Om Prakash Yadava

Cardiac tumours in infancy.

Cardiac tumours in infancy are rare and are mostly benign with rhabdomyomas, fibromas and teratomas accounting for the majority. The presentation depends on size and location of the mass as they tend to cause cavity obstruction or arrhythmias. Most rhabdomyomas tend to regress spontaneously but fibromas and teratomas generally require surgical intervention for severe haemodynamic or arrhythmic complications. Other relatively rare cardiac tumours too are discussed along with an Indian perspective.

On or "Off" pump coronary artery bypass grafting - is the last word out?

A glance at the history of the development of Coronary Artery Bypass Surgery (CABG) throws up the interesting finding that the first milestones were without cardiopulmonary bypass (CPB) support. Off-pump CABG (OPCAB), having predated Onpump surgery, has had a roller coaster ride for want of a clean, still and bloodless field, culminating in the introduction of CABG on CPB (On-pump) by Favaloro in 1967. This development profoundly “democratised” the CABG procedure in that now a broad number of surgeons could achieve better and reproducible results with considerably more optimum operating conditions. The initial enthusiasm for On-pump CABG gradually gave way to concerns regarding its safety, especially with regard to complications arising from CPB, and not CABG per se. Foremost of these relate to microembolic showering during manipulation of the aorta and neurocognitive dysfunction. In addition, CPB triggers a whole-body inflammatory response caused by contact activation of the complement cascade. This leads to multiple organ dysfunction affecting the kidneys, liver, lungs, brain and heart itself. Studies published over a decade and a half ago questioned the safety of On-pump CABG. The proportion of patients recovering without any complication was found to be only 64.3%. In addition, health insurance data and data from clinical studies showed that 10.2% did not leave the hospital within 14 days after the operation and 3.6% of the patients were discharged to a non-acute care facility. These and other observations, pari passu with the development of mechanical and pharmacological organ stabilizers and intracoronary shunts, resurrected OPCAB in the early 1990s. As regards surgical technique, the actual suture anastomosis of the vessels follows the same technique both in Onand Off-pump surgery. The difference is that unlike On-pump surgery, where the heart is arrested by means of cardioplegia,

Is radial artery Doppler scanning mandatory for use as coronary bypass conduit

Background Screening of the radial artery prior to harvesting as a conduit for coronary bypass may be performed clinically by the Allen test or by Doppler ultrasound. In a developing country like ours, the use of resources for Doppler studies may be questioned when Allen tests lead to a low rate of clinical sequelae. However, the rare occurrence of hand ischemia may be devastating and could justify the routine use of Doppler screening. This study aimed to address this question. Methods One hundred patients undergoing elective coronary artery bypass grafting were screened by the modified Allen test and Doppler ultrasound for suitability of use of a radial artery conduit. After harvesting, proximal and distal segments of the radial artery were subjected to histopathological examination. Results Of the 95 patients deemed suitable for radial artery grafting, 6 had mild calcification on Doppler ultrasound and 9 had calcification on histopathological examination. While Doppler showed atherosclerosis in 9 patients, only 6 had histopathological evidence of this (false-positive rate 3%). Of the 6 patients with histopathologic evidence of atherosclerosis, 2 were negative on Doppler (false-negative rate 2%). Conclusion Routine preoperative Doppler screening of the radial artery in the setting of limited resources is not justified. On the other hand, the time-tested Allen test which is easy to perform, interpret, and reproduce can be safely used as the sole screening test to harvest the radial artery.

Does Clinical Profile Preclude Use of Radial Artery as a Conduit in Coronary Artery Bypass Grafting

Aims: Use of radial artery in coronary artery bypass grafting has been supported by the results of several histopathology and angiographic studies that have shown excellent short, medium and long term results. However the effect of coronary risk factors on its results may be of concern. This study was undertaken to correlate the association of major clinical risk factors with intimal hyperplasia and atherosclerosis in radial artery using preoperative doppler studies, intraoperative morphometry and postoperative histopathology (HP) and morphometry. Methods and results: This was a prospective study involving 100 patients undergoing coronary artery bypass grafting surgery in whom radial artery was used as a conduit. The radial artery was assessed using preoperative doppler ultrasound studies, intraoperative morphometry and postoperative histopathology (HP) and morphometry. In our series hypertension (69%), diabetes mellitus (54%), tobacco usage (33%) and dyslipidaemia (10%) were dominant coronary risk factors. A correlation was sought to be established between these risk factors and presence of radial artery disease. Presence of diabetes did not correlate with radial artery disease (p=0.487). Although the prevalence of disease was higher in patients having hypertension, dyslipidaemia and history of smoking, the numbers were not statistically significant. (p=0.7085 for hypertension, p=0.248 for dyslipidaemia and p of 0.387 for smoking). Conclusions: In view of the variable or no predictive value of these clinical risk factors, we conclude that radial artery should be used as a second arterial conduit after internal mammary artery in all patients undergoing coronary artery bypass grafting irrespective of clinical risk profile.

Anaortic total arterial OPCAB - Panacea to all ills?

An interesting case report on anaortic total arterial off-pump coronary artery bypass surgery (OPCAB) published later in the journal, only go to attest the fact that there is no limit to technical ingenuity and permutation and combinations that can be drawn to do bypass surgery. After all heart needs blood, no matter how it comes. Compliments to the authors because the ‘whole’ that they have achieved is definitelymore than the sum of the parts viz Anaortic, Total Arterial and OPCAB. Lets look at the parts independently with a view to answering the conundrum e Can anaortic total arterial OPCAB be considered the best form of surgical revascularisation, as advocated by the authors?

The roving scalpel

With the ever evolving world order, the mechanics of practice of medicine too have changed. Earlier the catheter (hic... Cardiologist) was moving from one hospital to the other, but now the epithet—‘The Roving Scalpel’ (hic... Cardiac Surgeon) seems more apt and infact ubiquitous. Dwindling volumes as a result of onset of percutaneous interventions, both for coronaries and valves, as also a large number of mergers and acquisitions with new strategies based on networking of multiple low-volume centres, and they being serviced by a single team, have opened up new vistas. The dissemination of off-pump coronary artery bypass graft (CABG) seems to have added fuel to this, notwithstanding the fact that elaborate open heart surgery paraphernalia may not be even present in a centre, where these surgeries are being performed. Does this affect the patient care? What if a patient crashes and needs cardiopulmonary bypass support? What if a surgeon is involved in a major operation, just as when he is required for a previously operated patient in another institution? A recent study by Shroyer et al. [1] looks at just this scenario which now seems to be common-place in India. They use the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Data base for 543,403 CABG procedures performed between 2011 and 2014 spread across 1120 centres and involving 2676 cardiac surgeons. Nearly one fourth of the surgeons were operating at multiple centres and their observed-to-expected mortality ratios were higher than single centre surgeons (1.06 vs 0.97, p < 0.001). When data for multi-centre surgeon was further sub-analysed, the observed-to-expected mortality ratio was higher for surgeries performed at the satellite centre versus the primary operating facility (1.17 vs 1.01; p < 0.001). Compared with single centre surgeons, multi-centre surgeons had higher mortality rate (1.7 vs 1.6%, p < 0.001) and a higher major adverse complication rates (11.9 vs 10.5%; p < 0.0001). As more and more centres with tertiary care facilities are burgeoning in tier two and three cities, with very limited supply of the tertiary care human resources, this issue assumes paramount importance in our country. For the sake of economic expediency, a lot of corporate groups maintain one single team, which is made to rotate on daily basis by a rota to various satellite centres in a ‘wheel and spoke’ model of delivery of health care. This has found favours with both the health care providers as also the patients, who get delivery of tertiary health care services at their door steps. However, is this trend benign or does this compromise the interests of the patients? My take—no and yes respectively. There has been a debate on the volume-outcome relationship of most cardiac procedures, but more specifically CABG and conflicting reports are available in the literature, with Duke database [2] showing no such relationship and New York database [3] showing a strong association. Looking at the Californian database [4], Dr. Carey noticed, ‘high volume surgeons performing CABG procedures at a single high volume hospital had the very best risk-adjusted outcomes. High volume surgeons performing CABG at multiple hospitals had a higher risk-adjusted mortality than high volume surgeons operating at a single hospital. A heart surgeon who operated occasionally at multiple hospitals, had worse outcomes’. This therefore raises a major question as to is it ethically justified for a surgeon to be operating at multiple centres and is this legally tenable, should it be a cause for a litigation? This certainly calls for a national debate and proper policy guidelines as to what is that crucial volume below which the surgeon should not indulge in multi-centre practice. It requires no rocket science to intuit that an anecdotal surgery performed with a totally new operating team, in an alien environment, has a potential to be detrimental to the patient’s interests. Simultaneously, we must also define that in case multicentre practice is allowed, what is the level of in-house expertise that must be available round the clock for patient care, because the primary surgeon will theoretically not be * Om Prakash Yadava op_yadava@yahoo.com

Dual organ transplant

With heart failure epidemic raging in full fury, an increasing number of end-stage heart failure patients are presenting with cirrhosis of the liver. Simultaneous heart and liver transplant is an attractive option for these patients. Moreover, liver transplant provides synergism by reducing immunorejection of the heart. Dr. Atluri in conversation with Dr. Yadava discusses the indications, sequencing, protocols, and results of double organ transplantation.

“Returning smiles” to medicine

Very recently, Shetty and Arora carried out a national survey on the residents’satisfaction level [1], and I applaud and compliment them for their efforts. They provocatively title their manuscript— Is someone listening? My riposte, or shall I call it repartee—Can we afford not to listen? Physician burn-out and attrition is now a well-established global phenomenon. Though burn-out may be ubiquitous across all professions and arenas of life, but it assumes a very special importance in relevance to medicine, as it does not stay individual but affects health-care delivery and thereby the health of the community. It thus assumes a much grander and larger scale, and as Tait Shanafeldt fromMayo Clinic, Rochester, Minnesota would have it put, BIf it affects half of our physicians, it is indirectly affecting half of our patients.^ Such is the seriousness of the issue that the New England Journal of Medicine (NEJM) catalyst published a series of articles in June 2017 [2] exhorting medical profession—BSolutions are urgently needed.^ However, to the very contrary, when askedwhat the organization is doing to address the issue of physician burn-out, many of the NEJM Catalyst Survey respondents replied, Bnothing,^ Bnot enough,^ Bpaying lip service,^ and Btalking about the problem in committees but no action plan yet.^ Already in India, we are struggling with an acute shortage of manpower and if we do not care of what we already have, we will end up with an attrition rate of almost one-third of medical professionals, extrapolating and going by the western standards [3]. The biggest issue with physician burn-out is that we seem not to recognize the problem. In its preliminary and occult avatar, it may take vicarious shapes like emotional exhaustion, de-personalization, dissatisfaction, and disillusionment with self, lack of personal accomplishment, and even substance abuse, especially alcohol, before it manifests as a full-blown Bburn-out^ and therefore frequently over looked or missed. Even in the NEJM catalyst survey, while nearly two-thirds of individuals recognized physician burn-out as a serious problem in the health-care industry, only one-third thought it to be a problem in their own organization! The practice of medicine has changed and as Michael Schneck from Loyola, University, Chicago observes, BWe take people who are highly trained, highly educated individuals, selected because of their motivation in terms of humanism and the ability to learn copious amount of material, and we turn them in to highly educated factory workers.^ We ask them: How many patients have you seen in the OPD today? How many procedures have you done? How many angiographies or echocardiographies have emanated from your consulting room? How have you justified the pay you are getting? These are quality metrics (sic.... If I may be allowed to use this euphemism) that are being tracked by the administrators and promotors. These questions and the corporate philosophy of practice of medicine are an ante-thesis to what sensitivities toward the profession we have been brought up with. It touches the raw nerves of a sensitive brain and does not go down well with human sensibilities. Yet it is an open secret that these are mundane issues which every physician, especially in the corporate world, faces relentlessly on a day-today basis. No wonder then, that Schneck laments, BThe physician has lost stature as a team leader and is just another cog in the machine.^ The burgeoning knowledge of medicine and a vast panoply of imaging modalities, which are yet to prove any outcome benefits, but are available freely, are becoming a pain, both to the society and the profession, rather than a boon. Indirectly, this puts extra pressure on the physician to keep pace with this ever marching and explosive new medical knowledge. To address this issue, we must come out with clear cut facts and recommendations for clinical use of only those forms of treatment and imaging modalities, which have shown outcome benefits. A physician should not be expected to keep track of all the data available of hundreds and thousands of trials going on, with no sense or meaning, and mostly being carried out with personal interest of either the principal investigator or the sponsoring authority in mind. Even the electronic health * Om Prakash Yadava op_yadava@yahoo.com

Key updates from international coronary congress 2016—a review

This review focuses on the key issues raised during the International Coronary Congress (ICC) 2016. The left internal thoracic artery and the drug-eluting stents in relation to the left anterior descending artery re-vascularization have been compared and the role of Heart Team stressed upon. The current role of bilateral internal thoracic artery grafting is discussed. The importance of and tools for intra-operative assessment of graft patency have been outlined. The patency and related issues of saphenous vein grafts harvested using the no-touch technique has been discussed in detail. Following the discussion at ICC 2016 and review of literature, we conclude that left internal thoracic artery remains the best option for left anterior descending artery lesions and for left main and ostial or proximal left anterior descending artery lesions. The Heart Team should be approached for decision making. Bilateral internal thoracic artery usage should be encouraged especially in the Indian population which includes a higher proportion of younger patients with a particularly high prevalence of diabetes. Transit time flowmetry is a useful tool to confirm and assess whether intra-operative graft flow and saphenous vein grafts harvested with a no-touch technique have better patency than conventionally harvested vein grafts.

NBE versus MCI—the slug fest

There has lately been a lot of brouhaha and a tug of war between the Medical Council of India (MCI) and the National Board of Examinations (NBE) on the issue of equivalence of the degrees issued by each one of them. The MS, MD, DM, and MCh courses are conducted by MCI in University Teaching Hospitals, while the National Board runs the parallel system of education, awards the DNB degree, and is held in non-teaching hospitals, including private sector hospitals. The general impression seems to have been given by MCI that the training in teaching hospitals is far superior to the ones provided under the NBE umbrella. Though we do not have any hard core evidence one way or the other in Indian literature, recently, an article in JAMASurgery by Sellers et al. [1] has examined a similar debate in the American system where teaching and training in University hospitals was compared to the one offered by non-teaching community hospitals. The authors looked at a huge volume of data covering over 3600 surgeons, 1.2 million plus patients, and covering over 214 training programs in the states of New York, Florida and Pennsylvania in the USA and examined and analyzed the clinical outcomes data for nearly 3,12,000 patients undergoing treatment under 2300 surgeons. Contrary to the general belief, they found that the surgeons training in non-teaching hospitals out-performed those from the teaching hospitals in terms of morbidity, mortality, complications, and survival rates. They also found that these surgeons were more satisfied with the operative experience that they were exposed to in the nonteaching hospitals than their counterparts in the teaching hospitals. Further, it was found that most of the trainees passing out from the non-teaching hospitals settled in to private practice, and the probable reason offered by Dr. Balinger and Kao in an accompanying editorial [2] was BIt may give them more opportunities to focus on bread and butter general surgeries instead of the more esoteric cases referred to academic medical centres.^ Probably smaller number of trainees in these community hospitals also gives them better exposure to clinical work with less time spent on core research and in the animal or experimental labs. If one were to extrapolate these findings, I think the situation in India is quite analogous. Our private sector hospitals today are no less than the community hospitals in the western world, and they do give an exposure to a wide variety of cases rather than just referral cases to be found in some of the more celebrated and hallowed organizations like AIIMS and PGIs. The only difference that one may find is that in our scenario, most consultants are honorary, and they work on the BPay for Service^ model and therefore may not devote dedicated time in teaching and training students, as these are nonreimbursable activities. Speaking for ourselves, it is no open secret that a lot of busy cardiothoracic surgeons use their trainees only to do preand post-operative workup of cases, and intra-operatively, they are used for only sundry and collateral jobs like opening and closing the chest and conduit harvesting in coronary surgery. Therefore, it should be made mandatory by the regulatory bodies that all consultants working in a particular department which is recognized for post-graduate teaching and training must have dedicated, non-operating sessions, where only training and teaching activities can go on, and for these sessions, those who are not on full-time model must be adequately reimbursed to ensure that they do their job with due diligence and sincerity. As they say, there is no free lunch, and if you do not reimburse these busy consultants for the teaching episodes, we cannot expect them to show sincerity of purpose towards transfer and dissemination of knowledge. One thing however looks reassuring and heartening that if intended well, training at both, the teaching as well as nonteaching hospitals, is equivalent or at least can be made equivalent. Therefore, the parallel system of medical higher education, retained by the much maligned National Medical Commission, has much evidence base going for it for a big thumbs up. Let us, the Doctors, not resist for the sake of resisting and even government must show magnanimity by * Om Prakash Yadava op_yadava@yahoo.com