Mumbai doctors save life of Mulund resident after complex heart and liver surgery

Babu Michael underwent a complex heart and liver surgery

Mulund resident Babu Michael received a new lease of life after a team of Mumbai doctors from Jaslok Hospital & Research Centre successfully performed a complex surgery, in what they are calling a groundbreaking medical achievement.

The doctors conducted a simultaneous coronary artery bypass graft (CABG) surgery and deceased donor liver transplant (DDLT) on 63-year-old Michael. It is a complex dual procedure, which they say is a first in India, and highlights the hospital's expertise in complex medical procedures. The case also underscores the growing challenge of managing coexisting cardiovascular and liver diseases, a trend on the rise globally.

Michael was diagnosed with cirrhosis seven years ago after secondary to non-alcoholic fatty liver disease (NAFLD), a condition affecting one-third of India's population and increasingly linked to liver cancer. In 2021, he underwent a focussed radiation therapy (SBRT) for liver cancers, a treatment he required again in April 2024. While the tumours were partially controlled, his liver function began to decompensate, necessitating a liver transplant. During his pre-transplant evaluation, it was detected that he has significant blockage in his left main coronary artery.

Dr Rahul Chhabria, associate director, Emergency Cardiology said the coronary blockages require revascularisation with surgery prior to his liver transplant and that he was not a candidate for angioplasty as he had complex anatomy of his left main vessel and also it would have postponed his liver transplant.

This presented a complex dilemma: delaying the transplant to address the heart condition risked further cancer progression and liver deterioration, while performing either surgery alone carried significantly elevated risks due to the combined impact of both diseases.

The doctors came up with the initial plan considering a live donor transplant, but after careful evaluation, prioritising donor health and recognising the potential for recipient instability during such a complex procedure, the team decided against this approach.

Michael was then placed on the waiting list for a DDLT understanding the uncertainties and potential wait times associated with cadaveric donation. Hope arrived unexpectedly with the selfless generosity of the family of a 47-year-old deceased donor, turning their tragic loss into a life-saving gift for Michael. This prompted a rapid mobilisation of the hospital's resources, with intensive care units and social workers working tirelessly to facilitate the complex logistical and medical preparations.

The intricate surgical process began with Dr. Upendra Bhalerao, consultant cardiac surgeon, performing a beating-heart, off-pump CABG. This technique aimed to minimise surgical trauma and optimise Michael's condition for the subsequent transplant.

Dr. Bhalerao emphasised the high-risk nature of the procedure and the need for meticulous precision to ensure Michael's readiness for the liver transplant. Following a period of close observation to ensure stability and the absence of bleeding, the green light was given for the liver transplant.

The transplant team, led by Dr. Shailesh Sable, Dr. Pravin Agrawal, Dr. Vibha Varma, and Dr. Vivek Shetty, then commenced the complex procedure. The anesthesia team, comprising Dr. Mohit Rohra, Dr. Nikhil Konde, and Dr. Savi Shah, played a crucial role in maintaining hemodynamic stability and managing Michael's physiological parameters throughout both surgeries, performed within a time duration of 12 hours .

Remarkably, Michael tolerated both procedures well. He was taken off the ventilator on the second day and made a steady recovery, being discharged home after two weeks with both his heart and new liver functioning normally. The critical care team led by Dr Shruti Tandan, diligently looked after the patient's well-being in the pre-operative and post-operative period in the hospital

"In the era of modern medicine , we often stretch the limits. Cardiac disease is the leading cause of death in patients with NAFLD and it is important to screen patients for a silent heart involvement. This is one of such cases wherein a simultaneous very high risk dual surgery were performed by multidisciplinary team effort , careful planning and flawless execution. Mr Babu can live a normal life and we all feel satisfied about it," commented Dr Aabha Nagral, director gastroenterology, chief hepatologist and Liver transplant physician at Jaslok Hospital, who managed the patient over the last 7 years.

"This pioneering case underscores the importance of thorough pre-transplant evaluations, multidisciplinary collaboration, and the life-saving potential of organ donation. It also highlights the increasing need for innovative approaches to manage complex cases involving coexisting conditions, particularly in the context of the rising prevalence of NAFLD and cardiovascular disease" stated Dr Shailesh Sable, director liver transplant programme at Jaslok Hospital.

Speaking about the case Dr Upendra Bhalerao, consultant & coordinator cardiovascular thoracic Surgery mentioned "This was a very high risk and challenging procedure and the surgery also need to be performed well in time so as to make him suitable for liver transplant . The procedure was performed as beating heart of pump coronary artery bypass surgery. The cardiac surgical team was very diligent in maintaining hemodynamic stability , perioperative bleeding control and perfect outcome."

Delighted with the result, Mithila Michael, the daughter expressed, "After knowing the extent of his liver and heart problem, we thought it is impossible for him to survive with a good life. The team at Jaslok has put in Herculean effort to get his heart fixed and liver transplanted. We are extremely grateful for the support and effort and sincerely admire the dedication and team effort. We are also thankful for the donor family for their noble act of donating the liver to my papa."

Addressing the media, she added, "It was a very difficult time for us especially because I don't live with my family because I live overseas. I saw how my father was losing upper body mass and it is not only my father but also the family that was stressed. I want to thank all the doctors at Jaslok Hospital for their effort."

With the global trend of the challenge of managing coexisting cardiovascular and liver diseases, Dr Nagral speaking exclusively to mid-day explained, "Liver cirrhosis raise the possibility of tumour in people because liver cirrhosis is a pre-cancerous condition and therefore it has been recommended that all patients with cirrhosis should have an ultrasonography and a tumour marker called AFP ( alfafetoprotein) every six months for their lifetime so that these can be picked up early and treated. Waiting for symptoms to develop from a tumour may be too late to treat the tumour."

With a case like Michael's, she emphasises, "The possibility of heart attack increases in people with liver disease as the commonest cause of death in patients with fatty liver disease is from heart disease. Therefore it is important to screen them for coronary artery disease."

Adding to Dr Nagral, Dr Bhalerao speaking to mid-day added, "Patients with liver cirrhosis and fatty liver often have obesity , diabetes and hypertension as associated conditions - together called as Metabolic syndrome.

"This increase chances of developing blockages in coronary arteries causing heart attacks," concludes the Mumbai-based doctor highlighting the complexity of Babu Michael's case.