Question 1

It would be very helpful to talk to the audience about what kind of conditions, triggers or symptoms they should look for in patients, since most of them practise in resource-poor environments and need to know when to make a referral.

Dr. Udgeath Dhir · Accepted Answer

The most important symptoms are valvular: classic breathlessness, dyspnoea on exertion, and paroxysmal nocturnal dyspnoea, where patients cough at night and cannot lie flat, along with chest pain. On evaluation, echocardiograms and electrocardiograms combined with coronary angiography establish the diagnosis. On examination, a murmur, a raised jugular venous pressure, or an irregular rhythm suggestive of atrial fibrillation with an ejection systolic or diastolic murmur in the mitral area points toward rheumatic heart disease with mitral stenosis and regurgitation. In short, the heart has only a few ways of signalling distress, tachycardia or bradycardia, changes in blood pressure, breathlessness or pain, and any of these symptoms warrants evaluation by a physician.

Question 2

What are the cost implications for these surgeries?

Dr. Udgeath Dhir · Accepted Answer

Every surgery has a different cost, but as an approximate range, minimally invasive procedures, depending on the valve involved and the complexity of the case, generally run from $6,500 to $18,000, depending on the consumables used.

Question 3

How do you replace valves when doing robotic cardiac surgery?

Dr. Udgeath Dhir · Accepted Answer

Valve replacement is done the same way as conventional surgery, except through a robotic-assisted approach: instead of a large incision, four ports are used, and robotic arms carry out the same cross-clamping, cautery, scissors, needle holders and sutures used in open surgery. The only real difference is the approach, long instruments are operated through the robotic arms rather than by hand, giving the surgeon four arms instead of two, with the ability to switch between them.

Question 4

When doing cardiac valve replacement, how is the heart able to keep beating while the defective valve is being replaced?

Dr. Udgeath Dhir · Accepted Answer

For valve repairs such as tricuspid valve surgery, cardiopulmonary bypass is established through peripheral cannulation, one line into the aorta feeding the heart, and the SVC and IVC snugged with cannulas for venous return, so blood bypasses the heart via the bypass machine while the heart itself keeps beating. The body is cooled to around 30 degrees so the heart beats at a slower rate, allowing precise stitching while it is still beating, which is generally better for outcomes than arresting the heart, since some hearts do not come off bypass well after being arrested. Aortic and mitral valve work, heart transplants and acute dissections still require arresting the heart, but tricuspid repair is done on a beating heart specifically because the results are better that way.

Question 5

Which cardiac abnormalities are not candidates for air transport?

Dr. Udgeath Dhir · Accepted Answer

There is no absolute contraindication as such, complex cases including acute dissections and acute coronary syndromes have been safely transported, and some patients are shifted on ECMO. The determining factor is haemodynamic stability: patients on high inotropic support, requiring more than 5 litres of oxygen per minute, or with an unstable rhythm need to be stabilised where they are rather than shifted immediately. It is a dynamic, case-by-case decision made jointly by the shifting team and the receiving hospital based on a video call reviewing the patient's arterial blood gas and clinical parameters.

Question 6

What cardiac procedures are done by cardiac surgeons but not by cardiac surgeons?

Dr. Udgeath Dhir · Accepted Answer

This reflects a training distinction rather than a hard rule: cardiac surgeons handle coronary and aortic work, while vascular surgeons handle the thoracic and abdominal aorta and peripheral vascular disease, with some grey zones between the two. These are micro-specialisations within cardiothoracic and vascular surgery training rather than entirely separate fields, and which areas a given surgeon focuses on often comes down to personal interest, coronary, valvular and aortic work in one case, or peripheral and femoral vascular work in another, both trained under the same cardiothoracic and vascular surgery programme.

Minimally Invasive and Robotic Cardiac Surgeries

Questions Doctors Asked Dr. Udgeath Dhir