in life. All hospitals I went to rejected my case. But Dr Srinivas Prasad and Dr Vivek Jawali of Fortis Hospital decided to risk it for me. They put in a lot of effort into my surgery. I am very grateful to them,” a teary eyed 64-year-old Hamsaveni told South First when she spoke to the media for the first time, three months after her surgery.
What is this case about?
Hamsaveni, a native of Devanahalli, had a congenital heart ailment. Ten years before her condition deteriorated, she consulted a doctor at a private hospital in Bengaluru for severe breathlessness, who said that she had to undergo aortic valve replacement and coronory artery bypass graft.
“We spent almost ₹10 lakh for the surgery then. With great difficulty, my son managed to arrange for the money. But this valve worked only for 10 years,” Hamsaveni explained to South First.
Few months ago, she began to experience giddiness, chest discomfort, and breathlessness, prompting her to seek medical attention at her previous hospital.
There she was diagnosed with single-vessel coronary artery disease. It was revealed that the prosthetic valve that was implanted during her previous surgery had failed, resulting in severe re-narrowing of the blood vessel.
Her condition was so complex that the hospital refused to treat her. In fact, they said that it would cost up to ₹50 lakh but added that they wouldn’t be able to give her any guarantee.
While her condition was deteriorating, the family chose to take her to another hospital on Bannerghatta Road where the doctor admitted her for about 10 days, but then looking at her condition and previous surgery status, recommended that she visit a multidisciplinary centre.
As a last option, the family approached Dr Vivek Jawali, Chairman of Cardiothoracic and Vascular Sciences at Fortis Hospital. There, Hamsaveni was put under Dr Srinivas Prasad’s care.
A twisted aorta and failed valve
Dr Prasad explained the case in layman’s terms: “The aorta is the largest artery in the human body and is a vital part of the circulatory system. It originates from the left ventricle of the heart and carries oxygenated blood to the rest of the body. It’s often described as the main highway through which blood travels from the heart to reach all parts of the body.”
So let’s imagine that the aorta, the main blood vessel that carries oxygen-rich blood from your heart to the rest of your body, is like a highway. Sometimes, this highway can get twisted or turned in an abnormal way. Just like a twisted road can cause traffic issues, a twisted aorta can disrupt smooth blood flow. This twisting can lead to reduced blood flow and strain on the heart.
Meanwhile, the valves in one’s heart work like doors, ensuring blood flows in the right direction. If a valve fails, it means that the door isn’t closing or opening properly. If the door doesn’t shut tightly, it can cause blood to leak backward, thus disrupting the proper flow. This can make the heart work harder to pump the blood.
“In Hamsaveni’s case, due to her genetic condition, she had problems with her left valve. The surgery she had 10 years ago was aimed at solving the problem of her weak value. However, the doctors in the previous hospital she went to must have realised during surgery that her aorta is twisted and that it would be difficult to place the valve. Somehow a valve was placed and by God’s grace, she survived for 10 years. But her condition started to deteriorate recently, before she came to Fortis,” explained the doctor.
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Challenges doctors at Fortis faced
When you have both a twisted aorta and a failed valve, it’s like dealing with two significant traffic problems on the heart’s highway simultaneously. The heart has to work even harder to overcome these obstacles and maintain proper blood flow.
The heart, which is essentially a powerful pump, can struggle to meet the body’s needs for oxygen and nutrients and, hence, will lead to symptoms like severe fatigue, shortness of breath, chest pain, and other complications that require careful medical attention and management.
Dr Prasad said that Hamsaveni came to Fortis with severe heart failure and even multi-organ dysfunction. The doctors found that there was re-narrowing of her previous prosthetic aortic valve. Patient history and records showed that, in 2013, she underwent an aortic valve replacement for her congenital aortic valve abnormality.
“The first complication was that the valve itself was not a native one, it was a surgically placed prosthetic valve that had degenerated and abnormally tilted to the extent that tracking a new valve would be highly challenging. Also, her aorta was abnormally thickened and calcified (hardened by the deposits of calcium). It was abnormally twisted and tortuous. We realised that if we operated on this case, it poses a high risk of blocking the coronary blood vessel, leading to a heart attack on the operating table,” Dr Prasad explained.
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Case shared with multiple experts
With this kind of situation, the only option the doctors were left with was to first check with other experts in the country who perform such surgeries. CDs with images and videos of her heart were sent to several experts in India.
They had all suggested that the doctors not operate on her. Unconvinced, the doctor decided to share the CDs with experts in the US who were good valve experts do such surgeries.
Unfortunately, even those experts asked the doctors not to go ahead with surgery. One of the experts commented, “Unfortunately, this case has some substantial issues — the LCA and RCA are high risk for occlusion, the valve is canted to the point where crossing with the delivery system could be extremely challenging, and difficult (possibly suboptimal) deployment).”
“While these are all technical terms, his last line stated, ‘Would be a red signal case and would not attempt it.’ We were now in a catch-22 situation. Her son and daughter were in tears and we, as doctors, felt rather helpless. But we definitely wanted to take up this challenge,” said Dr Prasad.
The surgery that saved her life
Doctors, after several discussions of this complex case, decided to do a special and risky procedure called a hybrid TAVR (Transcatheter Aortic Valve Replacement). This meant that they wanted to replace the problematic valve in the heart using a method that’s less invasive than traditional surgery.
To do this, they planned to first fix the blocked artery near the heart using a minimally invasive technique called MIDCAB (minimally invasive direct coronary artery bypass). Then, they would proceed with the valve replacement procedure (TAVR) to fix the aortic valve. It’s like fixing two things in one go to help the heart work better.
However, while inducing anaesthesia, the patient experienced cardiac arrest and multi-organ failure, which led to a change in plans. Fortuitously, Dr Srinivas Prasad and his team, who had studied the case so well, not only had a Plan B and Plan C, but multiple plans in place to handle any kind of complication that could occur.
The doctors decided to immediately shift her to the Cath Lab for an emergency TAVR, where the catheter was passed through a blood vessel in the groin and guided to the aortic valve through the twisted aorta and tilted valve using innovative techniques. The new valve was then deployed to restore proper blood flow. As soon as this was done, her condition slowly began to stabilise.
However, her kidneys, liver, and other organs had to recuperate and so she was shifted to the Cardiac Care Unit and placed on a ventilator, where she was managed for the next five days. Ten days after her surgery, her condition, doctors said, began to stabilise.
Three weeks after surgery, Dr Srinivas received a video from the family. “It was a joy to see a video sent by her son where Hamsaveni was walking normally in her apartment complex,” he said.
Remembering the times she suffered, a visibly emotional Hamsaveni told South First, “He was not just a doctor but God to our family. I couldn’t breathe and felt so fatigued, I couldn’t walk too. This led to me put on so much weight. My face was swollen. My BP troubled me a lot. But now, I am doing very well. I have been asked to maintain a healthy lifestyle and have been given some medications. It’s been three months since the surgery and you can see the change in me.”
To be published in a medical journal
Dr Prasad said that in India, there are few such cases and fewer still are taken up for surgery, while most others are sent back after considering the complications that can arise.
“Like Hamsaveni, several people across the country and even abroad may be sent back due to high risks. Now, our surgical methods have shown that even such complicated case can be operated upon and salvaged. Very soon, this case will be published in a medical journal to ensure that other experts can also use this methodology for such cases,” said Dr Prasad.
A whole team of doctors, including cardiologists, physicians, a liver expert, a nephrologist, and anaesthesiologists, have worked on this case.
Dr Vivek Jawali said, “This case was exceptionally rare and challenging, requiring a tailored interventional and surgical approach. We knew that this was a case we couldn’t afford to give up on. It not only highlights the advanced capabilities of Fortis Hospital, but also underscores the unmatched expertise and unyielding dedication of our clinical team.”
Meanwhile Akshay Oleti, Vice President and Business Head of Fortis Bengaluru, said that this groundbreaking achievement sets a new standard in the field of cardiac surgery, offering hope to patients facing even the most complex and challenging conditions.