Aster Medcity News FROZEN ELEPHANT TRUNK A Hybrid Saga

AUGUST 2020 | ISSUE. 1 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Contents

1. Editor's Desk 3 LAV In The Time Of Corona Dr Boby Varkey Maramattom

2. Article Case 1 - 'Sub-Zero Heroes' And A Frozen Elephant Trunk Technique 4 Dr Manoj Nair, Dr Suresh Nair, Dr Rohith Nair, Dr George Varghese

Case 2 - A Neurosurgical Conundrum 7 Dr Dilip Panikar, Dr Anup P Nair, Dr Vineeth Viswam, Dr Feroze Khan, Dr Jitendra

3. New Equipment 9 New Devices At Aster Medcity- Sudoscan

4. Doctors 10 Gastroenterology Team

5. Medical Poem 11 The Dark Knight Dr Siddharth Bhattacharjee

6. Case Study 12 A Picture Is Worth A Thousand Words

Dr Bibu George, Dr Joe Thomas

7. CMS Communique 13 Revolution In Healthcare Affairs (RHeA) Dr T R John

2 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Editor's Desk LAV In The Time Of Corona

It is my pleasure to introduce the inaugural issue of Dr Boby Varkey Maramattom, MD,DM, FRCP [Lon], FRCP [Edin] our monthly Aster Medcity Newsletter. This will serve Lead consultant Neurologist, as a medium to highlight the clinical excellence of Aster Medcity our clinical and non-clinical departments. The cover image and article are about an exciting and rare hybrid combined surgical and interventional technique performed by the dynamic departments of Cardiovascular/ thoracic surgery and interventional radiology. This dynamic duo of ‘Sub-zero heroes’ often perform extremely complex and innovative aortic surgeries. Their track record in large vessel surgical and hybrid procedures has made them a referral centre across the country as well as in neighbouring countries for these procedures. For those of you, who may be still wondering about the editorial title, it refers to the unique Large arterial vasculopathy [LAV] procedure performed during this current pandemic.

The combined CTVS, interventional radiology and cardiac anaesthesia teams have overcome logistical difficulties in transportation, procurement of devices and technical challenges to pull off an extremely rare, risky and intricate procedure. The excellent clinical outcome and patient satisfaction are a testimony to precise communication, seamless team work and post procedural management in a multi-departmental framework. As we pass through challengingsocio- cultural-politicalenvironmental changes, many of our colleagues experience the stress and strain of work, transport and personal safety especially with the looming background threat of the Coronavirus pandemic. Across the globe, societies and countries have flattened the ‘curve’ and there is no doubt that we shall also prevail. Nevertheless, our world has transformed forever- in an evolutionary inflection point, towards physical social distancing and paradoxical digital mental connectivity. This issue highlights the discerning ‘human touch’ that is always necessary even with quantum technological leaps in Medicine.

3 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Article - 1 'Sub-Zero Heroes' And A Frozen Elephant Trunk Technique On the 8th of July 2020 at 2:30 PM, Dr Rohith Nair, Consultant Interventional Radiologist received an urgent call from an international number. The caller, a Consultant Anaesthetist from Srilanka, was precise and clear. A 59 year old man had been admitted with central shearing chest pain and intractable hypertension, about 3 weeks ago. Patient continued to have life-threatening and uncontrollable blood pressure. The CT images were shared with Aster Medcity. On reviewing the CT images, an aortic dissection, where the wall of aorta splits into two resulting in a double barrel blood flow in the aorta, was confirmed. The dissection had also extended retrogradely (towards his heart) stopping just short of the coronary arteries. A ticking time bomb of a case!

Fig 1: CT Aortogram: Green Arrow – Dissection Flap; Orange Arrow – Very narrow True Lumen

4 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

There was one major problem. The patient was hospitalized in Sri Lanka, about a hour away from the capital city and there were strict COVID restrictions in place. A core team comprising of Dr Manoj Nair (Sr CTVS Surgeon), Dr Suresh G Nair (Sr. Consultant Lead of CTVS Intensive Care), Dr Rohith Nair and Dr Johnson (ED Consultant) were formed. Dr Rahul Singh and his ICATT air-ambulance team were recruited to oversee the pre-transfer optimization of the patient and the logistics. The patient was air-lifted to Aster Medcity on the 21st of July and was received by the ED team and the ICU team of Dr Jobin and Dr Kavitha (anaesthetists on-call). Repeat CT imaging @ Aster Medcity showed an enlarging false lumen in the thoracic aorta with a paper-thin true lumen threatening the arterial supply to the right kidney and bowel. After an urgent multidisciplinary team meeting [MDT], the only option seemed to be a major and risky hybrid procedure using a frozen elephant trunk (FET) stent-graft.

The FET has two components – a soft graft component and a stiff stent (frozen) component. In early days such retrograde Type A dissections were managed by a hemi arch replacement with a plication of the true and false lumens with very high morbidity and mortality rates. FET is a major advancement in the management of such complex cases. The stent-graft and the devices were urgently flown in from Mumbai. In the hybrid cath lab, a wire was passed into the true lumen of the aorta via the right femoral artery to prevent the true lumen from collapsing and

compromising blood supply to the patients Fig 2: CT Aortogram : Blue Arrow – Acute organs. Intramural Haematoma in the Ascending aorta.

5 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

The patient was then shifted to the CTVS theatre. Dr Manoj Nair and Dr George Varghese Kurien, CTVS Surgeons, established an intricate bypass circuitry to enable adequate blood flow to all the vital organs. Then the diseased ascending aorta and arch were explanted. On-table deployment of the E- Vita Plus FET device into the descending thoracic aorta was done by Dr Rohith under trans-oesophageal echo guidance. Dr Manoj and Dr George then sewed the graft to the native aorta, which involved multiple suture lines. Anaesthetic team of Dr Suresh, Dr Joel and Dr Anupama orchestrated the day. Under their guidance, perfusionists (Mrs Saritha and Mr Sreeprasad) maintained the critical circuits required to keep the patient alive. The FET procedure is a major milestone in the surgical annals of .

JOTECH EVITA Open Plus FET device (a) Explantation of ascending aorta and arch with deployment of FET (b) Suturing of arch vessels to graft (c) Suturing of graft to aortic root.

Dr Manoj Nair Dr Suresh Nair Dr Rohith Nair Dr George Varghese CTVS Chief Of Anaethesiology Interventional Radiology CTVS

6 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Article -2 New equipment A Neurosurgical Conundrum Master Balu, 13 yr old boy noticed to have protrusion of left eye 5 yrs back, which gradually increased in size over the next years. For this he underwent a biopsy of the lesion and was lost to follow up after that. Now since 2 months he has progressively decreasing vision in both eyes for which he was admitted under Dr Dalvin Thomas at General Hospital, . Ophthalmological evaluation revealed significant loss of vision in both eyes, where only light perception was present in both eyes. MRI brain revealed an extra axial multiloculated lesion expanding the left ethmoidal, frontal , maxillary sinuses with compression of both optic nerves and a severely displaced left orbital contents . He was later transferred to Aster Medcity for better care and was admitted under Dr Dilip Panikar in the Department of Neurosurgery. After explaining the risks and prognosis he was taken up for surgery on 30-7-2020. It was a combined surgical team e ort comprising of

Dr PreDilip OP Panikar(Lead Consultant, Aster Neurosciences),Post OP Dr Anup P Nair (Consultant Neurosurgeon, Aster Neurosciences), Dr Vineeth Viswam(Lead Consultant, ENT Dept), Dr Feroze Khan (Consultant , ENT Dept), Dr Sourav Choudhary (Dept of

Neurosurgery), Dr Jitendra (Consultant Neuroanesthesia) that made the surgery proceed in a rewarding manner. The lesion was seen to involve both optic nerves extradurally and was involving majority of the paranasal sinuses. Lesion was decompressed from the transcranial and the transnasal route and was excised in toto and sent for biopsy. Post excision the proptosis reduced significantly. His condition got better and was discharged in a astable condition on 4-8-2020. He is planned to be kept on regular follow up depending on the final biopsy report (not yet validated) and periodic visual assessment.

7 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Fig 1

Fig 1 & 2 - preoperative image showing left sided proptosis

PostFig 3-OP preoperative MRI showing lobulated Fig 4- postoperative MRI showing enhancing lesion pushing the globe inferiorly and laterally near total excision of tumor

Fig 5 and Fig 6- Post operative images showing well decompressed bilateral optic nerves and significant reduction in proptosis

The Surgical team comprised of

Dr Dilip Panikar Dr Anup P Nair Dr Jitendra Dr Vineeth Viswam Dr Feroze Khan Lead Consultant Consultant Neurosurgeon Consultant Lead Consultant Consultant Aster Neurosciences Aster Neurosciences Neuroanesthesia ENT Dept ENT Dept

8 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

New Equipment New Devices At Aster Medcity- Sudoscan SUDOSCAN is a painless, brief test that provides an evaluation of sweat gland function and autonomic nervous system function. SUDOSCAN measures the ability of the sweat glands to release chloride ions in response to an electrochemical stimulus on the palms of the hands and soles of the feet.

SUDOSCAN test results can be used to determine autonomic dysfunction through the measurement of Electrochemical Sweat Conductance (ESC).

Utility- Small fiber nerve neuropathies, Diabetes mellitus, Parkinson disease, Chemotherapy induced polyneuropathy, Familial amyloid polyneuropathy and Fabry disease.

The department of Neurology runs a comprehensive neuromuscular and autonomic clinic on Thursday, We are the first institute in Kerala to offer a painless, non-invasive and quick autonomic test.- the SUDOSCAN which is a new method to diagnose and evaluate hitherto undiagnosed small fiber neuropathies. This clinic is run by Dr Boby Varkey M everyThursday.

9 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Doctors

Gastroenterology Team

Dr G N Ramesh Dr Ismail Siyad K H Dr Prakash K Senior Asso. Consultant Senior Consultant Senior Consultant

Dr Geetha Mammayil Dr N P Kamalesh Dr Jeffey George Senior Consultant Senior Consultant Consultant

Dr Vipin IS Dr Prashant M Dr Sidarth Chacko Consultant Consultant Consultant

Dr. Nilesh Namdeo Toke Dr. Chithra Thomas Dr. Ramis Abdul Aziz Dr. Cristine Ann Thomas Consultant Specialist Specialist Specialist

10 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Medical Poem The Dark Knight

The story begins with a father and his two sons.. They all fell sick at once.. Went to a hospital - the doctors did their usual dance, But the father got worse, and so did the sons. More people came in, with the same trouble The doctors did not know what was causing this sudden problem.

One night, the doctor went to drink with his friends They started to remember their good old college days How they would always play this one drinking game.. Guess the right word, else you pay! The doctor started to play the game.. He asked, “what is black and never hangs straight?”

His friend answered, it was out of the box But something in his mind fell into place

He rushed to the hospital and sent water from the father's brain To a place which would eventually explain This new problem that caused such a state-wide scare.

The news now had only one picture to share An animal that hung from trees and would shit on everyone's hair.

It was sad that the father and his sons died that day.. Many others followed on the same trail.. We had no answers that day, it is a truth we had to accept We only made plans, did our best to save the day.

The doctors tried to shut off the entire state, To check the problem where it first began.

No one thought the problems this animal would cause Would lead to a month-long pause, catch doctors completely off-guard.

No more! Not again! Let us all take a step Towards a safer tomorrow, have a better plan ahead Our hospitals need to spend their money, show some interest In how best we can manage an out-break scare And make sure the DARK KNIGHT does not pull another JOKER over our heads!

Dr Siddharth Bhattacharjee (MBBS)

11 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

Case Study A Picture Is Worth A Thousand Words Case • 76-year-old male • Left knee pain since 6 months duration • No other Comorbid Illness • 0/E Tenderness localizing to medial

joint line, Dr Bibu George Dr Joe Thomas Knee Crepitation Consultant Associate Consultant Orthopaedic Surgeon Rheumatologist

Radiograph: Osteochondral defect

Intra Operative Image

MRI: Bone marrow ederna + subchondral cystic changes & bony loss

Subchondral insufficiency fracture of the knee (SIF/SIFK) Subchondral insufficiency fracture of the knee (SIP/SICK) are stress fractures in the femoral condyles or tibial plateau that occur in the absence of acute trauma, typically affecting older adults. Post TKR

12 AGUST 2020 | ISSUE. 1 Aster Medcity e-Pulse

CMS Communique Revolution In Healthcare

Dr T R John Affairs (RHeA) CMS, Aster Medcity

After the second world war, even revolutionary technological advances such as nuclear weapons or ballistic missiles did not change the basics of warcraft. It took a humiliating defeat in the Vietnam war, for the US military to bring about a Revolution in Military Affairs and change in battlecraft.

Metaphorically speaking, Healthcare is also a battlefield. Despite tremendous technological advances, there has been no revolutionary changes in the way healthcare of the society was managed in the last century. The Covid-19 pandemic has exposed the fault lines in the current healthcare delivery system. It has paved the way for a Revolution in Healthcare Affairs and modern healthcare in a new world order.

The world has made a quantum leap into a digitalized society. The Covid-19 pandemic has accelerated these changes by a decade. Whether the Healthcare industry wishes or not, fundamental changes to the existing care delivery paradigm ares unavoidable. The survival of organizations and physicians will be determined by their degree of adaptation.

RHeA will involve introduction or maturation of new technologies (eg miniaturized pulse oximeter or ultrasound) their integration into new systems ( eg mobile phones or multipurpose handheld devices), adoption of appropriate operational concepts ( telemedicine and remote monitoring), and finally, the requisite organizational adaptation (eg smart clinics and digitalized hospitals).

To quote Dr , founding chairman of Aster DM Healthcare " Those who don't think ahead of the curve, are likely to perish in the post Covid era. There has to be a paradigm shift in our thoughts and actions, with all of us thinking out of the box, for sustainability, stability and growth in the new world order". His prophetic words are applicable not only to organizations, it is equally applicable to us clinicians.

13 HAPPY INDEPENDENCE DAY

15August

Editor Dr Boby Varkey Maramattom Dept of Neurology

Associate Editor Dr Joe Thomas Dept of Rheumatology Aster Medcity, Cheranelloor, , Kerala. Tel: +91 484 6699999 www.astermedcity.com