A city hospital conducted a complex cardiac surgery earlier this month, one in which the breathing tube was placed through the nose of the patient because his mouth had an extremely narrow opening.
The case was particularly challenging, the hospital said, because of “a rare and high-risk airway condition” and needed constant coordination between the surgery and anaesthesia teams.
The 41-year-old patient was suffering from severe aortic stenosis, a life-threatening condition where the main valve that controls blood flow from the heart becomes critically narrow.
This was due to a bicuspid aortic valve, a congenital defect in which the valve has only two cusps or leaflets instead of three, causing it to malfunction earlier in life.
The patient also had a ventricular septal defect (VSD) — a hole in the wall separating the lower chambers of the heart — allowing abnormal blood flow between them.
The patient also had severe anxiety requiring long-term medication and an extremely restricted mouth opening of just one finger width, making routine anaesthesia and airway management highly dangerous.
“Even minor changes in heart rate or blood pressure in such cases can prove fatal,” said a spokesperson for Manipal Hospitals Dhakuria, where the surgery was done a fortnight ago.
To minimise these risks, the medical team planned an advanced technique known as awake nasal tracheal intubation, in which the breathing tube is gently inserted through the nose while the patient remains awake and breathing independently, thereby avoiding sudden stress on the heart.
In this case, the patient underwent local anaesthesia in phases.
“Despite the patient’s anxiety and complex condition, the procedure was completed without any drop in oxygen levels or instability in vitals. This was followed by the heart surgery in which the damaged valve was replaced, and the hole in the heart was closed,” said Kaushik Mukherjee, consultant, cardiothoracic surgery at the hospital.
Mukherjee led the cardiac surgery.
Nilanjan Chakrabarty, a consultant in cardiac anaesthesia at the Dhakuria hospital, said conventional intubation was not an option due to the narrow opening.
“Awake nasal intubation allowed the patient to continue breathing on his own, eliminating the risk of airway failure or cardiac instability,” he said.
The patient was discharged on the fourth day after surgery and is recovering well at home, the hospital spokesperson said.