Seldom do so many things go wrong with a man’s heart when he’s not in love. But in Bera Ram Chaudhry’s case, now 53, everything began to go downhill, after his first heart attack. However, this tale of a farmer from Pipliya Kalan, a village in Rajasthan, and his heart, is also about the multiple things that were done to get it thudding robustly in its cavity again.
The first clue that all was not well with Mr. Chaudhry’s heart came in 2010, when he was still in his forties. He had a massive attack, his family rushed him to a hospital in nearby Jodhpur, where a stent was put in to a vessel had had occluded to let fresh blood course in again. Then, he went back home, and to his Afeem. Now, afeem is a poppy variant, and perhaps etymologically goes back to ‘Opium’, and plays a major role in this story.
A dangerous addiction
Opium might have exacerbated his heart condition, but only after his second attack during Diwali last year, when heart failure was diagnosed and a heart transplant was said to be the only way out, did his addiction turn out to be the primary villain.
He was rushed to a hospital in Rajasthan, and then another, where he was told he would require a heart transplant. As many health care seekers in this country do, Mr. Chaudhry and his wife, Dhaku Devi along with their son Pawan Lal Chaudhry, went shopping for the right treatment. They had checked out two hospitals in North India and two in the south, all of whom recommended a heart transplant, before they landed up at Dr. Cherian’s Frontier Life line, where the same verdict was handed out to him: heart transplant.
And then, entered villain afeem. “There was one major reason he could not have a transplant. A drug addiction is contra indicated for heart transplants as per international protocols. We could not give him a donor heart,” explains K.M. Cherian, senior cardiac surgeon, who counts the first heart transplant in the country in his list of achievements. Normally that statement might have sounded the knell for a patient. Why we are telling Mr. Chaudhry’s story was because it did not.
1 Patient’s diseased heart. Note excessive swelling on right, in the left ventricle. There is a portion that doesn’t contract in the region.
A bloated heart, blocked vessels, leaky valve
Mr. Chaudhry’s heart was dilated, meaning instead of that normal triangle laid on its side, his heart looked like a ball. As a consequence of this, his mitral valve had been stretched and was leaking. There were also three major blocks in his blood vessels, leading to reduced blood flow to the heart, making it ischemic, and with the heart muscle’s ability to expand and contract impaired it was also a clear case of cardiomyopathy.
Meanwhile, the patient was doing poorly, he could not sleep throughout the night, had to use five or six pillows to sit up at night and in the ICU, was put on ionotropic support that helped maintain circulation and blood flow. This stabilised him, and he went home only to return in the new year, with worsening symptoms.
With the transplant option ruled out, at that point it seemed as if, they would have to maintain the patient on drugs, but already that was not working for Mr. Chaudhry. “When we did the work up for the patient and put this through the multidisciplinary team, a unique solution came through, and we decided to go ahead with it. We took a week to decide this,” explains R. Anantharaman, who runs the heart failure clinic at Frontier Lifeline.
2 The surgeon makes the cut in the enlarged part, removing a portion of the swollen area or aneurysm. First, he repairs the leaking mitral valve, seen inside.
A cow patch to the rescue
“We decided to reconstruct the heart, and bring it back to its triangular shape, unclog the blocks and fix the valve,” Dr. Cherian explains, nonchalantly, making it sound as if it was a game with Lego blocks. It’s far more complex, obviously.
Using a technique called pacopexy, named after Francisco (Paco) Torrent-Guasp whose proved that the muscles of the heart were not long fibres, but rather like coil springs, Dr. Cherian attempts to remodel the heart. He cuts a patch off the left ventricle, the lower chamber of the heart, and stitches it up with a de-cellularised bovine pericardium. As exalted as it sound, it merely means that he used the heart wall of a cow after removing all its cells; and then injected the surrounding area with stem cells drawn from the patient’s own bone marrow. “This was done under the clinical trial protocol stipulated by the Department of Health Research, Government of India. We have the permit to continue this up to 2018” he explains.
“Typically, we would use this procedure in a non-ischemic cardiomyopathy case, where the arteries are normal and blood supply is not affected. Mr. Chaudry’s was an atypical case. Such a combination of things to happen to one man is not common, and such an operation, rare,” Dr. Cherian claims.
3 The surgeon sutures a patch of de-cellularised bovine pericardium onto the area just removed The patient’s own stem cells are injected into the nearby area. Three bypass grafts (in yellow) are created to improve blood flow through the blocked main vessel of the heart, the aorta.
And then, a dash of stem cells
The action of the stem cells, itself, the 73-year-old surgeon says, will kick in only in three to six months, and it is too early to comment on that aspect. The stem cells, he hopes, will revive the hibernating muscles of the heart into functioning again. But one needs to watch out if the proliferation of stem cells will cause a disruptions in heart rhythm; it is known to. But, since the bovine patch used was shorn of its original cells, the question of rejection does not occur, Dr. Cherian says. For one, this will spare the patient the ordeal of taking expensive immunosuppressants to keep his body from rejecting the heart, lifelong.
Indeed, there is a high risk to remodelling a heart, only the skilful surgeon would even attempt it, Dr. Anantharaman adds. The patient was on (balloon) support before the surgery and for about 72 hours after surgery. He has been advised a low salt, fat-free diet and a clutch of drugs to take, but that doesn’t seem to faze the Chaudhrys. “He is back from the dead. Now he can breathe, walk, even eat, doesn’t not have to support himself with six pillows while lying down. These restrictions are nothing, for us, it is a miracle that he is alive and walking today,” says the younger Mr. Chaudhry.
Mr. Bera Ram Chaudhry and Dhaku Devi moved out of the hospital seven days after the surgery, to his son’s home in Sowcarpet. He has been told to keep away from the opium, and he nods his head vigorously at that, his hands folded at his chest in a gesture of thanks, and hopefully, compliance. He seems cheerful, and all over again, in love with his wife in particular, and life in general.
