A new heart......
We hear how certain ‘boundaries’ were strictly imposed for the safety of the heart recipient. All those from OT A were barred from entering OT B, with a ‘communication’ team in the middle dealing with both sides.
While awaiting the new heart, it was Theatre Master Ashoka Ranatunga’s job to make sure that there was no movement between OTs A and B to prevent infection contaminating OT B and he did so through a lock-down. Even Consultant Cardiothoracic Surgeon Dr. Anil Abeywickrama, after retrieval of the donor heart had to scrub up afresh and don a new set of sterilized attire before being allowed to enter the other OT. All in all, the staff had used up 90 sets of OT suits that night.
The retrieval and transplant of the heart took place with military-precision, with the Cardiothoracic Surgeons practising on cadavers earlier to hone their skills and complete the ‘operation’ within one hour and 55 minutes because every second was of value.
Soon after Consultant Neurosurgeon Dr. Leslie Siriwardana and Consultant NeuroAnaesthetists Dr. Ravi Weerakoon and Dr. Udaya Karunaratne gave the go-ahead on brain-dead Sampath, this donor was wheeled into OT A. Scrubbed up and ready, side-byside were Dr. Abeywickrama and his team and veteran Consultant Transplant Surgeon Dr. P.K. Harischandra and his team.
Simultaneously, the heart, the liver, the pancreas, the kidneys and the eyes were retrieved.
It is Consultant Cardiothoracic Surgeon, Dr. K. Gnanakanthan, who gives the details of the procedure he performed along with Consultant Cardiothoracic Surgeon, Dr. Muditha Lansakara. The donor’s blood group and other necessary matches with the recipient had already been done, with both pre-op and post-op management being handled by Consultant Paediatric Cardiologist Dr. Sunethra Irugalbandara of the Sirimavo Bandaranaike Hospital and Consultant Cardiologist Dr. Roshan Paranamana of the Anuradhapura Hospital.
The retrieval was set for 7 p.m. with Dr. Abeywickrama sawing open the chest and peering closely at the donor heart. “He inspected the heart and found that it was contracting,” says Dr. Gnanakanthan, adding that the “donor heart was good”. It was only then that recipient Kumari was wheeled into OT B around 8 p.m.
Thereafter, the donor’s heartbeat was stopped by the administration of cardioplegia (intentional and temporary cessation of heart activity) and Dr. Abeywickrama ‘explanted’ the whole heart snipping it out with the superior and inferior vena cava, the ascending aorta, the main pulmonary artery and the left atrium with the pulmonary veins.
A similar procedure was being performed in OT B, with Dr. Gnanakanthan and Dr. Lansakara putting Kumari on the heart-lung (cardio-pulmonary) bypass machine; stopping her heart, taking it out by cutting very close to the heart, the superior and inferior vena cava, the ascending aorta, the main pulmonary artery and the left atrial wall but leaving behind the posterior left atrial wall and the pulmonary veins.
Having done the retrieval, Dr. Abeywickrama gently placed the heart covered in cold saline in a silver tray and handed it ever so carefully to the ‘communicators’ who in turn passed it on to the transplant team in OT B. It was on a ‘back-table’ in this OT that the donor heart was “prepared” with slight trimming here and there and cutting open the left atrium.
Easing the new heart into Kumari’s chest, the “stitching” (medically known as anaestomosis) began, starting with the left atrium of the donor heart followed by the pulmonary artery and so on. While the inferior vena cava was being stitched that the first clamp was removed, the new heart perfused and the blood supply restored.
Tangible moments of tension in OT B, a sense of expectation and suddenly murmurs of joy and laughter and sighs of relief, as the medical and surgical teams peered down at the operating table.
The time is etched into the memories of all – 11.14 on the night of July 7……..when the new heart of Kumari began with a slow-beat.
“Thereafter, we provided some electrical activation and the beat became stronger and stronger,” smiles Dr. Gnanakanthan.
The rest, of course, is now epoch-making history, with the transplant patient being taken off the heart-lung machine, stitched up and the chest cavity closed.
For the anaesthetic team, comprising Consultant Cardiac Anaesthetists Dr. Jagathi Perera, Dr. Aruni Jayasekera, Dr. Priyantha Dissanayake and their juniors, however, their work is not over as Kumari is still under their care in the CTICU.
Their stress and worry can only be imag- ined. “None of us had done it before but we read up extensively and felt confident because we have been part of very complex heart surgeries,” says Dr. Perera, with Dr. Dissanayake nodding vigorously.
“Haemodynamic monitoring (whether the circulation is performing its task of oxygen delivery to tissues) is vital, not only to keep the patient alive, but also to prevent any complications,” she says, referring to the many challenges they faced because Kumari’s heart was performing only at 10% when usually it should be 60% and the Ejection Fraction (the percentage of blood leaving the heart each time it contracts) was 10-15. They did not put her under general anaesthesia when inserting invasive lines to monitor pressure etc., but with her cooperation, even though she was scared, did so under local anaesthesia.
When under general anaesthesia and on the heart-lung machine, the tasks of the anaesthetic team would make a difference between life and death, as they had to maintain her pressure and ensure that all her other vital organs would not be endangered in any way.
“Kumari’s diseased heart was quite huge,” says Dr. Perera, while Dr. Dissanayake adds that the donor’s heart when transplanted was tiny, like that of a child.
The anaesthetic team had their anxious moments too – when attempting to send in the pulmonary-artery catheter, with the newly-stitched blood vessel hindering a smooth entry. As such, they had to make do with echocardiograms.
Another stressful moment was when Kumari was taken off the heart-lung machine and her pressure could not be maintained for about 45 minutes, with the anaesthetic team sending in maximum doses of medication and keeping the ECMO (Extracorporeal Membrane Oxygenation) machine, willingly loaned by the LRH, handy. ECMO technology is similar to the heart-lung machine but is more suitable for prolonged use in an ICU.
When on July 8, after Kumari had been transferred to the CTICU, the blood gases being “bad” brought on strong suspicions of a major bleed into the heart, the teams were compelled to open up her heart. This time it was not in the OT but in the CTICU itself, with the area being transformed into a miniOT, says Dr. Perera.
Paying tribute to the nursing and laboratory staff, she points out that small adjustments and major efforts at making-do, they did to perfection.
Dr. Perera adds that the final scare came in the form of a fungal infection, not spotted earlier but set off from the donor, which they blasted with powerful anti-fungal medication.
By July 9, however, a test feed was given to Kumari, with full-scale nasogastric (NG) feeding on Monday, with the anaesthetic team breathing easy only on Tuesday after all issues had been sorted out.
Others who were of immense support in this transplant were Consultant Haematologist Dr. Sunethra B. Athauda, Consultant Histopathologist Dr. A. Vithanage, Consultant Virologist Dr. Rohitha Muthugala, Consultant Microbiologist Dr. Mahen Kothalawela, Consultant in Transfusion Medicine Dr. Dharma Samarakoon and Consultant Judicial Medical Officer Dr. M. Sivasubramaniam.