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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 Kerala. 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, Ernakulam. 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 eort 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.