Archive for November, 2010

Blood pressure  measurement ,   probably  is the commonest investigation done  in our patients  in  the entire field of medicine . It is such a common thing ,  both physicians  and patients  fail to perceive  it as  an investigation . (It indeed is !)

Even though BP is  considered as a  clinical sign , measuring it requires a device called sphygmomanometer  . The BP apparatus has to be properly calibrated  with the mercury  , the tubing, the bladder  , inflation balloon  etc   need to be perfect.

The following fallacies are noted in the measurement of  blood pressure . Some of them are rampant* !


  • Posture of recording
  • Anxiety -White coat /Gender


  • Cuff width/Length
  • Arm circumference

Ocular errors

It is surprising , such an important tool has a scale of 2mm markings which is prone for parallax errors of light with  mercury column undulating .

Physician factors*

  • Hasty cuff syndrome , Rapid deflation .
  • Absent minded recording – Failure to note phase 4 to phase 5  due to inattention
  • Failure to hear phase 4 muffling  (Aging  medico  -Auditory insufficiency !)

It is  not at all  surprising  to note,   two BP readings rarely match ,  even if it is recorded by the same person with  same machine at the same time !

There are many  articles that describe in detail  ,  how to record blood pressure properly. But this article from  a relatively unknown  journal   from Purdue university  ,  tells  us  most   scientifically  , what  has been taken for granted  by the medical  community for so long  .

Loose cuff  hypertension (Link to the journal of  Cardiovascular engineering )

How much  stiffness  is to be applied in  the arm for optimal pressure recording ?

What is the incidence of hypertension due to  loose cuff  ?

Final message

The BP apparatus ,  though appears  as  an   innocuous   machine ,   the readings  that emerge  from it  determines ,  how millions of our fellow human beings are going to be labeled  ! ( High pressured  humans ,  slaves to  anti hypertensive  drug marketeers    for  rest of their  life ) .

So , realise  how important  it is , to measure  the blood pressure properly    !  Never be casual . . . with  this  machine .

Experience has taught us ,  while  it is very easy to name an  individual  wrongly as hypertensive  , it  often needs  Herculean  efforts  to remove this medical tag from their neck . The reasonings  are  many .( Academic , non academic and patient factors included )

Finally , in this funny planet  it is  a personal observation ( Or is it  an imagination ?)    some  men and women   tend to  enjoy  ,   being  referred to  as  high pressured !   Loose cuff  or tight cuff   ,  it simply do not bother them  !

Read Full Post »

Cardiology as  a specialty  has grown faster than any other field in medicine.  From  the days of  Da -vinci and  William Harvey  ,  the  urge to understand the  intricacies of  anatomy and physiology of this organ that sustain the rhythm of life ,   life was tremendous .

Heart was a gift of life  by God to the man kind

  • Few men dreamed about it.
  • Few were simply fascinated by it .
  • Some   exploited it in the name of science .
  • Only   few  spent the entire life  for it   ,  explored it  passionately . . . truly and genuinely .

One such person , we should all celebrate is Noble  O  Fowler  From Cincinnati USA. This unassuming  ,(In contrast to  some of the current hyped up  achievers !) has kindled thirst in the subject to many  youngsters .

His remarkable achievement included

  • The  pioneering thoughts about pre-infarction angina (Now labeled as unstable angina)
  • Pericardial physiology and pathology
  • A overall approach to cardiac patient with shrewed physiological and pathological sense.

His book cardiac diagnosis was a exclusively authored by him is still considered as unique as his life.

Some how this book never got published beyond the 1980 s.

I personally  dedicate this  little service to cardiology literature to the legacy of Noble O Fowler.

A tribute by his Collegue Robert J Adokph


Read Full Post »

Cadiac resynchrnonisation (CRT) therapy , is  the most famed  as well as  ridiculed treatment modality for refractory failure . It is facing a real tough time for survival now .(At least in class 4 CHF.)

Confident and  authentic data  are emerging  now , that CRT should not be  used  in advanced heart failure .(This is in total contrast with the original concept  ,  when CRT was introduced nearly  a decade ago !  more  of class 3 and 4 were enrolled ) . Bad outcomes are expected in advanced CHF. This is something similar to whipping the tired horse concept  which  found inotropes   to increase the mortality in severe heart failure .

The article in the current issue of circulation  shows  no mercy to CRT  in advanced CHF


So what  is  the answer to the ailing CRT industry ?

Go and catch class 1 and class 2 CHF population* .You will get plenty  , of course  it got ratified by MADIT -CRT trial .

* It is attractively called prevention of cardiac failure

Read Full Post »

For todays cardiologists traveling in time machine  may be made as   an  essential assignment . It seems  there is more to learn from history than the core medical science.

How  the knowledge evolved  ? . How  our ancestors toiled  ?  Where  are  the good old  medical   inspirations  ?

How  can we enjoy the fruits of success without knowing the  tree of it’s  origin ?

What you are going to leave for  the future man kind  ?

Learn how a  dream heart team led by Christian Barnard  created history in the year  1967 in a remote southern hemisphere  town ( To be precise Cape town ) , South africa .Click the link or over the image .Courtesey of Life magazine

Groote schuur hospital where Christian Barnard made history

Thanks  to the Life magazine  for providing these stunning pictures to the present generation


Christian Barnard and team after the historic  surgery .Groote schuur hospital .Cape town


Let us  salute  the men of  past  .We shall  take an oath   to  strive harder and  harder   and the least  , trivial achievements are not  glorified . .



Read Full Post »

A female child aged 14 was referred for progressive breathlessness  and  abdominal distension

Abnormally dilated right atrium with significant pericardial effusion .www.drsvenkatesan.com

Can you guess the diagnosis ?

Apart form RA ,RV dilatation , the RV apex is seen filled with coarse treabeculations.This is believed to be a type of non compaction http://www.drsvenkatesan.com

Still difficult to conclude  ?   Look at the following Image.

Tricuspid regurgitation is significant . http://www.drsvenkatesan.com

If you have thought  . . .

  • ASD with TR
  • Severe PAH/COPD
  • RV cardiomyopathy

All are  acceptable  differential diagnosis

But the real diagnosis is none of the above .

Need  more time  . . . the following   Doppler tracing  will settle the issue !

Doppler velocity in RVOT at 88mmhg. http://www.drsvenkatean.com

The final diagnosis was . . .

  • Severe valvular pulmonary stenosis
  • Marked RV,RA dilatation
  • Acquired non compaction of right ventricle
  • TR -Moderate
  • Pericardial effusion -Moderate
  • This patient also had dilated IVC, Hepatic veins that  lead to clinical ascites.

Here , RV functional assessment becomes vital , but it is difficult many times. A simple clue is , as  the RV is able to generate 88mmhg pressure it implies ,   the   contractility  should be near normal .

RV EF %,  RV Dp/Dt , Tricuspid annular motion by  tissue Doppler are additional measures. Cine MRI can be a useful investigation prior to intervention.

Final message

  • VPS is a common acyanotic disease. Most are benign  and  milder  forms are the rule.
  • Dysplastic valves preclude balloon valvotomy. (In late stages   little  difference between dysplastic / non dysplastic VPS is noted  )
  • Severe progressive VPS  , like in this patient needs immediate balloon dilatation or surgery.
  • Long term outcome  is excellent except in advances cases where irreversible RV dysfunction sets in.

Read Full Post »

A young women  with Rheumatic heart disease .


LA aneurysm

Giant left atrium in rheumatic MS . http://www.drsvenkatesan.com

Mitral regurgitation is significant .www.drsvenkatesan.com


When do you call  a left atrium as   giant  ?  When it is referred to as  Aneurysmal dilatation ?

It is all semantics. Whenever LA becomes more than 6 cm ,  at least in two diameters  many prefer to call it giant .

In India , 6 cm LA is such a common finding , we have kept a  cut off at an  arbitrary 9 cm .

What factors determine a LA to dilate like a balloon ?

The exact mechanism is not known.It could be  the  intrinsic weakness of LA wall ,  as very few with RHD develop this. Many LAs resists dilatation even in the midst of extreme LA pressure. But , it is a well-known fact , mitral regurgitation provokes greater LA dilatation than MS alone .This implies volumetrics  play a major role than  pressure dynamics  in determining LA size. Acuteness of hemodynamic insult is  inversely proportional to LA size.

By the way, what is the purpose of  recognizing  the LA as Aneurysmal ?

  • In plain X -ray chest , LA may  form the right heart border  over shooting the RA.
  • When LA becomes huge  , there is a  chance for mechanical complications  like dysphagia, phrenic nerve , bronchial compression etc .
  • Giant LA invariably increases the chance of LA clot.

Electro-physiological Issues

  • Atrial fibrillation , a usual accompaniment of giant LA ,  is often refractory . There is no  purpose  to convert to sinus rhythm . In fact ,  one should not attempt this. There was a time when surgical incisions  ,corridors , mazes were quiet popular.Now it is believed all these are adding further injury to the ill-fated LA .Electro-physiologists should be restrained . Pulmonary vein ablation should never be attempted in such cases as the focus of AF is elsewhere .

Implication in cath lab

During PTMC LA size can be an issue  as the plane of IAS is distorted and make things difficult for septal puncture . Further the balloon , guidewire  may often slip  back into RA .

Implication for the surgeon.

For the surgeon the implication could be more. As a cardiologist I can’t comment about that .One thing we have observed is when LA becomes huge , the size of mitral annulus is too fictitious and funnily enough we have recorded up to 6 cm of mitral annulus . No valve is available for this size . We learnt from the surgeons ,   large LA  rarely pose a  problem as they suture the much  smaller valve in a larger annulus .(Which  makes the task  that easier )

Does the LA size regress after surgery ?

In many  it does regress  , in as many it doesn’t. We have seen giant LAs continuing to trouble the patient even after a successful mitral valve replacement.

Read Full Post »

A classical echo of  a common AV canal .


Note  the free floating common AV leaflet



With all chambers interconnected it is a free for all circulation . The blood  seems to get mixed at the level of common AV orifice . Even though one expects severe cyanosis in common AV canal , the intensity of which is primarily determined

Common AV canal with free for all shunting . http://www.drsvenkatesan.com


the net blood flow to lungs which is dictated by  the pulmonary vascular resistance or the RVOT obstruction. This patient had no RVOT obstruction   but had  severe  pulmonary arterial hypertension.  In spite of raised PVR ,  some amount of volume over load of lungs  occur.

How to assess the  operability ?

Read Full Post »

Ever since coronary stents were introduced   metal market is having a  good time within human coronary arteries.The search  for the the elusive , ideal metal is still on   . . .  Nickel , stainless steel  , platinum  etc .

Some body thought , why not gold ?

For long ,  gold is known to be a good bio -compatible metal .

Two Gold stents were tried  .

  • Inflow dynamics  – AG Germany
  • Boston scientific –  NIR stent

Surprisingly , both showed   increased reactivity  with  coronary endothlium . The verdict  was  clear . Gold coated stent  was not good enough.


Gold allergy


Final message

With the advent of DES ,  gold coating of stents lost it’s popularity  .Unless  new innovations happen in gold metallurgy , the  future looks bleak  for this precious metal  , at-least  in  the human coronary arteries.

Read Full Post »

Radiation injury to coronary artery  is rarely given a thought , in spite of   prolonged fluro-scopic time  during  many complex angioplasties.While the cardiologists are fully protected the patient’s heart takes on the brunt of the attack.

What happens to the coronary endothelium -metal interface when X -rays pass through it ?

It is well known the radiation delivered to a tissue is many times  amplified if a metal interface is present. Further , the metals can produce heat on exposure to radiation . This absorption and heat varies with different metals .

The radiation injury to coronary endothelium  could be  significantly higher with DES , as the polymer in it absorbs more radiation than the bare metal stent. This could be responsible for late complications of DES.

The above  concept (unproven though !) is  proposed  by  http://circ.ahajournals.org/cgi/content/full/104/5/e23 .In this study Gold coated coronary stents were found to be less safe than conventional stent

It may take many years to know the truths  about  radiation injury caused by  of coronary stents  .

But always remember , unproven concepts are  not synonymous with wrong concepts !

Read Full Post »

A middle aged female came with palpitation and breathlessness for two months duration  to  our OPD.

Clinically a non ejection click was present .She was referred with a diagnosis of MVPS  to the echo lab

Her echocardiogram created a  real buzz in the lab .

What is the diagnosis ?

The diagnosis is  hidden somewhere in the frame.

How common is this entity ?

A Color flow imaging is available  will be posted  if requested .

Read Full Post »

« Newer Posts - Older Posts »