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Archive for May, 2016

ICDs are revolutionary devices in the management of patients at risk for electrical sudden death .Its is indeed a boon for patient’ s with a primary electrical disease with occasional risk for VT.

Unfortunately , the usefulness of ICD in patients with severe mechanical dysfunction is marginal at best as these patients succumb sooner or later inspite of ICD, especially if the episodes of arrhythmia is more.

This is understandable as electrical events are directly linked to primary mechanical problem and one begetting the other.Of late , we realised these patients require some methods to stop the arrhythmia generation in the first place rather than terminating it after it manifest.

ICD may be great devices but it simply does nothing in preventing an episode VT.It trys to battle the fire after its ignition.Not a great concept to be pride upon.At best it can be called as back up safety device.So , for long term therapy it seems we need additional support system to ICD .

This can either be RF ablation or medical therapy (Amiodarone ,Sotolol, Mexiletene).It is likely , intensive anti -arrhymic therapy is essential in most.In some patients all three modalities(ICD, RF ablation, drugs) will be required for complete protection.

The VANISH trial has added important data on this issue .

http://www.nejm.org/doi/full/10.1056/NEJMoa1513614?query=OF

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We all know to err is human , but most of us probably won’t agree medical mistakes , (bulk of which happen in the name of practicing state of the art of science ! ) could be the dominant theme in modern medical care !

BMJ exposes this  well known secret with the help of most authentic data from an apex scientific body CDC , Atlanta .

Reference

http://www.bmj.com/content/353/bmj.i2139#

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Bifurcation lesions (BFL) remain a true challenge to interventional cardiologists. For over two decades , at least a dozen strategies are being tried to conquer it without true success . . . if iam allowed to say that.

We often talk about side branch in BFLs.Ironically , the importance of side branch is largely determined by our cortical linguistic perception of the word “side”

The much famed Medina classification does little to clarify the importance of side branch with reference to left main vs non left main bifurcation lesions.

In true sense , both LAD or LCX can be side branches in left main BFL depending upon how one views it.
Commonsense would tell us, since LAD is a major vessel , LCX gets the side branch tag by default.

However, If LAD is diminutive, or its serving a infarcted , non functional zone and if LCX is really big and dominant, it has every right to reject the humiliation of being refered to as a sidekick.

Note , in non left main BFL there is no much confusion since main branch continues as main and side branch just exit.

Final message

Interventional cardiologists use the term “side and main branch ” in variety of ways .Though, it could mean vitally important things , oftentimes its simply semantics prevailing over complex coronary hemodynamics.

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