Dr. C.S.SADASIVAN MEMORIAL ORATION - 2014

Dr. C.S.SADASIVAN
MEMORIAL ORATION - 2014
Lokeswara Rao Sajja, MS, MCh, MD, FACS
Senior Consultant Cardiac Surgeon
STAR Hospitals, Hyderabad, India
The Journey of Surgery for
Coronary Artery Disease In India:
Adoption, Customization and Innovation
60th Annual Meeting of IACTS , Kovalam , Trivandrum , 20th-23rd February 2014

Video

 Dr C Sadasivan had a strong desire to
make India self-sufficient in all aspects
of Cardio Thoracic Surgery.
 He started 2years course - Masters in
Cardio Thoracic Surgery in 1959.
 He was conferred the Padma Shri
Award in 1969 in the field of Medicine
for his outstanding contributions for
Cardiothoracic surgery

KS Iyer
Baba Das
A . Sampath Kumar
P.Venugopal
Balram Airan
IM Rao
My Teachers at AIIMS
ML Sharma

My Co-Residents at AIIMS
V.Mohan Reddy Lokeswara R Sajja K.Samba Murthy

Denton Cooley
KM Cherian Alexander John
My Mentors
Sampath Kumar

Our Team at Star Hospitals

The Journey of Surgery for Coronary
Artery Disease In India:
Adoption, Customization and Innovation

 An estimated 47 million Indians had CAD
 Annual mortality was 2.3 million in India and
17 million world wide
 Incidence of CAD in India - 1960 - 1%
1994 - 10%
Projected incidence (2020) - 12.5%
The magnitude of problem of CAD in India (2010 data)
By 2015, India is estimated to have 62 million patients with
CAD. Of these, 23 million will be younger than 40 years of age
and only 11 million above 60 years of age
By 2020 India will have more individuals with
atherothrombotic disease than any other region
The prevalence rates of CAD in India have increased from
1.6% to 7.4% in rural populations and from 1% to 13.2% in
urban populations

2010 2015 Increase
from 2010
to 2015
All ages 47.0 61.8 32%
Indians with
coronary artery
disease (CAD)
<50yrs of age 28.4 37.3 31%
<40yrs of age 17.4 23.0 32%
<30yrs of age 8.3 10.5 27%
Deaths due to
CAD
All ages 2.3 2.9 26%
<50yrs of age 1.14 (50%) 1.5 (52) 32%
<40yrs of age 0.70 (30%) 0.92 (32%) 31%
<30yrs of age 0.33 (14%)
900/day
0.42(14%)
1150/day
27%
Tsunami of Premature Heart Disease in India (in million)

Younger age at presentation (<40Yrs)
 2.5% - Western Countries
 12-16% in India
 High incidence of multi-vessel CAD
 Diffusely diseased coronaries
 Distal disease
 Significant left ventricular dysfunction at presentation
The Journey of Surgery for CAD
Unique features of Indian CAD

Coronary angiograms showing diffuse CAD

Echocardiogram Images

MRI Images
Marked LV dilatation and thinning of myocardium

CT Angio showing diffusely diseased coronaries

Endarterectomy in diffuse CAD

Coronary artery bypass surgery was performed by
Dr. Rene Favalaro in 1967 at Cleveland Clinic in a
systematic fashion

Dr. Dudley Johnson of Milwaukee was instrumental in
popularizing CABG in USA

Dr. Denton Cooley
Texas Heart Institute

In India, Dr. K M Cherian working at
Southern Railway Hospital performed
first Coronary Artery Bypass Surgery
in June 1975 using saphenous vein
graft
The Era of Indian Coronary Artery Surgery
Courtesy : Dr.KM Cherian

Oh! They re here to handle Indian
Indian affordable common man getting
coronary bypass surgery done in foreign countries

Indian dignitaries getting coronary bypass
surgery done in foreign countries

PV Narashimha Rao Jai Pal ReddyNT Rama Rao

Indian dignitaries getting primary CABG in India

Indian dignitaries getting primary
coronary bypass surgery in abroad and redo in India

Phenomenon of Reverse Influx

Training aspects of coronary bypass surgery

Denton Cooley Rene Favalaro Dudley Johnson Floyd Loop
Albert StarrJohn W Kirklin
American cardiac surgeons who trained Indian surgeons
Bruce W. LytleAlfred J. Tector

James TatoulisCalafiore AM
American, European & Australian surgeons who trained Indians
Hendrick B.Barner Barratt Boyes Alan Carpentier
Buxton BF
Sir.Magdi yacoub
Victor Chang

KM Cherian KR Shetty MR Girinath Venugopal
Naresh Trehan S Bhattacharya A.Sampath Kumar
Indian Pioneers of coronary surgery who trained next generations

RK Panda Devi P Shetty D.Prasada Rao Nitu Mandke
Bhaba Das Vivek Jawali T Alexander John
Pioneers of Indian coronary surgery

Over this time coronary artery bypass grafting (CABG) has gone
through three distinct eras in its evolutionary journey.
The first, or “experimental”,
The second, or “vein graft”, era
current era is that of “mixed venous and arterial grafting”.
Eras of coronary surgery in its evolutionary journey

Evolution of coronary bypass surgery in India

1975 : Dr.K.M Cherian did the first single vessel CABG with
saphenous vein graft at Southern Railway Hospital,
Perambur, Madras .
1983 : 35 centers all over India performed about 6000
CABG procedures
1993 : About 10,000 procedures performed in 50 centers
1999 : Number of procedures increased to 11,450
2009 : 60,000 CABGs performed
Currently 92,000 CABGs are performed yearly
Progress of Coronary Surgery in India
May not be an exact estimate in view of
absence of a central database registry

2000 2004 2007 2008 2009 2010 2012
On-
pump
16,682 18,881 38,052 46,868 43,941
Off –
pump
25,682 26,874 36,055 43,289 48,274
Total
CABG
25,000 30,000 42,364 45,753 74,107 90,157 91,942
Total
OHS
42,000 50,000 68,982 73,400 99,063 1,17,312 1,31,000
CABG Trends in India

 All vein grafts
 Good target coronary arteries
 Good left ventricular function
 Limited co-morbidities
Standard CABG procedure in early 1980s
(Vein graft era)

CABG using all vein grafts
Saphenous vein harvest techniques

 LIMA to LAD
 Additional vein grafts
 Increasing co-morbidities
 Compromised LV function
Standard CABG Procedure in late 1980s and early 1990s
(Mixed venous and arterial grafting era)

IMA Harvesting CABG with LIMA-LAD &
Saphenous vein to other targets

Internal Mammary Artery
 Internal Mammary Artery is the best arterial
conduit for CABG
 The importance of using the Internal Mammary
Artery graft to LAD is widely accepted.
 IMA graft demonstrated highest long-term
patency rates

 Young patients undergoing CABG
 Non availability of venous conduits
CABG using bilateral internal mammary arteries
in late 1990s

LIMA Harvest
RIMA Harvest
Pedicle harvest of bilateral IMAs

Skeletonized harvest of bilateral IMAs

 Bilateral ITA grafting is performed only in 6-7% of
Indian patients
 Whereas 10-11% of patients in Australia and Europe
received BITA grafting .
 The routine use of BITA grafting has been resisted
by several surgeons for multiple reasons.
 Increases in the difficulty and duration
of the operation
 technically challenging
 increased risk of sternal wound complications
Limitations of use of BITA grafting

Skeletonization of IMA Modified pedicle harvest
Reduction of sternal wound complications
Division of the IMA pedicle
proximal to terminal
bifurcation

Arterial conduits used are
 Bilateral IMAs
 Radial artery
 Gastroepiploic artery
 Inferior epigastric artery
Total arterial revascularization in late 1990s

 Second best arterial conduit
 Excellent short, mid & long -
term patency rates
 Less blood loss compared to
BIMA
 Free grafts / composite graft
Radial artery

Gastroepiploic artery
 Excellent patency rates
 Infrequent use in India
 Frequently used conduit
in Redo CABG

Total Arterial Revascularization
using pedicle Bilateral ITAs
(LITA-RITA „Y‟ graft)
Total arterial revascularization
using bilateral pedicle in situ
IMA grafts

TAR using bilateral skeletonized IMA grafts

Total arterial revascularization using LIMA - RA Y graft
and RIMA- RA composite graft

Various patterns of total arterial revascularization

Images courtesy
Dr Ramakanth Panda
Total arterial revascularization using skeletonized BITA

On-Pump CABG
 Currently about 40-45% of CABG s are performed
 Offers more complete revascularization
 More suitable for diffuse disease
 More suitable for hemodynamically unstable patients
Early part of the evolution of coronary bypass surgery all CABGs
was performed with the aid of cardiopulmonary bypass.

On-Pump CABG Diffuse CAD (on-pump CABG)

Off-pump CABG
 India’s first beating heart bypass surgery
in 1992 by Dr.Vivek Jawali
 Dr. Baba Das started Beating Heart
coronary bypass surgery program in the
country in 1992

Off-pump CABG
 Tissue stabilizers – Octopus, Maquet
 Cardiac Positioners – Starfish, Urchin
 Intraluminal shunts
 Mister-blowers
With the availability of various types of

ACROBAT SUV Vacuum Stabilizer
Urchin

OPCAB for CAD
Intracoronary shunts

OPCAB using Starfish and Octopus

Off-pump CABG
LAD arteriotomy Insertion of intracoronary shunt

Off-pump CABG
LIMA is being anastomosed to LAD Completion of LAD anastomosis

Off-pump CABG
PDAAnastomosisObtuse marginal branch anastomosis
Later on to the inferior and lateral wall targets

Intra-myocardial LAD
Off-pump CABG
Sequential LAD anastomosis
for Dual LAD

OPCAB On-pump CABG
Less bleeding Technically less demanding
Less renal dysfunction Shorter learning curve
Less short-term neuro-
cognitive dysfunction
Better long-term graft patency
Shorter hospital stay Lateral wall targets easier to graft
Higher rates of complete
revascularization
Off-pump vs On pump CABG

Re-operative CABG
 Young age at primary operation.
 Comprise of 4% of the patients undergoing CABG
 Decreasing trend in the prevalence of redo CABG
 Currently safe procedure

Blocked Grafts
LIMA- LAD , SVG - OM
LIMA-LAD
Anastomotic narrowing

Blocked SVG to OMBlocked SVG to RCA Stenosed RA graft to LAD

Sternal reentry
Reoperative CABG
exposure of the heart

Reoperative CABG -
Control of patent LIMA
Reoperative CABG -
Vein Graft Disease

Reoperative CABG RIMA- LAD
SVG proximal anastomosis in progress

Transmyocardial Laser Revascularization
(TMR)
Institute of cardiovascular diseases, Madras (1994)
Escort Heart Institute and Research Center , New Delhi (1995)
 An evolving technique
 Few centers carryout TMR
 Indicated in disabling angina not
amenable to other modes of treatment

 Growing research on safety and feasibility of coronary
revascularization via robotic assistance
 Smaller incisions with minimal scarring
 Less trauma to the patient, including less pain
 Shorter hospital stay (usually 3 to 4 days)
 Decreased use of pain medications
 Less bleeding
 Decreased risk of infection
 Shorter recovery
 Expensive
 Longer operating time
Robotics in Cardiac Surgery
Centers : New Delhi , Hyderabad, Chennai, Mumbai, Pune

da VinciTM Surgical System
Surgeon Console Intuitive Movement

MICS CABG
Centers : Hyderabad, Bangalore, Chennai, Delhi, Mumbai
 Growing in popularity
 Needs specialized
instrumentation All the coronary
targets can be reached
 Off-pump/ pump supported
CABG
 Angiographic graft patency to
be reported

MICS CABG
IMA is being harvested

MICS CABG
Exposure of LAD after pericardiotomyCompletion of IMA harvest

Awake Cardiac Surgery
 Dr. Vivek Jawali Performed
India’s first awake CABG

Awake CABG
Dr. Jawali did India’s first Awake Cardiac surgery (Surgery
without GA or ventilator,
done under continuous high thoracic epidural) in June 199
9. Performed world’s 1st awake open heart surgery (a
74 yrs pt underwent triple bypass with aortic valve replace
ment without G.A. or a ventilator) in April 2002

 Infrequent
 Surgical left ventricular restoration
aimed to restore the volume
 To restore shape
 Techniques of repair
 linear repair
 endoventricular patch plasty
Surgery for L V Aneurysms

LV Aneurysm with clot

LV Aneurysm Repair
Endoventricular circular patch plastyLIMA to LAD

 Prevalent problem among patients
undergoing CABG
 Quantification of MR
 Surgical options for severe MR
 Repair
 Replacement
Surgery for Ischemic MR

Undersized mitral
annuloplasy
Ischemic mitral regurgitation
testing the valve

CABG
LV restoration
MV Repair
Triple procedure for CAD

CABG with Concomitant Valve surgery
 Aortic Valve Replacement
 Mitral Valve Replacement /MV Repair

CABG with concomitant surgery for congenital heart disease
A case of TOF and CAD
Critical stenosis in mid LAD Coil closure of AP collaterals

Indian Cardiothoracic Publication out put during 1966-2013

Participation in International Trials

Dr. P. V. Satyanarayana
Dusk Database for Coronary Artery Bypass Surgery

Our Contribution

Publications on surgery for CAD
Over 50 papers on CABG were published in
International Journals of cardiovascular surgery
 Journal of Thoracic and Cardiovascular Surgery,
 The Annals of Thoracic Surgery,
 European J of Cardiothoracic Surgery,
 Asian Cardiovascular and Thoracic Annals,
 Journal of Cardiac Surgery,
 Texas Heart Institute Journal,
 Cardiology,
 Indian J of Thoracic and Cardiovascular Surgery

 Papers on CABG,OPCAB, Redo-CABG, CABG in LV
dysfunction, LMCA stenosis, surgery for Ischemic MR,
dual LAD ,post MI VSD
 Current Review in Annals of Thoracic Surgery from
India (2005)
 Editorial on “The strategies for optimizing outcomes in
patients with compromised renal function undergoing
CABG” in Cardiology, an European Journal was
published in 2008
Publications on surgery for CAD

42nd Annual Meeting in
Chicago, January 30 –
February 1, 2006

Citations
 Citation of the work done in India. on
patency of Radial Artery grafts in the text
book “Cardiac Surgery in the Adults” by
Laurence H Cohn-2008,2012
 Current Opinion in
• Cardiology,
• Nephrology and Hypertension,
• Anesthesiology
 Surgical Clinics of North America,
 Manual of Perioperative Care in
Adult Cardiac Surgery
 Revisiting Cardiac Anatomy:
A Computed-Tomography-Based Atlas
and Reference

Our experience in surgery for coronary artery disease
Primary CABG
 Period: February 2000- December 2013
 Total number of CABGs : 9,811
on-pump CABG: 4199
off-pump CABG: 5612
 On-pump CABG mortality : 52/2951:1.76%
 Off-pump CABG mortality : 10/2842: 0.35%
Redo CABG
Total number : 204
Mortality : 04 (1.9%)

CABG with associated procedures
 CABG +MV repair: 233
 CABG + Valve replacement :162
 Aortic valve : 83
 Mitral valve : 61
 DVR : 18
Our experience in surgery for coronary artery disease
 CABG +LV restoration : 101
 CABG +carotid endarterectomy : 15
 CABG + aorto bifemural bypass : 04

With all the limitations, we have gone a long way in coronary
artery surgery. India could have been the ideal venue for a study
like SYNTAX Trial
It is noteworthy that perhaps the highest number of off-pump
CABG surgeries are performed in India and needless to say we
should have been the pioneers in popularizing several aspects of
OPCAB Surgery.
Coronary artery disease is assuming pandemic proportions in our
Country and we may have to perform 10 times the number of
surgical interventions than we do today in the face of rising health
care cost .
Call for attention

Call for attention
To meet the challenges of tomorrow we have to develop
indigenous technology and adopt the same to our clinical
practice.
We need to focus on outcome analysis and publication in our
practice to make our experience known to the world.
We may have to continue the journey with the conventional
and established techniques while trying to embrace the
evolving technology.

It is essential to restructure our integrated training program to
create a new generation of cardiothoracic surgeons through multi-
disciplinary training that would prepare them for new paradigm.
Call for attention
The Journey continues………..

Thank you
“ Success is not final, failure is not fatal:
It is the courage to continue that counts”
- Winston Churchill

Dr. C.S.SADASIVAN MEMORIAL ORATION - 2014

Recommended

Recommended

More Related Content

Recently uploaded

Recently uploaded (20)

Featured

Featured (20)

Dr. C.S.SADASIVAN MEMORIAL ORATION - 2014