Wonders of recycling blood!

By Shanika Sriyananda

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Imagine her heart beats and lungs move while she is in deep ‘slumber’. Medically, though the heart is ‘drowned’ in blood, her heart throbs. The fifty-six year old patient is not supported by a machine that keeps her two vital organs moving.

While the small, but miraculous ‘turbine’ - the heart- is still in full swing, the cardiac surgeons are busy in a three-hour surgery to correct the blocks - two on the left: the left arteria descending artillery and circumflex artillery and the right coronary artillery - which will cease the patients heart soon if not corrected soon.

Well, its yet another ‘by-pass’ surgery which is one of the most known heart operations, like ‘koththamalli’ for common cold, in Sri Lanka.

For Dr. Y. M. K. Lahie, the Resident Consultant Cardiac Thoracic Surgeon at Nawaloka and his team, it is yet another heart operation. But for us it is the first time, as Dr. Lahie says, that a media coverage is allowed at this ‘beating heart’ surgery.

By-passes nature too

It is not only by-passing the heart, but a moment which by-passes nature too. It is a surgery where a drop of blood is not drained into the sink and recycled during the surgery.

For decades, in the traditional coronary by-pass procedure, the patient’s heart is stopped and blood flow and breathing are regulated by a heart lung machine.

But with the modern discoveries in the field of heart surgery, using off-pump by-pass, or operating on a beating heart, the experts say it will prevent patients from suffering the cognitive decline that is often associated with traditional by-pass surgery.

“Octopus please”, says Dr. Lahie explaining the importance of using the patient’s own blood to prevent the risks involved in bank blood; though it is safe; and also to avoid other complications that might trigger when outside blood is pumped.

The octopus is a gadget which stabilizes the portion of the heart during surgery and as it does not move the surgeons find it easy to put sutures.

“We are doing this surgery without a heart-lung machine which is also another advantage for the patient as it will damage the blood. During a heart surgery or any other surgery there is a blood loss. And also when we use this machine the blood gets diluted and blood is lost.

Here we save the blood and also minimise the bio-chemical changes”, elaborates Dr. Lahie showing the ‘reservoir’ where the blood during the surgery is collected, purified and transfused during or at the end of the surgery.

Sister Renuka is giving some drugs from the line through the neck and also getting blood from the patient through radial arterial to do some blood tests.

Lasts a lifetime

The heart in view during stages of the by-pass.

“Here, we use patients own artilleries and veins and avoid using any foreign material to do the surgery. The advantage is we can do a complete graft and correct whatever the blocks are”, Dr. Lahie further explains as he cuts through the inner covering of the heart, the peri cardium and finds the mammary artillery, which according to the surgeon, is worth millions and cannot be purchased from anywhere.

“It will last a lifetime. It is the best graft for the coronary heart surgeries and better than all the stances that man has ever discovered. This is god’s gift to mankind. It has a tremendous blood flow”, marvels Dr. P. Kamalaneshan, the Assistant Surgeon.

“We are not ready to by pass the blocks and restore the blood supply to the heart. Check the pressure”, directs Dr. Lahie and digging into the ‘compartment’ in search of the heart. Here is the beating heart and he says that some have misunderstandings that the heart will be taken out to do the by-pass. “It’s a myth and no where in the world is a by-pass done taking the whole heart out”, the medical artists at the job tells us.

Minute

The surgeons need to master the job using chopsticks too. In that eight-inch opening where the heart is beating and lungs are moving the two surgeons are ‘playing’ finely with the surgical equipment avoiding even the slightest damage to the heart. One tiny extra cut will bring a disaster. They start grafting the mammary artillery to the left interior descending artillery which is the main artillery of the heart.

Who decides the type of surgery, it is the surgeon or the patient? “The surgeon will decide whether it is a beating heart operation or otherwise depending on the situation of the patient. This patient’s blood group is O negative and very difficult to get in quantity. So here it is a good technique, recycling the blood”, replies Dr. Lahie.

The fingers move rhythmically putting sutures to the tiny 5 millimetre cut in the artillery. At the end of this ‘sawing session’ with the tiniest needle that I have ever seen, the grafting is completed with 20 permanent sutures with synthetic threads called polyprophlian.

Dr. Lahie proceeds to enlighten us. That the cut varies depending on the size of the block. Diabetic patients have very distal blocks and small artilleries and grafting becomes a problem. Controlling diabetes and cholesterol and avoiding all other risk factors are very important before the surgery and even after the surgery. Minutely they cannot overlook the risk factors.

It is 10.30 in the morning and the first blockade in the heart is now completed while the suction is used to collect the blood into the cell saver. Now it is time to graft the vein harvested from the right leg of the patient. Not only the leg veins - radial artillery - harvested from the hand too is grafted.

Star fish

“Star fish please”, that is Dr. Kamalaneshan. “It is like you have come to a sea food restaurant. Most of the small equipment are named with sea creatures”, he says while lifting the apex of the heart using the ‘star fish’ to turn the heart the other side and stabilizing it to graft the vein.

“If the left main artillery is blocked the surgery becomes urgent. You cannot wait and if there is a severe block on all the artilleries that is also an indication for urgent surgery. When a person gets a heart attack with three blocks or even a single block and after a heart attack the heart is weak as heart muscles die.

A clear view of stabilising the heart for grafting a vein.

Some of the muscles may not recover. Better to do it before the damage occurs. That is why we advice patients who have to be watchful about symptoms and those who have strong family history of heart failures and are suffering from risk factors, to seek immediate medical advice rather than waiting until the heart gets weaker and weaker.

A patient with a one block can go for angioplasty that is stenting. But in cases where there is a block but stanching cannot be done because the block is severe and close to the main artillery, they need by pass surgery”, Dr. Lahie enlightens us during the job .

Stitches are put to the six inch vein where there is a possibility of bleeding. Then the coronary artillery opened and the graft put on to the opening while the ‘blow mister’ is sucking whatever blood is collected in the ‘compartment’.

The surgeons say that lifestyle changes. Stress and less exercises led more young males and females in their 30s to get coronary artillery blocks. This life saving effort needs a good medical team including good anaesthetic and as these surgeons stress the surgeons alone cannot bring good results in heart operations.

One stich in a wrong place can make a big difference. No short cuts here and artilleries on which the whole heart depends are measured in millimetres. The patients’ chest is covered with an antibiotic layer and a single grafting will take 45 minutes.

Now the surgeons are trying to mimic the nature. The heart is lifted and it is back in the compartment. The graft that is put into the artilleries will put into the ayota, which is the main blood supply to the entire body.

The blood is gushing heavily from the tiny hole cut in the ayota. It will do enough to bathe the whole ceiling. Now the beating heart surgery is nearing completion where the left arteria descending artillery is bypassed to the left internal mammary artillery, and the vein is grafted to the top end of the ayoto and the distil end to the circumflex and right coronary.

After three and half hours long highly delicate surgery, a tiny drop of blood is not wasted. Instead, the surgeons are able to save one to three pints of blood which will be given to the patient once she in this case is transferred to the Intensive care unit in the next few minutes.

Burnt

The remaining places which are leaking blood are burnt with electric current and two tubes are inserted to drain the remaining blood after the surgery.

Now the fine work is finished and the surgeons start fixing the strong bone using stainless steel wires, which will last till the patient dies.

“She will go home within ten days; but”, cautions Dr. Lahie, “she has to take extra care about her food; needs to follow the doctor’s advice”.

Putting the final stich on the chest of the patient will not end the ‘medical drama’. It will continue until he or she regains consciousness. Until then the medical staff is too breathless. For it is a tough session which decides a life.

In this hi-tech era, an alternative fluid for human blood is yet to be tapped. It is miraculous that the surgeons too ‘go green’ by recycling and re-using human blood.

Pix by Wimal Karunatilake