• Abdominal aortic aneurysm’s are common in men past the age of 65. Aneurysm larger than 5.5 cm in diameter can rupture. Rupture accounts for more than one in 50 of all deaths in this age group.
• Patients with abdominal aortic aneurysms larger than 7 cm lived a median age of only 9 months.
• In the USA every year 15,000 people die from ruptured aortic aneurysms. It is the 13th leading cause of death in the USA
• All aortic aneurysms expand gradually, the rate of increase in diameter ranges from 0.1 to 1 cm per year
• Emergency aortic surgery is a 5 to 10 times riskier procedure than planned surgery

In the initial stages, thoracic aneurysms grow slowly at about 0.1 cm per year. As the size increases, it grows faster.

• Medical treatment with control of BP and 6 monthly CT or MRI scan follow up, when the aortic aneurysm is less than 5 cm in diameter except in Marfan syndrome where medical follow up is advised even when the aortic aneurysm is less than 4.5 cm in diameter.
• Endovascular aortic aneurysm repair (EVAR), or thoracic endovascular aortic repair (TEVAR) for moderate size aortic aneurysms. This technique is also used in patients who are high-risk for open surgery. Advantage of this technique is the ease of implanting a covered metal stent inside the aortic aneurysm from a small cut in the groin without opening the chest or abdomen. The procedure can be performed with local anaesthesia.
• Surgical repair of thoracic aortic aneurysms

Surgery is generally indicated for aneurysms larger than 5.5 cm in diameter. However, in Marfan syndrome surgery is indicated even when the aneurysm is smaller.

30-day mortality following thoracic aneurysm surgery is approximately 2.9%.

Survival following ascending aorta replacement, usually in combination with aortic valve replacement, is about 70% at 5 years and 50% to 60% at 10 years. Survival may be lower for patients who require urgent or emergency operation. Five year survival rate in operations on the aortic arch is about 80% for repair of the descending thoracic aorta, the five year survival rate is 71% in repair of thoracoabdominal aorta, the five year survival rate has been reported as 71%.

Success rates of elective operations on the ascending aorta is 97%, on the descending aorta is 97.1% and for thoracoabdominal aortic operations is 88.1%.

Bentall surgery

• Bentall surgery is an open heart surgery done on patients with aortic root aneurysms who require replacement of diseased aortic valve and dilated ascending aorta.
• A composite graft of mechanical or tissue valve stitched to a Dacron tube is used to replace both the diseased aortic valve and dilated ascending aorta
• Dacron is a polymer also known as Terylene.
• By creating two holes in the Dacron tube both the coronary arteries are re-implanted.

In David procedure, the patient’s own aortic valve is repaired and re-implanted inside a Dacron tube.

By preserving the patient’s own aortic valve, lifelong anticoagulation is not required

Indications

• Aneurysm of ascending aorta is commonly associated with the bicuspid aortic valve.
• Dissecting aneurysm of ascending aorta

Procedure

• Surgery is done under cardiopulmonary bypass by splitting the sternal bone In the centre.
• After protecting the heart muscle with the potassium-rich solution, aneurysm of the ascending aorta is replaced with a piece of Dacron tube.

• Surgery is done under general anaesthesia after vertically splitting the sternal bone in the centre.
• The heart is connected to the heart-lung machine and body is cooled to 18° centigrade to protect the brain and vital organs when the blood circulation to the brain is reduced or stopped.
• At 18° centigrade blood circulation to the body is stopped and right atrial pressure is kept at 15–20 mm of hg to perfuse the brain in a retrograde manner and also to flush any air out of the innominate and carotid arteries.
• Aortic arch, innominate artery, left common carotid artery and left subclavian artery are replaced by a composite Dacron tube with the four side branches.

• When the aneurysm reaches 5.5 cm in diameter repair is indicated to prevent sudden rupture

Thoracic aneurysm is a very serious medical condition. If left untreated past the size of 5.5 cm in diameter can lead to sudden rupture or tear causing massive internal bleeding and sudden death.

• Under anaesthesia, the patient is made to lie on the right side. Then the left side of the chest is opened with a long incision to expose the descending thoracic aortic aneurysm
• At 18° centigrade temperature, circulation is arrested and Venus pressure is kept high at 15 to 20 millimetres of Mercury to retrogradely perfuse the brain and also to keep the neck arteries free of air.
• The descending thoracic aorta is replaced with a piece of Dacron tube.

• Atherosclerosis which is the hardening of the aortic wall is the most commonest cause.
• Genetic disorders like Marfan syndrome, Ehlers-Danlos syndrome and Loeys Dietz syndrome.
• Dissecting aneurysm of thoracic aorta extending to iliac arteris.

• Pulsating mass in the abdomen
• Pain in the abdomen, chest or lower back

• Severe pain
• Dizziness
• Increase in heart rate
• Drop in blood pressure

• A detailed history and physical examination
• CT scan of thorax and abdomen
• MRI scan

• If the aneurysm is less than 5.5 cm in diameter, medical treatment can be tried with the BP control, smoking cessation - CT scan to be repeated every six months to check the size of the aneurysm.
• If the aneurysm is more than 5.5 cm in diameter, open repair is ideal
• Hybrid repair, thoracic endovascular aortic repair (TEVAR) and open repair
• Thoracic endovascular aortic repair (TEVAR)

• Surgery is done under general anaesthesia and with the heart-lung machine supporting the blood circulation with low-temperature protecting the brain and vital organs.
• Unlike most heart surgeries open repair of thoracoabdominal aneurysm is done by making the patient sleep on his/her right side. Afterwards, an incision is made from the upper back below the scapula bone to a point in the abdomen between the belly button and ribcage.
• The entire length of the aortic aneurysm is opened and replaced with appropriate size Dacron tubes.
• All the vital branches of the aorta starting from spinal arteries, arteries to liver, intestine and kidney arteries are re-implanted into the Dacron tube.
• 
• During the surgery blood loss is reduced by using cell saver which collects, cleans and returns the blood to the patient.
• Generally, patients can be weaned off from the breathing machines in one or two days depending on the associated medical conditions and ready to be discharged after 10 to 15 days from the hospital.

• Endovascular repair involves the use of a catheter that is inserted into the groin. The catheter is used to insert a self-expanding stent-graft into the aneurysm.

• Abdominal aorta is the most commonest location for the development of aortic aneurysms.
• 2-8% of males over the age of 65 suffer from abdominal aortic aneurysm.
• Every year 200,000 people are diagnosed with abdominal aortic aneurysm in USA.
• Ruptured abdominal aortic aneurysm is the 15th leading cause of death and 10th leading cause of death in men older than 55 in USA.

• Majority of the abdominal aortic aneurysms are asymptomatic.
• Pain in the stomach, sometimes constant.
• Backache worsened by movement.
• Lump in the abdomen from which you can count the pulse.

• More than 90% of the patients with abdominal aortic aneurysm smoked at some point in their life.
• Fatty deposits on the wall of the artery damage the wall, a process called atherosclerosis.
• High BP and alcohol also can damage the wall of the arteries.
• Genetic diseases like Marfan syndrome can cause abdominal aortic aneurysm due to the weakness of the arterial wall.
• Very rarely infections of the arterial wall can result in aneurysm.
• Occasionally injury to the abdominal aorta can result in aneurysm.
• Aneurysms may run in families.

• Main complication of abdominal aortic aneurysm is the rupture of the aneurysm which results in severe abdominal or back pain, low BP, nausea and vomiting, dizziness and features of shock.
• Rare complication of abdominal aortic aneurysm is blood clot from the aneurysm moving downwards and blocking one of the lower limb arteries.

• Control the blood pressure to prevent enlargement and rupture of the aneurysm.
• Stop using tobacco products like cigarettes and chewing tobacco.

• People past the age of 65 are more vulnerable.
• Tobacco users are more vulnerable.
• Those with the family history of an aneurysm are more vulnerable. If your first-degree relative had an abdominal aortic aneurysm you are 12 times more likely to develop the same.
• Those who are obese or overweight.
• Men are more vulnerable than women.
• Those having aneurysm in other locations of the body are more vulnerable.

• Most of the time abdominal aortic aneurysm is accidentally designed when an ultrasound is done for some other reason.
• Abdominal ultrasound is an easy and simple test to diagnose abdominal aortic aneurysm and also to plan the treatment.
• CT scan of the abdominal aorta can give all the vital information required to plan the intervention.
• MRI can provide again all the vital information about the size and extent of aneurysm.

• Surgery is recommended if the aneurysm is larger than 5.5 cm in diameter, 3 to 6% of them will rupture in one year after the diagnosis.

• If diagnosed early and treated effectively aortic aneurysm is a curable condition.

Within the first few weeks surgical incision site pain gradually settles down. How ever, it will take at least 2 to 3 months time for the patients to get back to work.

• About 10% of the patients die before reaching the hospital.
• If untreated another 50% will die within a month.
• Mortality rate of ruptured abdominal aortic and thoracic aneurysm is 85 to 90%.

• If the abdominal aortic aneurysm is less then 5.5 cm it can be observed at regular intervals for increasing size.
• Aneurysms larger than 5.5 cm needs surgery or endovascular stenting to prevent rupture and serious consequences.

• 
• About 85% of abdominal aneurysms occur below the arteries to the kidneys and the rest occur at the level of kidneys or above involving the arteries supplying the intestine and the liver.
• In open surgery aneurysm sack is opened and synthetic tube is used to replace the diseased aorta. It is performed under general anaesthesia by opening the abdomen in the midline. Bleeding is controlled by clamping the aorta above and below the aneurysm and a synthetic tube made up of Terylene is stitched to cut ends of the aorta. This restores the normal blood supply.

• Wound infection
• Severe bleeding
• Blood clots from aneurysm blocking leg arteries
• Brain stroke or heart attack
• Erectile dysfunction in men

After successful procedure, problems of the graft is much lower with open surgery than endovascular surgery. Patients of open surgery need less scans and follow-up

• Leakage of blood around the graft.
• Infection of the graft.
• Blood clot blocking the leg arteries.
• Brain stroke or heart attack.

As long as there are no infections and the stent graft doesn't move, they are known to last for a lifetime. Problems arise when the graft moves or the “seal” is lost (rarely) and the aneurysm sac starts to grow again. This is why, monitoring of stent grafts with CT angiograms or ultrasounds is very important. These rare cases can again be treated with stent grafting.

Up to 80 percent of aortic aneurysms are caused by "hardening of the arteries" (atherosclerosis). Atherosclerosis can develop when cholesterol and fat build up inside the arteries. High blood pressure (hypertension), cigarette smoking, family history and age also contribute to atherosclerosis. Atherosclerosis accelerates the breakdown of collagen and elastin, two proteins that provide strength, structure and elasticity to the wall of the aorta. Over time, this causes the walls of the aorta to weaken and become damaged. Elevated blood pressure through the aorta can then cause the aortic wall to expand and bulge.

Aortic aneurysms often have no symptoms at first; in fact, many are first discovered during an examination for another condition. If the aneurysm is pressing against nearby tissues, patients may notice a deep, steady pain in the back, abdomen or groin. Abdominal aortic aneurysms may also cause a pulsing sensation in the abdomen.In most cases, an unruptured abdominal aortic aneurysm (AAA) will cause no symptoms, unless it becomes particularly large.

If the aneurysm continues to expand, it can rupture. The layers of the aortic wall can also separate (aortic dissection). This produces severe, tearing pain in the chest, back or abdomen. The potential for rupture is the most serious risk associated with an aortic aneurysm. A ruptured aortic aneurysm can cause life-threatening internal bleeding and/or a stroke.

Stent grafts are used in transcatheter endovascular aortic repair (EVAR) procedures to seal aortic aneurysms. The grafts usually consist of a self-expanding stent frame that is covered with material to seal the vessel walls and prevent blood leaks feeding the aneurysm.The stent graft is a tube made of a thin metal mesh (the stent), covered with a thin polyester fabric (the graft). The tube is collapsed so it is narrow and can fit through your blood vessel. When the stent graft reaches the aorta, it is opened up and fastened in place.

The procedure is carried out in a sterile environment under fluoroscopic (X-ray) guidance. The procedure can be performed under general, regional (spinal or epidural) or even local anaesthesia. After accessing the patient's femoral arteries (leg arteries), vascular sheaths are introduced into them, through which guide wires (small calibre wires), catheters (plastic tubes) and the endograft (stent graft) are passed. Diagnostic angiography (images of disease segment) of the aorta helps to determine the location of the patient's arteries, so the stent graft can be deployed without blocking these. The “main body” of the endograft is placed first, followed by the “limbs” which join the main body and extend to the iliac arteries, effectively protecting the aneurysm sac from blood pressure. The endo graft acts as an artificial lumen for blood to flow through, protecting the surrounding aneurysm sac. This reduces the pressure in the aneurysm, which itself will usually thrombose and shrink in size over time. The procedure itself generally takes 2 to 3 hours. Patient will stay in the hospital for 1 to 2 days. Full recovery will take about a month

The number of times a normal heart beats in a minute is called heart rate.

The normal adult heart beats 60-100 times in a minute.

Trained athletes and elderly individuals tend to have a heart rate lower than 60 beats/minute.

For children, the normal heart rate is 100-150 beats/minute.

When the heart rate of an individual is above or below the normal heart rate, it is considered to be a heart rhythm disorder.

This condition is also referred to as ‘arrhythmia’.

A slow heart beat is referred to as ‘bradycardia’.

An increased heart rate is called ‘tachycardia’.

A drop beat is a transient pause in the heart rhythm.

An extra beat is called ‘Ectopic beat’.

In a lot of instances, this is not a serious cause of concern but its frequent occurrence can be an indicator of arrhythmia.

Arrhythmia may occur to anyone from new born children to adults.

It becomes more common with advancing age.

It may be associated with structurally normal heart as well as with other disorders of heart like valve diseases.

Arrhythmia displays a wide range of symptoms that can be detected in both adults and children.

In adults, the symptoms include skipped heartbeats palpitations, rapid or irregular heartbeat and difficulty in breathing.

Children may experience constant weakness, shortness of breath, lightheadedness and difficulty in eating/feeding in addition to skipped, rapid or irregular heartbeats.

In extreme cases patient may lose consciousness.

Arrhythmia impairs the electrical system of the heart and results in improper blood supply to the body.

This can lead to a heart failure, loss of consciousness, and in some cases sudden cardiac death.

It can also create blood clots that may move to the brain to cause a stroke.

An electrocardiogram (ECG) and echocardiogram are used by the doctors to detect arrhythmia.

Tests such as Holter or external loop recorders are available to monitor the heart rate over a long term.

An advanced option for detecting abnormal heart rhythm is electrophysiology studies.

Electrophysiology is a branch of cardiology that studies the electrical makeup of the heart it's disorders, that is arrhythmia.

It employs a minimally invasive procedure where an electrically sensitive cardiac catheter* is placed in the heart and the electrical conduction is studied.

*A cardiac catheter is a long, flexible, thin tube that is inserted into a large blood vessel (in the arm, groin or neck region) that leads to the heart.

An Electrophysiologist is a cardiologist who specializes in the electrical system of the heart and heart rhythm disorders.

Radiofrequency Ablation (RFA) is a procedure performed to treat a rapid heartbeat.

A physician guides a catheter with an electrode at its tip to the damaged or abnormal area of the heart muscle.

This stops them from conducting the extra impulses that caused the rapid heartbeats.

In cases of slow heart beat or Bradycardia, a device called Pacemaker is implanted in body (by minimally invasive technique), which maintains appropriate heart rate by giving electrical impulse when needed.

Cardiac Resynchronisation Therapy is another device like Pacemaker, which can be implanted to improve the pumping capacity (EF) of heart in selected cases.

In patients with risk of sudden cardiac death, an Implantable Cardiac Defibrillator (ICD) could be lifesaving. It is a device that is implanted like a pacemaker and has the ability to diagnose and deliver life saving shock appropriately in selected individuals with risk of sudden cardiac death.

Arrhythmia can greatly affect the quality of life of the patient. EPS/RFA have been successful in effectively treating arrhythmia.

It is a more convenient alternative to a medication regime. Medicines will need to be taken daily and life long with potential side effects. They may also need to be changed frequently.

Almost all electrical disorders of the heart can be treated with advanced 3 Dimensional EPS/RFA system and device therapy today.

EPS/RFA have displayed an acute procedural success of 90-95% for most of the arrhythmias.

The recurrence rate is between 5-10% for most of the arrhythmias treated with EPS/RFA.

All procedures involve some small risks. The risk associated with most electrophysiology procedures is less than 1%.

The risk is higher in sick patients and it is advised to consult us early.

Major life threatening complications are very rare, and can be managed with timely treatment.

The typical duration of stay is 24-48 hours in the hospital.

Ejection fraction is the measurement of how much blood is being pumped out of the heart. The ejection fraction of a healthy individual is between 55% and 70%.

The left ventricle is the major pumping chamber of the heart. If the Left Ventricular Ejection Fraction (LVEF) drops below 35%, the patient may be at risk of developing an arrhythmia.

This drop may even lead to sudden cardiac death which can be prevented with the help of an Implantable Cardioverter Debrillator (ICD) to constantly monitor the heart. During an arrhythmia, the ICD gives an electric shock to the heart and brings it back to the normal rhythm.

Syncope is the sudden loss of consciousness. If the reason behind the fainting episode is known to be harmless (e.g. standing in the heat), it is not a cause for concern.

When the reason for the syncope is unknown, it may be caused by arrhythmia. Hence, it is recommended to consult a cardiologist in such a case. They may perform an electrocardiogram (ECG) to assess the cause.

We, at Narayana Health, take pride in our excellent electrophysiology division with distinguished experts with subspecialty expertise. Our world-renowned electrophysiologists specialize in both pediatric electrophysiology and adult electrophysiology.