Here is what it takes to carry out open heart surgery

A team of experts visiting Mulago hospital heart institute have carried out more than 30 surgeries during their fifth vocational training team mission that lasted 15 days.

A total of 23 catheterisation procedures to correct mostly birth defects have been carried out as well as 10 open heart surgeries.

Another 500 children with heart defects remain on the waiting list.

Joanita Namugera was one of the beneficiaries of the free heart surgery.

At about 7am, baby Namugera is brought to the main operating theatre at the heart institute, where she is scheduled to undergo an open heart surgery.

This was after she had been diagnosed with a hole in the heart.

Namugera is one and 10 months old. Doctors say ideally, they would have waited to carry out the operation since her heart is still small but because of the nature of her heart defect (ventricular septal defect), is causing other complications such as high blood pressure in the lungs, a decision was taken to carry out the operation.

If left untreated, VSD leads to increased blood flow in the lungs, which causes high blood pressure. Overtime, this can also lead to irreversible damage of the lungs.

Starting the surgery
The team of experts that is going to perform the procedure called Dacron patch closure or banding has already assembled in the theatre, ready with their equipment.

The team includes three surgeons. For this particular case, the lead surgeon is Prof. Mark Turrentine, the head of congenital heart surgery at Indiana University School of Medicine.

He is assisted by doctors Tom Mwambu and Michael Oketcho, both consultants in cardiothoracic surgery, at the Uganda Heart Institute at Mulago.

Two scrub nurses – these are medical professional who assist surgeons in the operating room, two anaesthetic doctors, two runners who pass on the necessary equipment as required by surgeons and perfusionists who operate the heart-lung machine are also in the theatre.

Others include an anaesthetic technician to help assemble the equipment and a bio-medical engineer in case any of the equipment breaks down during the process.

At this point, Namugera is laid on the operating table in preparation to put her to sleep using drugs, although the operation she is to undergo is not definite.

Expert take
Dr Mwambu explains that depending on how well she responds to high oxygen, the team will either continue with the repairs or put a temporary band on the iota, to regulate the amount of blood that flows to the lungs.

Pulmonary artery banding is the narrowing of the pulmonary artery with a band, to reduce blood flow and pressure in the lungs.

It is used for ventricular septal defect on patients who are unable to withstand the open heart surgery procedure. For children, the band can be removed later, and the defect corrected with surgery.

The patient is then put to sleep using anaesthetic drugs.

First, the patient is connected to the aneasthetic machine which has a monitor that displays the electrical activity of the heart, the pressure in the heart and arteries, the temperature as well as the breathing speed of the patient, Dr Mwambu explains.

A body marker is used to mark the part that will be opened as the rest of the body is covered, leaving out only the operating area.

Using an electro cautery machine, which generates electrical energy, the surgeon cuts open the patient’s chest to reach the heart.

Dr Alfred Omo, a senior cardiothoracic surgeon explains that the electro cautery machine generates heat which helps prevent bleeding as the patient’s chest is being opened.

Slowly, they spread apart the cut halves of the sternum with a retractor, something similar to a brace which allows the entire chest and heart to be open before the surgery.

Heart-lung disease
At this point, the heart-lung machine - a device used in open heart surgery to support the body during the surgical procedure, while the heart is stopped takes over the role of the heart and lungs after the machine is connected to the patient by a series of tubes that the surgical team places in the heart arteries and blood vessels.

“The heart-lung machine is used to provide blood flow and respiration for the patient while the heart is stopped. Surgeons are able to perform coronary artery bypass grafting or open-heart surgery for valve repair or repair of cardiac anomalies, and aortic aneurysm repairs, along with treatment of other cardiac-related diseases,” notes Dr Omo.

By now, the procedure has taken two-and-a half hours.

At 10am, the baby’s heart is stopped, after being administered with an injection which helps to stop the heart from pumping, as well as preserve it. This process is repeated every 25 minutes.

Fortunately for Namugera, after opening her heart and diverting it to the machine, her response to oxygen is positive.

The doctors agree to do a permanent repair using the Dacron patch stitched around the holes.

Using an artificial Dacron patch, the surgeons stitch the patches to cover or block the two holes found in her child’s heart, one on the upper atrium, and the other between the left and right ventricles.

Initially, the doctors had seen one hole during prior tests and scans, but when the heart was opened, another hole was discovered between the heart chambers. Both were repaired.

Within 45 minutes, the process of repair is complete, and profusion – which supports the normal functions of the heart and lungs during surgery, is stopped. The cannulas are gradually removed as the heart resumes its function.

At the end of the operation, the surgeon gradually allows the patient’s heart to resume its normal function, and the heart-lung machine is stopped.

The patient is then connected to the ventilator – an artificial device that helps breathing for patients who are unable to draw in and out air on their own. At 11am, the heart beat becomes normal and the surgeons embark on stitching the chest.

But before the stitching starts, another smaller tube called chest drainage tube is inserted to help in draining fluids that may remain after the surgery. It is then connected to the water suction machine that will later be connected on the Intensive Care Unit bed, where the patient will be kept for the next three days.

At exactly 11-48am, the surgeons put the last stitch on the patient after over five hours of the operation.

The doctors congratulate each other about another successful open heart surgery that will change the life of baby Namugera forever, at least if nothing wrong happens after the surgery.

The procedures usually take four to 10 hours depending of the defects.

At this point, the nurses start preparing to transfer the patient to the ICU, where she will be kept under close monitoring. To minimise the risks involved in moving patients in critical conditions, an ICU bed fitted with a monitor, an oxygen cylinder and an ambu bag – which is used to aid breathing for the patient is used.

In the ICU, about six nurses wait to receive the patient. Each of them takes a specific task as the patient is ushered in the room.

The intensivist – a physician who specialises in the care and treatment of patients in intensive care prepares and connects the patient to the ventilator, one of the nurses takes charge of the chest drainage, another draws blood samples for further tests, while another takes record and receives the patient’s medical reports.

Dr Mwambu says that such procedures require a huge, trained human resource force as well as infrastructure.

On average, at least 15 to 18 medical personnel are directly involved in one single open heart surgery.

For now, little Namugera’s parents will have a reason to smile after she became one of the beneficiaries of the free surgery, that would otherwise cost her about $20,000 or Shs50m.

[email protected]