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 a pansystolic or mid-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

The valve is replaced the same way as in conventional surgery. Robotic cardiac surgery is robotic-assisted: instead of a large incision there are four ports, and the robotic arms carry the long instruments I would otherwise use by hand. The cross-clamp, cautery, scissors, needle holders and sutures are all the same. Only the approach changes: instead of my two hands and an assistant, I have four arms through the robot, and I can switch from one arm to another.

Question 4

Which cardiac abnormalities are not candidates for air transport?

Dr. Udgeath Dhir · Accepted Answer

There is no absolute or relative contraindication as such. We have transferred complex cases, including acute dissections and acute coronary syndromes, and we shift many patients on ECMO. The exception is the haemodynamically unstable patient: one on high inotropic support, with multiple inotropes running, or with an unstable rhythm should be managed where they are rather than shifted. Transfer has to be teamwork between the team shifting the patient and the receiving centre. We hold a video call, review the parameters, the arterial blood gas and the clinical condition, and take a consensus decision on whether to shift. In medicine nothing is static: a stable patient may become unstable in the next two hours, and an unstable patient may become stable, so the patient is optimised first and the airlift planned. There have been patients we could not airlift because of haemodynamic compromise, but most can be moved, even on ECMO.

Question 5

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

In the tricuspid valve case shown, the patient is already on cardiopulmonary bypass through peripheral cannulation. One cannula in the femoral artery returns blood to the aorta, and the SVC and IVC are snugged around the venous cannulas, so blood from the upper and lower body drains to the bypass machine and the roller pump perfuses the aorta while the heart keeps beating. Because this is right-sided surgery and the left side is not opened, the risk of air embolism is minimal. The body is cooled to about 30 degrees, the heart beats at a slow rate, and the valve is stitched while it is still beating. A beating heart is what the heart is made for. Aortic and mitral valve surgery, heart transplants and acute dissections still require arresting the heart, but in certain situations arresting the heart can be detrimental and it may not come off pump; those are the cases done on a beating heart.

Question 6

Which procedures are done by cardiac surgeons, and which by vascular surgeons?

Dr. Udgeath Dhir · Accepted Answer

Where I trained, we were trained in cardiac, thoracic and vascular surgery together. Broadly, cardiac surgeons handle coronary and aortic work, while vascular surgeons handle the thoracic and abdominal aorta and peripheral vascular disease, and there are grey zones between the two. My own work is mostly coronary, valvular and aortic surgery and heart transplantation. A junior colleague on my team, trained as a cardiothoracic and vascular surgeon like me, focuses on peripheral vascular work, popliteal and femoral, and I assist him. These are micro-specialisations rather than separate super-specialities: within cardiothoracic and vascular surgery the organs are the same (the heart, lungs, lymph nodes and aorta), and each surgeon focuses on the area they are most passionate about.

Question 7

Doctors in developing countries often see patients who clearly need intervention abroad but cannot afford the trip or the treatment. How can a specialist help in those situations?

Dr. Udgeath Dhir · Accepted Answer

We are all doctors and we are here for humanity. Treatment should not be denied for monetary reasons. I have been with the Fortis organisation for nine years, and whenever I have asked for financial help for a patient who needed it, it has never been denied. I can assure you of that on my own behalf and on behalf of my organisation. You can also be given my personal mobile or WhatsApp number to call me and discuss complex cases, or any new procedure you intend to do; timings may vary after my operating hours, but I am always available. Just as justice delayed is justice denied, treatment delayed is treatment denied, and treatment should not be delayed or denied on any basis.

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