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Open heart surgery beyond belief
Doctors successfully complete a major heart operation on a little boy without a blood transfusion, reports Smriti Daniel
Miscael Joshua is a walking tribute to modern medicine. Even more interesting is the fact that within his small body, science actually made allowances for religion. The little 5 1/2 year old with a growth in his heart and the religious beliefs of a Jehovah’s Witness was far from being the ideal candidate for heart surgery. But thanks to Dr. Prasad Krishnan, Consultant Cardiac Surgeon, Chief Anaesthetist Dr. J.M. Shahani and the rest of the team at the Apollo Hospital, Miscael is back on his feet.

“The religious beliefs, age of the patient and the need for open heart surgery made this case complicated,” said Dr. Krishnan. Adds Dr. Shahani: “The case was so complicated that Miscael had set a record for being the first child under the age of ten to have open heart surgery in Sri Lanka without any blood transfusion.”

The surgery to remove the growth that was obstructing the flow of blood to the lungs would require that Miscael’s heart be prevented from beating for the duration of the surgery. This in turn meant reliance on the heart-lung machine and the necessity for hemodilution.

Miscael’s parents, Muhundhan and Shiyamala Nataraja, explained that they did not believe in blood transfusion. Creating further complications to the surgery was that they would not even allow their own blood to be stored separately and then given back in a transfusion. “As per their religious beliefs, if the blood is not in continuity with the body, it cannot be transfused back to the patient,” explains Dr. Krishnan.

“Taking out the growth involved getting inside the heart. Such surgery required that the heart be stopped – at least for half an hour. To do this the doctors connected Miscael to the heart-lung machine (also known as a pump-oxygenator or cardiopulmonary bypass) and thereby effectively bypassed the heart.

Dr. Krishnan says a certain volume of fluid, in this case blood, is required for circulation to proceed smoothly and for the machine to work. This volume is traditionally obtained through transfusion, which was of course not an option in this case. To build up the required volume, Miscael’s blood would have to be carefully diluted. This meant that its oxygen carrying capabilities would be diminished, something that could impede the little boy’s recovery.

Additionally, all the blood that little Miscael had would also have to be loaded with substances that prevented clotting – something which would further complicate his post-operative recovery. Therefore, Dr. Shahani explained, literally every drop of blood became crucial and great care was taken throughout the surgery to avoid any wastage of blood.

Of particular note was the anaesthesia techniques used in the surgery. Dr. Shahani skilfully employed hypotensive anaesthesia — anaesthesia accompanied by deliberate lowering of blood pressure to reduce blood loss. All steps from cutting the skin to the insertion and removal of the tubes inside the main blood pipes of the heart had to be done extremely carefully to minimize blood loss and thereby decreased the danger in Miscael’s surgery.
Dr. Shahani also used certain drugs to help the blood clot in the post-operative period.

“The patient's blood was first tested to determine haemoglobin levels and then we gave him drugs to build up haemoglobin levels prior to surgery,” says Dr. Shahani, adding that “care was taken to minimize the number and size of blood samples drawn for testing, both before and after surgery”.

Miscael’s initial blood count registered haemoglobin levels at 12.7 while after the surgery it was 8.3 – the lowest ever in the hospital, says Dr. Shahani.
Also of some concern was Miscael’s medical history — in addition to the growth, the child also had an abnormality in his heart muscle, something that apparently runs in the family.

Medical science in Sri Lanka has risen to the challenge of such cases before, though not in someone so young. An occurrence that is entirely understandable considering the fact that of our 20 million population, only 4,000 are Jehovah’s Witnesses. “Of nearly 11,000 cardiac operations I have handled, only about five were Jehovah’s witnesses, all of whom were adults,” says Dr. Shahani, further illustrating the rarity of such cases.

Miscael’s surgery, which proceeded without a hitch, took about three hours. Follow-ups indicate that the boy is well on the road to recovery. Miscael spent nearly ten days in hospital. His hospital bill came to nearly Rs. 450,000, his father, Muhundhan says. The money which came in part from the President’s Fund and largely from relatives has helped this family restore the health of their only son.

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