The Bailout that was a Boon

Posted by Hema Nair on Fri, Feb 28, 2020  
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Junaid is a chirpy little boy, apple of his mother’s eye, but also a heavy burden on her. She and her husband had gathered together whatever money they could spare and come to Bangalore hoping to cure their son. God in his absentmindedness, had created for him an imperfect heart with a hole in it.


Fixing baby hearts, especially the complex anomalies is very challenging business. After all the blood (literally) and toil, if you don’t get it right, you may make matters worse, even to the extent of sending them home in a box. So, we take a long hard look at it from every angle before putting knife to skin. There’s echocardiography, cardiac catheterization and sometimes a CT or MRI before a course is charted. Since we don’t trust ourselves in a matter of such import, we also hash it out in a weekly congress with our colleagues, weighing our options and deciding on the best correction. So it was, that after all of this, little Junaid landed on our operating table one fine day.


Statistics tell us that 1% of all babies born will have abnormal hearts. These anomalies range across a wide spectrum of complexities that will ultimately decide the baby’s life expectancy and health. Those of us fortunate enough to have structurally normal hearts, own 4 chambers, 4 valves, two walls and the flow of blood will follow all the traffic signs. We have two pumping chambers, the right and left ventricles, which pump the blue blood and red blood separately to the lungs and the rest of the body respectively. In the less fortunate ones like our patients, we may have to repair valves, close holes, redirect flows, and sometimes even send the child home with only one pump, instead of two. Here we let the blue blood flow by itself into the lungs to get its oxygen and dedicate the remaining pump to the body.


Is it a compromise? Of course, it is!


But we have few options when these babes are born with only one fully functional pump. The whole body, with its brain, organs, muscles and bones needs it more in order to function optimally; to live, play and work. The lungs will just have to manage with what flows in passively - and miraculously, it does!


These babies can now survive, even thrive with this one pump, almost into the 4th or 5th decade, where otherwise left to nature, they would have withered and given up sometime in their childhood. They may not win medals for sports, or sky dive, but then how many of us can do that even with two pumps?


Junaid’s heart had a defect in the ventricular septum, the wall that separates the two main pumping chambers of the heart. We keep sane in our field by using acronyms to simplify the names of the diseases our patients have, and we call this defect, a VSD. That in itself is a straightforward ‘hole in the heart’ situation that is easily cured by a VSD closure using a patch. But unfortunately, one of his ventricles, the one that drives the blood to the lung, appeared a little small on the MRI scan. That was not good news, because the treatment for him would be the single ventricle pathway.


Often times, the plan for a patient keeps changing with more information coming in and the picture changing. When we did the ECHO on Junaid just before the surgery, we felt that the pump was not as small as we thought it was on the MRI and changed the plan to patching the hole to his heart so he would get two pumps. This would undoubtedly have been the best result for him. Unfortunately, we had overestimated the size of the ventricle, and after the repair, he was worse off than before. Although his VSD was sealed, the smaller pump was not able to take the load of pumping all the blood into the lung. This resulted in the blue blood spilling over into the left side through a pop off valve, and flowing into the rest of his body, turning him very blue. Such severe lack of oxygen in his blood, would not have been compatible with life. His life was now in jeopardy after his corrective surgery. There followed a period of despair and introspection among all of us in the team. In our eagerness to give him the best correction, we had let the ECHO mislead us to making the wrong decision, and Junaid would pay the price for it.


Sometimes when we are lost in the maze of an anomalous heart and the convoluted paths of the blood flowing within, we look for a way out with whatever means we have at our disposal. We consult with our seniors, brainstorm with each other, even look heavenward for guidance. One of us thought of measuring the pressure in the lung, which was very high before his surgery, and would’ve made the single ventricle pathway untenable. But now, after the VSD closure, the pressure had dropped to permissible levels and would enable us to direct half of the blue blood from the upper part of the body directly into the lungs. We decided to go ahead with this bailout surgery and put him on the heart lung machine again. It worked and the diverted blood flowed passively into the lungs without difficulty, leaving only blood from the lower half of the body to flow into the small ventricle, following its natural path. This was only 2/3rd the original volume and could be handled by the ventricle despite its small size and inefficiency. So, what would have been a one pump repair ended up being a one and half pump repair. We had gone wrong on the assessment and having lost our bearings for a bit, had arrived at an alternate and better destination. Junaid now had an extra half ventricle instead of the single ventricle like was initially planned.


This turn of events is the stuff of dreams. Our bailout solution in him ended up being a better one. Barring any untoward incident, he should go home and live a long and productive life with very little limitation in his lifestyle.


Sometimes in our line of work, we make errors in our judgement or lose the plot during a procedure. Confronting these failures is one of the toughest things we have to do. It is easy then, for us to fall into a pit of self-reproach and guilt. But at times like these, we catch a break and end the day full of hope and brimming over with a profound sense of gratitude.


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