The department of cardiovascular and thoracic surgery at Amrita Institute of Medical Sciences is one of the busiest programs in the country. Over two thousand cardiac surgical operations are performed annually.
Surgery for coronary artery disease
The department of cardiovascular and thoracic surgery at the Amrita Institute of Medical Sciences is well equipped for holistic management of coronary artery disease including life threatening mechanical complications of myocardial infarction (heart attack).
Special features of this program include emphasis on off-pump CABG (surgery is per-formed while the heart continues to pump blood by itself without the need for a heart-lung machine) and total arterial revascularisation. Minimal access techniques for coronary artery bypass grafting are being used for appropriate patients. The department has acquired a reputation for success in complex coronary artery bypass surgeries done on high-risk patients who have poor heart muscle function and multiple comorbidities.
Our surgeons are well experienced in successfully performing CABG along with carotid endarterectomy (surgery to remove plaque in your carotid arteries and help prevent a stroke), correction of ischemic mitral regurgitation and DOR procedure (surgical method to restore a dilated left ventricle to its normal, elliptical geometry) as and when required.
Surgery for Heart Valve Disease
Valvular heart disease includes any disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left and the pulmonary and tricuspid valves on the right). Normally functioning valves ensure that blood flows with proper force in the proper direction at the proper time. In valvular heart disease, the valves either become too narrow and hardened (stenotic) and fail to open fully, or are leaky and unable to close completely (incompetent). The mitral and aortic valves are the ones most frequently af-fected by valvular heart disease.
These problems may be the result of a valve that was abnormal at birth that has stiffened or become leaky over time or due to acquired problems like infections (like rheumatic fever or infective endocarditis), atherosclerosis, connective tissue disorders or de-generation of valve with age etc. Valve repair or replacement provides a solution for problems related to heart valves.
Mitral Valve Repair Program
Amrita has a well integrated mitral valve repair program. If the mitral valve is leaking, it can most of the time be repaired by a combination of the techniques of mitral valve repair like inserting a cloth-covered ring around the valve to bring the leaflets into contact with each other (annuloplasty), removal of redundant/loose segments of the leaflets (quadran-gular/ wedge resection), supporting the leaflets with artificial (Gore-Tex) cords etc.
Advantages of Mitral Valve Repair
Mitral valve repair provides better long-term survival, better preservation of heart func-tion, has less complications, lower risk of bleeding, stroke and infection (endocarditis) after surgery and removes the need for long-term use of blood thinners (anticoagulants).
For these reasons, our surgeons are committed to mitral valve repair.
Valve Replacement surgeries.
Replacement is more commonly used to treat aortic valves or severely damaged mitral valves that are not amenable to repair.
There are two kinds of valves used for valve replacement.
At Amrita Hospital all complex single double and triple valve replacements are performed with excellent results.
Hypertrophic Cardiomyopathy (HCM)
Hypertrophic cardiomyopathy (HCM) is a genetic condition disease in which the heart muscle (myocardium) becomes abnormally thick (hypertrophied) and the mitral valve starts leaking. This condition is much more common then we think. The thickened heart muscle can make it harder for the heart to pump blood.
Many people with HCM live a complete normal life but others develop heart conditions which shorten life or decrease the persons quality of life including making them target of heart failure, sudden cardiac arrest and sudden cardiac death.
Amrita Institute of Medical Sciences has a comprehensive program the first of its kind in country to help these patients and their families. This starts from screening patients for this disease, early diagnosis and almost curative surgical treatment (extended septal myomectomy) for this problem.
Heart Transplant and Ventricular Assist Devices
Amrita has a highly skilled and experienced multidisciplinary team of heart transplant spe-cialists that includes cardiologists, heart surgeons, intensivists, transplant coordinators, social workers, dietitians, physiotherapists, adn staff nurses. Each member of the heart transplant team offers specialized service in the care of our patients.
With our team you can be sure that if you receive a heart transplant at Amrita, you'll get the most innovative and refined care this country has to offer.
What about patients who have intractable heart failure and are not candidates for trans-plants or are waiting for donor? We have solutions for these. Our team is also exceptionally experienced and certified to implant ventricular implants like THORATEC HEART MATE 2 and BERLIN HEART (circulatory device that is used to partially or completely replace the function of a failing heart) which would act as a bridge therapy for transplant can-didates and destination therapy for non transplant candidates.
Extracorporeal Membrane Oxygenation (ECMO)
Extracorporeal Membrane Oxygenation (ECMO) is an advanced form of life support used to treat infants, children, and adults in whom the heart or lungs or both are not func-tioning. ECMO is achieved by draining venous blood through a closed circuit, removing carbon dioxide and adding oxygen using an artificial lung, and pumping the blood to the circulation (by artificial pumps) via a vein (venovenous ECMO) or an artery (venoarterial ECMO).
The cardiovascular team at Amrita provides "24/7" support for those critically ill patients in whom all other modality of treatment has failed and who need ECMO to sustain life till the organ function improves.
We plan to expand in this area and aim to start mobile unit to institute ECMO at distant areas where this facility is not available.
The presence of clotted blood or thrombus clogging the arteries of the lung with chronic pulmonary embolism (CPE) leads to a serious condition called chronic thromboembolic pulmonary hypertension (CTEPH), wherein patients present with progressive breathlessness and deteriorating function of the right ventricle of the heart. Pulmonary thromboendarterectomy is the surgical procedure done for the removal of blood clots in the arteries of the lung and restoration of lung and right heart function. This is a complex procedure in which the heart and lung function are temporarily stopped for a period of time (circulatory arrest) using advanced bypass techniques while the surgeon operates on the clogged arteries. Amrita is one of the few specialised centres in India equipped with the expertise to perform this complex procedure.
We continue to update ourselves with cutting-edge technology in our effort to make it available to our patients in the most affordable way.
Lung cancer has emerged as the leading cause of death among all cancers in males, especially smokers in India in the last decade. The prognosis of lung cancer is heavily dependent on early diagnosis, assessment of the stage of disease and appropriate management protocols which may include surgery, radiotherapy and/or chemotherapy.
Comprehensive lung cancer management at Amrita epitomizes the ‘multidisplinary approach ' wherein the treatment protocols are individualized for each patient by a team of doctors including a thoracic surgeon, pulmonologist, radiation oncologist, medical oncologist, oncopathologist and radiologist.
The surgical expertise offered for lung cancer includes minimally invasive surgical procedures like mediastinoscopy and thoracoscopy, which aid in the early diagnosis of cancer and therapeutic procedures like lobectomy (removal of the affected parts of the lung) and pneumonectomy (removal of one entire lung) using conventional open and minimally invasive techniques (VATS).
Previously lung cancer was managed surgically with lobectomy or pneumonectomy which required patients to have adequate lung function for undergoing the procedure but the novel concept of Lung parenchymal sparing procedures extends the benefits of surgery (segmentectomy and sleeve resection) even to patients with borderline lung function who, earlier had been condemned to palliative therapy.
Intraoperative planning for radiotherapy using surgical clip markers, brachytherapy wires and CT-guided wire localization techniques for solitary pulmonary nodules are used as and when required. Accurate staging of the cancer mandates mediastinal lymph node dissection wherein lymph nodes in the chest are dissected out and sent for pathological evaluation to confirm their involvement. With our facilities to provide postoperative adjuvant radiotherapy or chemotherapy our patients are assured of comprehensive lung cancer management all under one roof.
Chest Wall Tumour Excision and Reconstruction
Osteochondroma, osteoclastoma, hemangioma , rib and sternal metastases and advanced lung cancers involving the chest wall present with swelling, pain or even pathological fractures are treated. Our unit specializes in chest wall tumour and sternal tumour excision and reconstruction of the defect caused with various prosthetic materials like Prolene mesh, vicryl mesh and Polymethylmethacrylate (PMMA) implants to provide good cosmesis . Complex reconstruction after removal of part of the lung and adjacent chest wall is also done with good long term results. We are the only centre in Kerala specialised in managing sternal infections especially post coronary bypass sternal osteomyelitis with VAC therapy and muscular flaps.
Mediastinal Tumour Excision
Mediastinal tumours like thymoma, retrosternal goiter , lymphoma, duplication cyst, pericardial cyst, neurogenic tumours and germ cell tumours are found incidentally on routine chest x-ray or present with chest pain and breathlessness. These tumours are amenable to surgical excision to provide complete cure. Our unit in Amrita specializes in keyhole surgery to remove mediastinal tumours through keyhole (1-2 cm ) incisions on the chest using high definition state of the art endoscopes. Amrita is well known for its expertise in the field of retrosternal goiter management which needs the sternum
(breastbone) to be cut for approach.
Bullectomy, Pleurodesis & Lung Volume Reduction Surgery (LVRS)
Chronic smoking and certain congenital abnormalities (alpha -1 antitrypsin deficiency) cause the alveolar walls of the lung to weaken and balloon out (bullae). Patients usually present with sudden onset of severe unilateral chest pain caused by rupture of bullae and accumulation of air in the chest cavity (spontaneous pneumothorax). Bullectomy and pleurodesis is done as a minimally invasive keyhole procedure in which the surgeon uses video-assisted thoracoscopic techniques and lung endostaplers to remove the affected ballooned-out area of the lung (bullae) that causes the lung to permanently stick to the chest wall and thus prevent recurrence. Chronic smokers develop localized overinflation especially in the upper lobes of the lung (centrilobar emphysema) for which doctors perform lung volume reduction surgery (LVRS) which gives good relief from severe breathlessness.
Tuberculosis and other infections of the lungs can cause fluid accumulation in the chest cavity (pleural effusion) which can further become infected to form pus (empyema) . This causes the lung to become trapped in a fibrinous layer (pleural peel) that prevents the normal expansion of the lung and thus compromises its function. We perform the surgical procedure called decortication both by open surgery or minimally invasive techniques wherein the pleural peel is removed and the lung expands to its normal size and regains full functional capacity with good immediate and long term relief for the patients.
Chest injuries like rib and sternal fractures, lung contusions and flail chest (a condition where three or more ribs are fractured in two or more places) caused by road traffic accidents and accidental falls undergo expert management at AIMS in the hands of competent thoracic surgeons, cardiac anesthetists and critical care specialists who are available round the clock to manage emergency situations. Pain management techniques like intercostal nerve blocks, epidural analgesia, advanced ventilatory techniques like intermittent positive pressure ventilation (IPPV) and surgical fixation of the “flail” segment with titanium implants form the standard of care for trauma patients admitted at Amrita.
Thoracic Sympathectomy ( Left Cardiac Sympathetic Denervation )
Certain conditions that are caused by sympathetic overactivity like increased sweating in the palms and feet (hyperhidrosis) and, life threatening arrythmias of the heart unresponsive to standard medications are now managed by thoracic surgeons at AIMS who are trained to do thoracic sympathectomy via key hole technique. This novel surgical procedure is being practiced the world over as the curative solution to these distressing problems .
The thymus gland which is situated behind the breastbone (sternum) can become enlarged (hyperplasia) or can harbour small tumours benign (thymoma) or malignant (thymic carcinoma) which mandates its removal by a surgical procedure called thymectomy. Thymectomy is also indicated in situations where an enlarged thymus gland is associated with autoimmune pathologies like myesthenia gravis and pure red cell aplasia. We regularly perform both open and keyhole technique for thymectomy with remission rates of myasthenia gravis upto sixty percent which is comparable with western standards.
Mediastinoscopy is a minimally invasive surgical procedure where the surgeons use a specialized instrument called the mediastinoscope which uses a miniature camera to visualize the structures in the centre of your chest cavity (mediastinum) and it can even take appropriate biopsies from lymphnodes or tumours. This is vital to early detection of lung cancer in smokers and for keyhole diagnosis of various chest diseases. Doctors at Amrita hospital use the latest Lerut Distending Mediastinoscope for performing routine mediastinoscopy in thoracic patients as an OP procedure through a small (1 cm) incision at the root of neck, which minimizes the pain and allows speedy discharge from hospital.
Minimally Invasive Thoracic Surgery ( Keyhole Chest Surgery )
Minimally invasive thoracic surgery also called video-assisted thoracic surgery (VATS). It is the surgery of the chest that is performed with a thoracoscope (small high definition video camera) using small incisions (1 – 2 cm) and special instruments to minimize trauma. The videocamera transmits images of the operative field onto a videomonitor that is positioned next to the patient. Instead of the traditional single 10-15 cm muscle cutting, incisions used in traditional open surgery,VATS uses 3 - 4 ports, 1 - 2 cm incisions through which the videocamera and surgical instruments are passed into the chest to perform the procedure.
Amrita hospital is equipped with the Karl Storz HD VATS unit and the latest innovative Endocameleon camera technology that enables the surgeon to visualise vital structures in the chest cavity from zero to one hundred and twenty degrees and to perform complex thoracic procedures with more dexterity and less operating time.
Compared to traditional open surgery, patients who undergo VATS experience:
Who are the candidates for minimally invasive thoracic surgery?
Almost all the thoracic procedures performed in an open manner can be performed in a minimal invasive manner. There are still some situations like severe chest wall adhesions , bleeding and large tumours more than 6 cm that are relative contraindications for the minimally invasive approach. The surgical efficiency and oncological outcome of the minimally invasive surgery is comparable to open surgery as proven by numerous studies worldwide.
Thoracic surgery procedures routinely performed at AMRITA using VATS include
Diseases of Aorta
Old age, long standing uncontrolled hypertension, smoking and connective tissue diseases are the important risk factors that contribute to diseases of the aorta like aortic dissection (tear in the aorta that causes blood to flow between the layers of the wall of aorta), aortic aneurysm (ballooning out of wall of the aorta) and penetrating aortic ulcer. ‘Centre for Aortic diseases’ at Amrita hospital is one of the first initiatives in the country to provide patients with ‘comprehensive and total’ aortic solutions by a core team of
cardiothoracic surgeons, cardiologists and radiologists trained to offer surgical, endovascular or hybrid therapeutic options. Amrita offers the latest endovascular aneurysm repair (EVAR & TEVAR) wherein doctors treat complex aortic diseases with aortic stents introduced through the lower limb arteries obviating the need for complex surgical procedures.
Aortic Surgical procedures performed :
Severe pain in the lower limbs on walking (claudication pain) leading to devastating complications like loss of limb and/or function is due to blockage of the arteries to lower limbs over the course of time due to accelerated atherosclerosis due to hypertension, diabetes mellitus, smoking and old age. Open surgical bypass techniques like aortobifemoral bypass, femorofemoral bypass,femoropopliteal bypass and endovascular procedures like stenting and angioplasty to increase blood flow to lower limbs are regularly done at Amrita with excellent results.
Arteries in various parts of the body commonly can become weakened due to infection or injury which causes them to balloon out (pseudoaneursym). Unless they are managed surgically pseudoaneurysm can rupture and cause complications. Pseudoaneurysm repair of the femoral artery (artery of thigh) is a common procedure done at Amrita as a day care surgery.
Carotid endarterectomy is the surgical procedure done in cases of stroke (cerebrovascular accident) patients in whom blocked arteries to the brain can be opened up to restore blood supply and thus prevent a major stroke later in life. Amrita has an excellent comprehensive stroke program with surgical, medical and rehabilation services. We specialize in doing carotid endarterectomy as an isolated procedure or as a combined procedure with other cardiac operations like coronary artery bypass grafting with stroke rates below 1%. This procedure opens up new avenues in stroke management that are certain to benefit stroke patients. Other carotid surgeries for rare diseases like carotid artery aneurysm and carotid body tumors are regularly done.