Treatment Offered at SSSIHMS, Whitefield

Electrophysiology and Device Therapy

Electro-Physiological Study (EP Study). The normal heart beats according to the electrical impulses from the sinoatrial node to the atrioventricular node. Sometimes additional abnormal pathways form and cause dangerous changes to the normal rhythm of the heart (arrhythmias). EP study is a diagnostic procedure done to find out extra pathways that cause these arrhythmias.

Radio Frequency Ablation (RF Ablation). This is a remedial procedure for arrhythmias. A special catheter is maneuvered into the position identified by the EP study to be the anomalous pathway and the tip of the catheter is heated through application of Radio Frequency to burn the extra pathways, preventing further arrhythmias (ablated).

Temporary Pacemaker Implantation (TPI). A normal heart beats at a “pace” that causes the heart to eject blood into the aorta at the required pressure to circulate to the whole body. Due to various reasons the heart begins to slow down leading to a condition called bradycardia. Consequently the blood flow to the systemic circulation reduces (low cardiac output) leading to other complications. Temporary Pacemaker Implantation is a procedure wherein a catheter is positioned into the heart muscle and electrical impulses sent from an external pacemaker at the required pace to enable the heart to pump out its normal volume. This can be done under situations ranging from emergency interventions (accidents, organ failures, etc.) to procedural requirements in the Cath lab. In an emergency situation the TPI may itself suffice till the necessary action is taken and the heart returns to normal. Cath procedures requiring TPI include the process of Permanent Pacemaker Implantation (PPI); TPI is done to keep the heart beating normally till the PPI is completed.

Permanent Pacemaker Implantation (PPI). When a TPI fails or the heart muscle is beyond salvage and cannot regain its original pace a PPI is performed. This is a semi-surgical procedure done in the Cath lab itself. Pacemaker is a little device implanted in the chest to regulate the heart rate and rhythm. Through a simple procedure the implantation is often done in the operation theatre or cardiac catheterization lab, and usually takes an hour or two.

Pacemakers usually are implanted under local anesthesia; one will be relaxed, but awake, during surgery. Usually, pacemakers are implanted just under the skin in the upper chest. Typical complications for pacemaker implants are not life threatening, but may require a repeat operation or a longer than normal hospital stay. Common complications include bleeding, infection, lead dislodgment, and lead or pacemaker problems following surgery. Complications occur less than 1% of the time.

Intra Cardiac Defibrillator Implantation. When the ventricles of the heart, especially the left one, beat on their own at a fast rate — e.g. 200 bpm as against the normal 120 bpm — it is called Ventricular Tachycardia. When this arrhythmia cannot be cured by ablation, the only other solution is to apply an electrical shock to bring it back to normal rhythm. Patients are implanted with a defibrillator that is programmed to sense this VT and “shock” it back to normal. The procedure for implantation is similar to that of the pacemaker but the instrument is a defibrillator instead of pacemaker.

Biventricular Pacemaker Implantation. The left and right ventricles of a healthy heart pump out blood in a synchronized beat/rhythm. Some hearts do not have this synchronization, which leads to cardiac dysfunction and heart failure. To help such conditions, a special variety of pacemaker is implanted to bring the two ventricles back into sync and consequently improve the functioning of the heart.

Cardiac Surgical Procedures

Cardiac surgery consists of basically two types of procedures, Open heart and Closed heart, the former being done with the help of a heart lung machine and the latter without the need for a heart lung machine.

The commonest open heart procedures include coronary artery bypass CAB (the commonest surgical procedure in the world today), valve replacements, aneurysm repairs and correction of congenital heart defects.

In SSSIHMS, a majority of Coronary artery bypass procedures are done without the help of a heart lung machine (Off pump Coronary Artery Bypass — OPCAB) but with a fully assembled pump available, if needed.

Majority of the valve procedures are replacements, with repairs accomplished when feasible. Aortic aneurysms, depending on their location, are treated appropriately, with valve conduits or grafts as indicated. Total correction procedures form a major part of the pediatric surgical procedures, with palliative closed procedures when indicated. Examples of closed heart surgery include PDA ligation, Bi-Directional Glenn, Blalock-Taussig shunt, Coarctation of Aorta repair, and so on.

Following are the most common procedures done in the department of CTVS at SSSIHMS Whitefield.

Cranial Surgery Procedures

Excision of Cranial and Spinal Arterio-Venous Malformations (AVMs). These are complex surgeries aimed at removing malformed conglomeration of blood vessels that parasitize the brain’s blood supply. The operation involves meticulous dissection around the tumour-like growth of abnormal blood vessels and removal in toto. Similar AVMs in the spinal cord require greater expertise; however the procedure involved is similar to the one described above.

Clipping of aneurysms. Intracranial aneurysms are out-pouchings of blood vessels, similar to a balloon. These may burst causing life threatening sub-arachnoid haemorrhage. We are equipped with the facilities to perform “clipping” of these aneurysms in any location in the brain after performing a digital subtraction angiogram (DSA). Clipping means that the aneurysm is removed from the circulation by application of a clip at its base.

Surgery for giant aneurysms under CPB. For certain aneurysms which are located in exquisite areas or are giant in size, clipping as described above may not be feasible. In such cases, the help of the Cardiac surgery team is sought to perform a Cardio Pulmonary Bypass and temporarily block the blood flow to the site of the aneurysm. This is done by cooling the patient to profound hypothermia conditions and initiating Total Circulatory Arrest. The window of opportunity is around 30 minutes within which the clipping has to be accomplished. This expertise is available in only a handful of centers around the world.

Dural AV fistula (DAVF). DAVFs are rare anomalies which may be managed with either open surgery or interventional procedures. At SSSIHMS a variety of operative strategies are employed in an attempt to disconnect the abnormal communication between an artery and a vein.

Excision of Cavernomas. Cavernomas are mulberry shaped overgrowth of intracranial small blood vessels, which may bleed. They may be located in almost any part of the brain or spinal cord. Great care has to be exercised in removal of these lesions which may be small and may be located in eloquent regions of the brain or at great depth. Sophisticated surgical aids like a neuro-navigation system are often employed to reach the lesion and remove it without damaging the surrounding brain tissue.

Trigeminal Neuralgia. This is a painful condition involving the face where the patient presents with unbearable, episodic, shooting pain in a particular portion of his/her face. The offending structure is usually a loop of an intracranial blood vessel which irritates the nerve conducting sensation from that portion of the face. Surgery is very gratifying and involves separating these two structures under the operating microscope.

Intracranial gliomas. These are brain tumours which may range from benign to malignant high grade tumors (Grade I to Grade IV). Depending on its location, size and patient condition, the surgical strategy is planned for tackling each tumor.

Acoustic tumors (Vestibular schwannoma). These are common tumors arising from the nerve responsible for conducting the sound from the ear. Unfortunately even in this day and age, the patients seen at SSSIHMS present at a late stage with some even losing vision and almost all tumors being extremely large in size.

Meningiomas. Meningiomas are benign tumors arising from the covering of the brain and spinal cord. Depending on its location, the surgical approach is planned.

Complex cranial base tumors. Cranial base surgery is a sub specialty in neurosurgery which is oriented towards the approach of lesions located at areas in the brain where routine surgical approach may not be successful.

Pituitary tumors. The pituitary gland, which has been described as the master gland in the human body, may be home to a variety of tumors, some of which may present with mass effect (visual deterioration, neurological symptoms) and others with endocrinological symptoms. Trans-nasal, trans-sphenoidal approach is used commonly to operate these tumors, i.e. the surgeon operates on the pituitary gland through the nose. Other larger tumors may require an intracranial approach.

Skull tumors. A variety of primary and secondary skull tumors are seen. Surgery involves removal of the tumor and reconstructing the bone defect.

Intracranial metastasis. The brain is a common site for the lodging of cancer deposits from primary malignancies elsewhere in the body. Sometimes the location of the primary may elude detection.

Intraventricular tumors. The ventricles of the brain are cavities filled with the cerebrospinal fluid. A whole range of tumors, from the most innocuous to the most malignant, may be harboured within the ventricles. By virtue of its location, the approach has to be planned in great detail before embarking on surgery.

Degenerative Spinal Conditions, Tumours and Infection

Lumbar Spondylosis — micro lumbar discectomy, laminectomy. Lumbar disc disease is one of the most common conditions encountered in the clinic. If non-operative measures fail, surgery is offered. Surgery is done with the help of an operating microscope or with the endoscope. The surgery involves removal of the disc material and decompressing the compressed nerve roots.

Lumbar Spondylolisthesis — pedicle screw fixation, PLIF (posterior lumbar instrumentation and fusion), ALIF (anterior lumbar instrumentation and fusion). Lumbar spondylolisthesis means a slip of one vertebra over another. Correction involves realignment with the help of titanium alloy screws and rods and bony fusion.

Cervical Spondylosis — anterior cervical discectomy, laminectomy, laminoplasty, corpectomy and instrumentation, lateral mass plate or screw fixation. Cervical Spondylolisthesis — anterior and posterior fusion.

Similar to lumbar disc disease, the cervical or uppermost portion of the vertebral column may also degenerate. One or two levels of disc protrusion and cord compression are treated by removing the offending disc and fusing that level by interposing a bone chip in the space. For two or more level involvement, the disc spaces concerned and the intervening vertebral body are removed and a large bone graft placed, reinforced by placing a plate and screws (corpectomy). A larger level of involvement requires either removal of the back portion of the vertebrae (laminectomy), which may be aided by placing screws through the lateral masses. Sometimes laminectomy may be inappropriate and here the back portion of the vertebrae may be opened out (laminoplasty).

Thoracic Disc Disease — laminectomy, discectomy. Similar to cervical and lumbar degenerative disc disease, the thoracic vertebrae may also degenerate, though less frequently. However, the approach for these locations is more complex because of the lungs and heart located in front of them.

Spinal Tumors — intramedullary (glioma, ependymoma), IDEM (intra-dural extramedullary tumour), vertebral bony lesions. Spinal tumors require gentler handling and precision. They may range from benign IDEM which originate from either the nerve roots or from the coverings, to tumors arising from the neural tissue itself.

Spinal Infection — tuberculosis, pyogenic spinal infections. Tuberculosis infection of the spine may require surgery because of the compression of the neural structures by the pus or destroyed bony elements. Surgery is followed by anti-tuberculosis chemotherapy for a course of one and a half years.

Further Detail

Sometimes additional abnormal path ways form and cause dangerous changes to the normal rhythm of the heart (arrhythmias) EP study is a diagnostic procedure done to find out extra pathways that cause these arrhythmias.

When the ventricles of the heart especially the left one beats on its own at a fast rate eg: 200bpm as against the normal 120bpm, it is called Ventricular Tachycardia.

Neurological conditions evaluated and treated routinely at SSSIHMS include the following:

Spinal Cord Diseases: When surgical intervention is required then the patients are reffered to the sister dept of neurosurgery.

Peripheral Neuropathies including Guillain-Barre´ Syndrome: ENMG, NCV and Nerve biopsies are conducted for diagnosis.

Tumors of the Nervous System: These once diagnosed are dealt by the Neurosurgery department.

However the procedure involved in similar to the one described above.

The Orthopedic department does following surgeries on regular basis:

Services in Dental specialty including consultation, diagnosis and treatment for the following:

The following laparoscopic and open surgeries on regular basis: