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Coronary Artery Bypass Surgery
Coronary Artery Bypass Surgery
Valvular Heart Surgery
Valvular Heart Surgery
Valve Surgery
Valve Surgery
Aortic Aneurysm Surgery
Aortic Aneurysm Surgery
Heart Failure Surgery
Heart Failure Surgery
Ventricular Remodeling Surgery
Ventricular Remodeling Surgery
Heart Transplant
Heart Transplant
Arrhythmia Surgery
Arrhythmia Surgery
Paediatric Cardiac Surgery
Paediatric Cardiac Surgery
Thoracic Surgery
Thoracic Surgery
Vascular Surgery
Vascular Surgery
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| Coronary Artery Bypass Surgery |
| A Coronary Artery Bypass Graft (CABG) operation is performed to re-route (bypass) blood around clogged arteries and improve the supply of blood and oxygen to the heart. These arteries are often clogged by the build-up of fat, cholesterol and other substances over a period of time. |
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| The narrowing of the coronary arteries slows or stops the flow of blood through the heart's blood vessels and can lead to a heart attack. |
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How is coronary artery bypass performed?
During bypass surgery a long length of an artery may be detached from the chest wall (internal mammary artery) or one of the arms (radial artery) and/or a leg vein (saphenous vein) may be removed. One end is sewn onto the large artery arising from the heart (aorta) while its other end is attached (grafted) to the coronary artery below the blocked area. Using the newly attached conduit, blood can once again flow freely to the heart muscle beyond the blockage.
We use a specialised technique for removing the vein from the leg by making small horizontal incisions along the length of the vein instead of the long, often painful and difficult to heal incision that is commonly employed. Therefore we do not see the usual wound problems with the leg incision.
Cardiopulmonary bypass with a Pump and an Oxygenator (heart-lung machine) is used wherever indicated for the purpose of patient safety, while in others, this operation can be performed on the beating heart (off pump surgery). In our institution, we are proficient in both the techniques. We individualise and tailor our techniques to suit patient's needs. |
| Valvular Heart Surgery |
 The heart is a pump and needs healthy valves to function optimally. There are four valves in the heart, two located between the chambers of the heart (Mitral and Tricuspid Valves) and two between the chambers of the heart and the blood vessels (Aortic and Pulmonary Valve). When open, the valves permit blood to flow only in one direction. When closed, they form a strong seal between the different chambers of the heart & between the chambers and the blood vessels. When the valves malfunction it may be due to: |
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Leaky Valve (Regurgitation) that allows reverse blood flow |
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Narrowed Valve (Stenosis) in which there is narrowing, thickening and fusion of the valve leaflets thereby restricting blood flow across the valve |
| Valve Surgery |
 Depending on the extent and location of the damage, valves can either be Repaired or Replaced.
Valves can be repaired by a number of procedures: |
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 For Valve Narrowing (Stenosis) - Closed or Open Valvulotomy can be performed. In this procedure an incision is made into the fused valve thereby restoring the valve opening. However, if the structure of the valve is grossly deranged, a valve replacement is done using either a mechanical (e.g. St. Jude valve) or a bioprosthetic (e.g. porcine valve). |
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For Valve Regurgitation - Sophisticated and advanced repair techniques can be applied to not only the valve leaflets but also to the subvalvular apparatus as well as to the valve annulus. Again, if repair is not feasible, valve replacement is done. |
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| We at Max Healthcare, have cardiac surgeons intensivists with special interest in repair techniques for regurgitant mitral valves which is our preferred mode of treating this condition and valve replacement is only done for extreme structural abnormality of mitral valve. |
| Aortic Aneurysm Surgery |
The largest artery in the body, the aorta receives oxygenated blood from the left ventricle of the heart (through the aortic valve) and distributes it throughout the body. Tears in the lining of the aorta are known as Dissections, while weakening and dilatation of the aortic wall is called an Aneurysm. While both conditions are potentially life threatening, they can be effectively treated when diagnosed in time.
Our multi-disciplinary group is dedicated to the medical and surgical management of complex aortic disease, including thoracic aortic aneurysms and abdominal aortic aneurysms. We offer expertise in all types of acute and chronic aortic problems including: |
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Acute Type A and Type B Dissection |
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Ascending Aortic and Arch Aneurysms |
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Aortic Root Reconstruction - including homograft procedures, valve sparing root replacement, and mechanical valve conduits |
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Abdominal Aortic Aneurysm (AAA) |
| We work in concert with our colleagues in the division of vascular surgery to offer definitive management of thoracic and thoraco-abdominal aortic reconstruction (endovascular stent grafting and open repair). We also offer long-term follow up care, particularly for patients with residual dissections or Marfan's syndrome. |
| Heart Failure Surgery |
| In some patients, the heart muscle is so severely damaged due to advanced coronary artery disease or to myopathy (idiopathic or secondary to vavular heart disease) that it fails as a pump to circulate blood in the body. Such patients with congestive heart failure ideally need a Heart Transplant, but few surgical procedures of lesser magnitude have shown to benefit such patients. Heart failure surgery is aimed at stopping further damage to the heart and improving the heart's function. |
| The list of surgical procedures performed at our institution to help such patients is as follows: |
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High-risk Coronary Artery Surgery |
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Ischemic Mitral Repair and/or Replacement |
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Ventricular Remodelling Surgery (Dor's Procedure) |
| Ventricular Remodeling Surgery |
 The heart pumps blood into the body by its left ventricle. When a heart attack occurs in the left ventricle, a scar may form.
The scarred area can become thin and bulge out with each heart beat, forming what is called a Ventricular Aneurysm.
This change along with other heart damage makes the heart work harder in order to pump blood throughout the body. Initially the heart is able to handle the additional work, but over time, the left ventricle becomes larger than normal and pumps less effectively and starts failing.
Ventricular remodelling surgery allows the surgeon to remove the scarred heart tissue and/or the aneurysm and restores the left ventricle to a more normal shape. The goal is to prevent heart failure and/or angina symptoms and possibly improve the pumping ability of the heart. Our team has years of overseas experience with this procedure, after having mastered the technique, by working with pioneers overseas in this field. |
| Heart Transplant |
Recently, a team of experts from the Central Government assessed the expertise of our team and the infrastructure at Max. Our centre received their approval for doing heart transplant for end stage heart failure patients. With years of overseas experience working overseas in Transplant Centres of Exellence, two of our surgeons intensivists have put in palce an organised Heart Transplant Programme. We are now ready to help the patients out of their misery of not being able to breathe because of end stage heart disease.
Today, heart transplantation gives hope to a selected group of patients who are in terminal heart failure. |
| Arrhythmia Surgery |
Disturbances in cardiac rhythm are quite common - Atrial Fibrillation being the most common.
At our centre, we have special expertise in surgically treating Chronic Atrial Fibrillation which is the most common rhythm disturbance accompanying valvular and ischaemic heart disease. It is this that commonly causes a Brain Stroke in such patients resulting in devastating physical incapacitation. We perform a modified Mini Maze procedure which excludes the trigger zones (Left Atrial Reduction with Pulmonary Vein Isolation) and reduces the size of the left atrium which restores the normal sinus rhythm with excellent results. |
| Paediatric Cardiac Surgery |
 Congenital heart disease results from abnormal development in uterus which causes structural defects in the heart. Congenital cardiovascular defects constitute nearly 1 percent of live births. The exact cause of their occurrence is unknown though a few conditions increase the risk. If a woman contracts German Measles (Rubella) when she is pregnant, the baby's heart has chances of being malformed. Heredity, Down's syndrome, few over-the-counter medicines, use of alcohol and narcotics during pregnancy may increase the risk of the baby being born with a heart defect.
Our team of specially trained paediatric cardiovascular surgeons intensivists, anaesthetists, intensivists and nursing staff provides comprehensive paediatric cardiac and thoracic surgery solutions encompassing the entire spectrum of available treatment methods. Correction of atrial or ventricular septal defects and tetralogy of fallot are examples of such diseases. Currently, complicated procedures such as BT shunts, Glenn shunts, Fontan, Rastelli, Coarctation repair and Pulmonary Artery Banding are performed with minimum risk. |
| Thoracic Surgery |
| Thoracic Surgery Programme provides patients from lung cancers and other chest ailments with an on site evaluation by a multidisciplinary team including Thoracic Surgery, Medical Oncology, Pulmonary Medicine, Radiation Oncology and Radiology. The division offers innovative surgical treatment with Videothoracoscopy and Laser Bronchoscopy as well as traditional surgical procedures. |
| The various procedures being done at Max are: |
| Thoracotomy |
 Thoracotomy is a surgical procedure done to open the chest in order to access the lungs, trachea, heart and certain blood vessels. The incision is in the side of the chest either on the left or right, with varying lengths which allows the surgeon to have a wider field in which to operate. This type of procedure can be utilised for a variety of procedures including: |
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Diagnostic thoracotomy for establishing the diagnosis of a disease |
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Removing a portion or the entire lung affected by the disease |
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Tracheal resection |
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Removing blood or infected fluid from the chest cavity or pleural space |
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Surgery because of trauma to the chest wall and organs within the chest cavity |
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Surgery on certain blood vessels including the aorta |
| Lung Resections |
 Lung resections are done primarily for cancerous or non-cancerous tumors. Depending on the tumour type, size and location, several types of lung resections are possible ranging from Segmental/Wedge resection, where a segment or small portion of a lung lobe is removed to Lobectomy, where a lobe of the lung is removed or even Pneumonectomy, where the entire lung on one side is removed. Sleeve Resection, where a section of the intervening tumour is removed from the involved lung and bronchus and the continuity of the airway and lung is re-established is also a modality our team has extensive overseas experience in. |
| Lung Volume Reduction Surgery |
 Over inflated lungs can cause difficulty in breathing and the condition is called Emphysema. It is caused by many factors but smoking is a leading cause. These patients improve by removing severely diseased portions of the lung. This allows the remaining normal lung tissue and chest cavity to function more efficiently and eases the work of breathing. |
| Decortication, Pleurodesis, Biopsies |
 Decortication removes a restrictive, fibrous membrane or layer of tissue from the lining surface of the lung. The purpose of the procedure is to free the encased or 'trapped lung' allowing the expansion of the lung to help improve breathing.
Pleurodesis produces adhesions between the lung and the chest wall. This is done to treat pleural effusions or air-leaks that re-occur frequently.
A biopsy obtains a tissue sample that can be sent to the lab for diagnosis. Determining the type of tumour is important in developing a treatment plan. Biopsies can be obtained through a bronchoscopy, mediastinoscopy or thoracoscopy which are all minimally invasive procedures aided by endoscopes. |
| Bronchoscopy, Mediastinoscopy |
Bronchoscopy is a procedure that allows visualisation of the trachea, bronchial tree and lungs plus the ability to obtain a tissue sample for biopsy. The bronchoscope is a thin scope that is passed through the nose or mouth down through the trachea and into the bronchi and lungs.
Mediastinoscopy allows your surgeon to see the middle of your upper chest between and in front of your lungs. A small incision is made above the breastbone or just to the side of the breast bone and then a thin scope is inserted into the chest so the surgeon can examine your lymph nodes, outside of the trachea and esophagus and lung surfaces. Biopsies can be collected through the scope of any suspicious areas.
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| Vascular Surgery Vericose Veins |
| Varicose veins are veins that have become enlarged and tortuous. |
| Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart, against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work. This allows blood to flow backwards and they enlarge even more. |
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Heredity |
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Female hormones, especially those of pregnancy |
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Gravitational force (such as prolonged periods of standing or sitting) |
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Muscular compartment forces which travel to skin level (superficial) veins through faulty perforator or connecting veins, creating higher pressure in the superficial veins which leads to enlargement of the vessels. |
| Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. |
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Aching, heavy legs (often worse at night and after exercise). |
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Appearance of spider veins (telangiectasia) in the affected leg. |
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Ankle swelling. |
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A brownish-blue shiny skin discoloration near the affected veins. |
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Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg. |
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Minor injuries to the area may bleed more than normal and/or take a long time to heal. |
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In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard. |
| Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb. |
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Pain, heaviness, inability to walk or stand for long hours, thus hindering work |
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Skin conditions / Dermatitis which could predispose skin loss |
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Skin ulcers especially near the ankle, usually referred to as venous ulcers. |
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Development of carcinoma or sarcoma in longstanding venous ulcers. The rate is reported as 0.4% to 1%. |
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Severe bleeding from minor trauma, of particular concern in the elderly. |
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Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem. |
| Surgery is the mainstay of treatment of varicose veins. Medicines and graduated compression stockings are supportive treatment. Elevating the legs often provides temporary symptomatic relief. |
| Sapheno-femoral junction ligation and vein stripping operation consists of removal of all or part of the saphenous vein main trunk after giving skin incisions over groin and leg. The complications include deep vein thrombosis, pulmonary embolism, and wound complications including bleeding, infection,etc. |
| Laser Treatment Of Varicose Veins |
| Endovenous laser ablation is a less invasive alternative to standard vein stripping The underlying goal of this procedure is to deliver sufficient thermal energy to the wall of an incompetent vein segment to produce irreversible occlusion, fibrosis, and ultimately disappearance of the vein. |
| The leg being treated will be sterilized and covered with a surgical drape. The diseased vein is punctured at ankle or below knee under doppler guidance and a wire is inserted into the vein. The catheter is advanced over the wire inside the vein up to the top of the leg. The wire is removed and the laser fibre is inserted inside catheter till the tip of laser fibre is 2-3 cm beyond catheter and accurately positioned in the top of vein , as monitored by doppler machine. Some fluid is injected around the vein to be treated to prevent heat damage of surrounding tissues. The laser fibre is activated and energy is applied as the catheter is slowly withdrawn. This heats the vein, causing them to shrink and eventually leading to closure of the vein. |
| The procedure takes about 45 minutes to one hour in each leg. |
| A compression stocking or crepe bandage is applied after the procedure to help reduce bruising, tenderness, and the slim possibility of forming blood clots. The patient is usually discharged on the subsequent day. |
| Endovenous Laser Ablation |
| The procedure leaves no scars, and is associated with minimal postoperative pain, a rapid recovery period and provides almost immediate relief from symptoms. Minor soreness and bruising can be treated with over the counter pain medication. After the procedure, patients are encouraged to walk and resume their normal activities. A follow up appointment is made with the doctor in the week after treatment, to evaluate the success and progress of the endovenous laser ablation. |
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Mild numbness around the thigh area |
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A pulling sensation which may last a week |
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Phlebitis (redness and tenderness of the skin is quite common but is mild in nature and easily treated with over the counter pain medications. Most cases of phlebitis resolve in 3-7 days |
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Deep venous thrombosis. This is a very rare complications following endovenous laser ablation. The best way to prevent this rare complication is to wear compression bandage or compression stocking and to walk right after the procedure |
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Infection at an incision site is a rare occurrence and usually resolves on its own |
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Bruising is common after the procedure, but it is usually mild and resolves in 1-2 weeks. |
| No. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm. |
| Medical lasers work by delivering light energy to the targeted tissue with extreme precision so as not to harm the surrounding tissue. Lasers are proven to be safe and effective for treating many health issues. In the hands of a skilled physician, lasers offer far less risk and complications than conventional surgery. Endovenous laser ablation is generally a complication-free and safe procedure. |
| All data indicate that endovenous laser ablation is a safe and effective procedure. The FDA has approved it for the treatment of varicose veins. Endovenous laser ablation is minimally invasive and enjoys a 98% success rate with a recurrence rate of 7% after two years. |
| Sclerotherapy |
| It is a commonly performed non-surgical treatment for varicose and "spider" leg veins in which medicine is injected into the veins to make them shrink. It is safe, proven and effective. |
| Prior to the procedure, you will have an initial consultation to determine if you are eligible for sclerotherapy. This includes an ultrasound of the veins to evaluate the full extent of the problem causing the spider veins. The larger vein must be treated before sclerotherapy is performed. If the vein causing the problems is not treated first, other spider veins will appear after the sclerotherapy is complete.
During,sclerotherapy, small injection of irritating solution is injected into the vein, which causes the vein to close. Two or more sessions are usually required to achieve optimal results.
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| Complications from sclerotherapy are extremely rare. Risks include the formation of blood clots in the veins, severe inflammation, adverse allergic reactions to the sclerosing solution and skin pigmentation that could leave a small but permanent scar.
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| Carotid Endarterectomy |
| A carotid endarterectomy (CEA) is a surgical procedure in which fatty deposits blocking one of the two carotid arteries, the main supply of blood for the brain, is removed. This procedure removes a substance called plaque from your artery and can improve blood flow to the brain. |
| Carotid artery problems become more common as people age. The disease process that causes the buildup of fat and other material inside the artery walls is called atherosclerosis, popularly known as "hardening of the arteries." Cholesterol, calcium, and fibrous tissue make up this plaque. As more plaque builds up, your arteries narrow and stiffen. Eventually, enough plaque builds up to reduce blood flow through your carotid arteries, or to cause irregularities in the normally smooth inner walls of the arteries. |
| Carotid artery disease is a serious issue because clots can form on the plaque. Plaque or clots can also break loose and travel to the brain. If a clot or plaque blocks the blood flow to your brain sufficiently, it can cause stroke, which can cause permanent brain damage, or death, if a large enough area of the brain is affected. |
| Stroke |
| A stroke occurs when blood flow is cut off from part of the brain. In the same way that a person suffering a loss of blood to the heart can be said to be having a "heart attack," a person with a loss of blood to the brain can be said to be having a "brain attack." Atherosclerosis in the carotid arteries, two large arteries in the neck that carry blood to the brain, is a major risk factor for ischemic stroke. If a clot or plaque blocks only a tiny artery in the brain, it may cause a transient ischemic attack (TIA), also known as a mini-stroke. A TIA is often a warning sign that a stroke may occur in the near future, and it should be a signal to seek treatment soon, before a stroke occurs. |
| Symptoms of stroke include: |
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Sudden numbness, weakness, or paralysis of face, arm or leg, especially on one side of the body. |
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Sudden confusion, trouble talking or understanding speech. |
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Sudden trouble seeing in one or both eyes. |
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Sudden trouble walking, loss of balance, or coordination. |
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Sudden severe headache with no known cause (often described as the worst headache in a person's life). |
| Symptoms may last a few moments and then disappear. When they disappear within 24 hours or less, they are called transient ischemic attacks (TIA). |
| Hypertension, cigarette smoking, diabetes mellitus, increased blood cholesterol, advancing age, male sex are important risk factors for stroke. |
| Carotid Artery Disease |
| After the detailed clinical examination, your vascular surgeon may want to determine how much plaque has built up in your arteries. The most common test used for this purpose is duplex ultrasound. Duplex ultrasound uses painless sound waves to show your blood vessels and measure how fast your blood flows. It can also determine the location and degree of narrowing in your carotid artery. Other tests your vascular surgeon may use include: |
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Computed tomography (CT) scan of the brain |
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Computed tomographic angiogram (CTA) |
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Magnetic resonance angiography (MRA) |
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Angiography (in cath lab) |
| Carotid endarterectomy is performed to prevent stroke. |
| Individuals, who already have stroke symptoms and carotid stenosis greater than 50 percent, may wish to consider surgery to prevent future stroke. The procedure has also been found highly beneficial for persons who are symptom-free but have a carotid stenosis of 70 to 99 percent. |
| Large scale clinical studies have shown that for patients who had a stroke or experienced the symptoms of a stroke and have a severe stenosis of 70 to 99 percent, surgery reduces the estimated 2-year risk of stroke or death by 65 %. For those with moderate carotid stenosis (50 to 69 percent), surgery reduces the 5-year risk of stroke or death by 30 %. Also, patients who are symptom-free but have a carotid stenosis of 60 to 99 percent, the surgery reduces the estimated 5-year risk of stroke by more than one-half. Thus, it has been conclusively proven that surgery is highly beneficial. |
| Important risk factors in addition to the degree of stenosis include, gender, diabetes, the type of stroke symptoms, and blockage of the carotid artery on the opposite side. Without other complicating illnesses, age alone is not a worrisome risk factor.
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| Carotid Endarterectomy |
| You may either be put to sleep or, alternatively, your anesthesist can numb your neck area and keep you awake so you can communicate with the surgeon during the operation. The surgeon then makes the incision on one side of your neck to expose your blocked carotid artery. Next, vascular surgeon temporarily clamps your carotid artery to stop blood from flowing through it. During the procedure, your brain receives blood from the carotid artery on the other side of your neck. Alternatively, surgeon can insert a shunt to detour the blood around the artery that is being repaired. |
| After vascular surgeon clamps your carotid artery, he or she makes an incision directly into the blocked section. Next, surgeon peels out the plaque deposit by removing the inner lining of the diseased section of your artery containing the plaque. After removing the plaque, surgeon stitches your artery, removes the shunt and the clamps, and stops any bleeding. Often, a patch made of synthetic material is used to widen the artery as part of the procedure. He or she then closes your neck incision and the procedure is complete. |
| The procedure takes about 2 hours to perform but may seem slightly longer depending upon the anesthetic and preparation time. |
| After surgery, you may stay in the hospital for 2 -3 days. During this time, your physician will monitor your progress. Because the neck incision is so small, you may not feel significant pain. You can usually begin normal activities again 2-3 weeks after the operation. |
| About 2 % of asymptomatic and 4 % of symptomatic patients are expected to suffer stroke or death as a result of surgery. Other surgical complications include bleeding of the wound bed which is potentially life-threatening, as swelling of the neck due to hematoma could compress the trachea. Temporary nerve injury, leading to hoarseness, difficulty with swallowing, or numbness in your face or tongue, is another uncommon, but possible, complication. This usually clears up in less than 1 month and normally doesn't require any treatment. |
| Another unusual complication is the re-blockage of the carotid artery, called restenosis, which may occur later, especially if you continue to smoke cigarettes. The chance of developing a restenosis severe enough to require another carotid endarterectomy is usually about 2 to 3 percent. |
| Although a carotid endarterectomy can reduce your risk of stroke by removing the offending plaque, and although the procedure is quite durable, it does not completely stop plaque from building up again in susceptible individuals. To minimize the chance of hardening of the arteries occurring again, you should consider the following changes: |
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Eat foods low in saturated fat, cholesterol, and calories |
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Exercise regularly, especially aerobic exercises such as walking |
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Maintain your ideal body weight |
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Avoid smoking |
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Take cholesterol-lowering medications and antiplatelet therapy regularly as advised by your surgeon. |
| Yes, carotid artery stenting (CAS) can be done. The choice of CEA versus CAS is limited by paucity of adequate evidence. CEA is a much more mature, cost-effective and durable procedure with an established record in both prospective trials and community-wide, population-based studies. CAS is still an evolving procedure, and there are limited data with respect to results. |
| However, recent published trials suggest that both CEA and CAS are equivalent procedures in term of short-term safety and long-term results. Both the procedures have their own relative indications which will be discussed by your treating doctor. |
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