she was in her thirties, when first she met me in opd 5 yrs back. She was extremely breathless , orthopenic with swelling all over the body. Symptoms were for the past 3 months . Clinically she looked like in congestive cardiac failure.

Definitely she was on downward spiral of Frank starling curve. Her heart had enlarged.  She was accompanied by her husband and a small daughter.

After diagnosing and doing echocardiography, her pumping capacity was 20 to 25 %.

I explained to her and family about the disease.

But somehow , i could not gather courage to discuss prognosis with her. I admitted her.

Her medication was adjusted ionotropes withdrawn and sent home with advice to come on regular follow up.

Her husband  a respectable and mature man run a small atta chaki business. She had two kids .Both school going.

On Opd follow ups , she use to be cheerful, unmindful of her disease , doing all house hold activities against medical advice. Her family was also totally unaware about the impending doom.

She was quite regular about her visit . She use to face exacerbations of heart failure very bravely defing natural history of heart failure. There was an invisible bond which I developed with there family.

2 years back she was rehospitilised with acute LVF. Her blood pressure was 70 mm of his.  She was on heavy doses of ionotropes along with usual cardiac failure medication. Every attempt of reducing ionotropes led to decrease in BP jeopardising kidney supply.

This time i explained fully about the prognosis to her husband. Some how her husband had an intuition.

After 5 to 6 days , some how she again came out of almost certain calamity by her sheer grit and determination.

10 days after that hospitalisation , she came to opd with her daughter and frankly asked ...

bhayia. .... how much time i have got. Plz tell me frankly. I have to plan certain things.

There was no sign of fear on her face. She was pretty cheerful , confidant , put up a brave face against certain adversity.

I also respected her a lot. By avoiding eye contact,  I tried to be diplomatic.

She was extremely polite but firm and again asked the same question.

I told her that diseases don't read books . As per literature, u have already crossed your median survival.  There are case reports where people with similar condition lived more than 15 yrs.

She laughed and said smilingly .... my dear brother. .. I have understood.

I started reading vigorously about heart failure. Wat else could have been done. Her angiography was normal . She was already evaluated for CRT and denied. Valsartin +sacubatril was not on the scene yet.

One lingering thought about heart transplantation came to my mind. Family was not that much affording  type to incur the expense of this major surgery. Besides there were technical difficulties of finding suitable donor etc. etc.

....

Three months later , she again readmitted with Sustained VT. Immediately cardioversion was done , electrolytes were stabilised.  Medicines recalibrated.

Hoping against hope I discussed her case with the leading cardiologist of the country and changes in her treatment regime was made accordingly.

I discussed this case with my army friends and possible heart transplant option.

I discussed in detail with her husband. Finacial consideration were also thought,  deliberated and agreed upon. Only hitch was if we could get positive response from heart transplant centres.

Our joint efforts finally wore fruits , I got an email from a leading hosp in south about this possibility becoming a reality.  I immediately conveyed it to the family.  There was jubilation, in fact we all celebrated. Indeed she is going to defy the rules of the game. She had challenged yamraj and surely she was going to conquer death though for the moment.

I was also accompanying them .

Next day ...she again got readmitted with an other episode of VT. Again cardioverted. But this time her BP was 60 mm. There was no urine output. She was stuprose. I sat beside her in CCU. , touched her forehead. She opened her eyes and tried to smile. There was so much i wanted to tell her. But i never knew how to begin. Something in me wanted to trace the whole story with her.  She caught hold my hand and again closed her eyes never to be reopened again .

Her husband embraced me and little kids were crying inconsolobly. The cruel divine justice had been delivered.

In an frantic attempt, i tried to auscultate looking for familiar heart sounds. This time heart lacks sounds and murmur. Heart was beating mournfully along the decrescendo of her life

The final common pathway is the heart. For what matters finally how the human spirit is spent.

I turned to gaze at her one last minute. Despite the hardships. she had maintained enduring resilience, unmatchable tenderness , savoring a life filled with love .

May her soul rest in peace.

Regards

dr amardeep garg

Interventional Cardiologist

Patiala