• Home
  • Aim of this blog

Dr.S.Venkatesan MD

Expressions in cardiology

Feeds:
Posts
Comments
« Ignorance based cardiology : What is the relationship between blood cholesterol and plaque cholesterol ?
As CABANA waves a final good bye to catheters in AF . . . let the pulmonary veins rejoice ! »

Why routine thrombus aspiration is prohibited in STEMI ?

May 12, 2018 by dr s venkatesan

It was 1912 , Titanic had just sank off the Atlantic . When the world attention was elsewhere , An unassuming young Dr.Herrick J.B silently working in his Michigan lab inquisitively proposed thrombus occluding the coronary artery is the chief culprit in acute myocardial Infarction.It took seven more decades when Davis et all from Glasgow .UK. proved it by doing dramatic angiographic studies soon after STEMI in year 1979.

Now, even after 100 years , we, the confused cardiologists debate endlessly in glamorous global conclaves in exotic locales whether to aspirate these humble looking thrombus, threatening to damage the myocardium with every passing moment !

Why is this controversy ?

My answer

I am failing to understand the concept and the answer is elusive .While every one agrees that thrombus is true culprit, in bulk of the STEMI , still we are not authorised (In an assertive fashion ) either to lyse as first choice or to aspirate as second choice.

It seems vital, thrombus must be tackled vigorously by any means. Drugs,lytics,(Intravenous or Intra-coronary.) by micro and rheolytic catheters .Only documented, flow limiting complex mechanical lesions must be stented. If we are convinced tackling thrombus by mechanical means is problematic (As studies would suggest ) lysis should prevail over aspiration as a routine measure by default isn’t ?

*It’s a been quite a while , the world cardiology community has made it appear thrombolysing a patient who is otherwise eligible for primary PCI ! a “coronary crime*” Ofcourse , I must say , I proudly commit that crime with rewarding results in many MI patients.

*In fact , I would think not promoting or delaying prompt lysis should qualify for the definition.

In the management of STEMI, prehospital lysis followed by a Intensive care in a good coronary care center is best modality.

This doesn’t mean in-hospital lysis is banished. Yes, STEMI is a cardiac emergency , but triaging STEMI patients must be done by scientific means (STEMI risk score) as well with accumulated wisdom .Rush only true emergencies into cath lab. (A best estimate is about 20 % of all STEMI) If we are not able to decide which STEMI will require prompt PCI , it would Imply we need to go back and do once more the basics postings in coronary care of resident days !

An angry counter from a young Interventionist

Only God can tell whether a given patient with STEMI will (or will not) derive maximum benefit from pPCI. We are not yet trained to make that decision by looking at patient and his ECG.So my logic is all STEMIs are equal. I will continue to do emergency angioplasty in all STEMI patients . I expect them blindly to accept all the potential complications arising out of poking the thrombotic milieu in those low risk patients who might have done well with thrombolysis.

Never afraid of challenges. It is like going to war. Casualties are bound to happen.We have enough technology , Imaging , expertise, to tackle all those complex lesions we encounter during primary PCI especially in elderly comorbid patients. We can even do a triple vessel angioplasty , left main etc. Only Yesterday I posted in my nonstop whatsapp group , where I did a dramatic acute angled bifurcation angioplasty for a stable STEMI patient that required a iFR guided jailed side branch assessment and 3d OCT transmitting stunning snaps of fresh thrombus, ending with a semi culotte procedure.The patient is doing well with a Impella 2.5 device and a high frequency ventilator support and my anesthetist has promised me to wean him soon ! I must actually thank his Glo-Health plus Insurance company for clearing the procedure.

An Important tip for complex lesions during STEMI

We need to know there is always a saving grace , if for some reason we couldn’t accomplish PCI due to complexities of the lesion with multiple IRA mimickers. We can always sheepishly thrombolyse these patients inside cath lab . . . a modality just few minutes ago would have been ridiculed with all our vigor to convince the anxious family for a costly Invasive procedure !

Reference

1. SIEGELR The man who discovered coronary thrombosis; James Brain Herrick, 1861-1954..J Med Soc N J 1958 May;55(5):201-4.

2.Davies W. F. M. Fulton W. B. Robertson The relation of coronary thrombosis to ischaemic myocardial necrosis M. J. Journal of pathology February 1979

3. Herrick Original paper . https://jamanetwork.com/

Rate this:

Share this:

  • LinkedIn
  • WhatsApp
  • Twitter
  • Facebook
  • Email

Like this:

Like Loading...

Related

Posted in Cardiology -Criteria, Cardiology -Therapeutic dilemma, cardiology wisdom, Coronary angiogram, cost effectiveness in cardiology, STEMI, STEMI -Managment, STEMI-Primary PCI, Thrombolysis, Thrombolysis -Tips | Tagged herrick davis coronary, primary pci, thrombolysis vs primary pci, total taste tapas |

  • Categories

  • Archives

    • January 2023 (7)
    • December 2022 (3)
    • November 2022 (5)
    • October 2022 (5)
    • September 2022 (4)
    • August 2022 (3)
    • July 2022 (9)
    • June 2022 (2)
    • May 2022 (1)
    • April 2022 (2)
    • March 2022 (1)
    • February 2022 (3)
    • January 2022 (7)
    • December 2021 (3)
    • November 2021 (5)
    • October 2021 (8)
    • September 2021 (4)
    • August 2021 (6)
    • July 2021 (6)
    • June 2021 (7)
    • May 2021 (5)
    • April 2021 (4)
    • March 2021 (3)
    • February 2021 (6)
    • January 2021 (8)
    • December 2020 (4)
    • November 2020 (5)
    • October 2020 (7)
    • September 2020 (7)
    • August 2020 (10)
    • July 2020 (6)
    • June 2020 (9)
    • May 2020 (9)
    • April 2020 (5)
    • March 2020 (7)
    • February 2020 (3)
    • January 2020 (4)
    • December 2019 (4)
    • November 2019 (6)
    • October 2019 (3)
    • September 2019 (6)
    • August 2019 (3)
    • July 2019 (1)
    • June 2019 (3)
    • May 2019 (2)
    • April 2019 (2)
    • March 2019 (2)
    • February 2019 (4)
    • January 2019 (2)
    • December 2018 (2)
    • November 2018 (2)
    • October 2018 (2)
    • September 2018 (1)
    • August 2018 (2)
    • July 2018 (3)
    • June 2018 (1)
    • May 2018 (3)
    • April 2018 (1)
    • March 2018 (3)
    • February 2018 (3)
    • January 2018 (1)
    • December 2017 (3)
    • November 2017 (3)
    • October 2017 (3)
    • September 2017 (2)
    • August 2017 (2)
    • July 2017 (2)
    • June 2017 (2)
    • May 2017 (4)
    • April 2017 (3)
    • March 2017 (3)
    • February 2017 (5)
    • January 2017 (3)
    • December 2016 (2)
    • November 2016 (5)
    • October 2016 (4)
    • September 2016 (3)
    • August 2016 (5)
    • July 2016 (3)
    • June 2016 (4)
    • May 2016 (3)
    • April 2016 (6)
    • March 2016 (4)
    • February 2016 (3)
    • January 2016 (5)
    • December 2015 (6)
    • November 2015 (5)
    • October 2015 (8)
    • September 2015 (2)
    • August 2015 (5)
    • July 2015 (7)
    • June 2015 (4)
    • May 2015 (6)
    • April 2015 (5)
    • March 2015 (7)
    • February 2015 (15)
    • January 2015 (8)
    • December 2014 (5)
    • November 2014 (9)
    • October 2014 (7)
    • September 2014 (9)
    • August 2014 (5)
    • July 2014 (11)
    • June 2014 (5)
    • May 2014 (4)
    • April 2014 (5)
    • March 2014 (8)
    • February 2014 (8)
    • January 2014 (5)
    • December 2013 (7)
    • November 2013 (7)
    • October 2013 (14)
    • September 2013 (12)
    • August 2013 (15)
    • July 2013 (15)
    • June 2013 (15)
    • May 2013 (15)
    • April 2013 (15)
    • March 2013 (15)
    • February 2013 (15)
    • January 2013 (15)
    • December 2012 (15)
    • November 2012 (15)
    • October 2012 (15)
    • September 2012 (15)
    • August 2012 (15)
    • July 2012 (15)
    • June 2012 (15)
    • May 2012 (15)
    • April 2012 (15)
    • March 2012 (15)
    • February 2012 (15)
    • January 2012 (15)
    • December 2011 (15)
    • November 2011 (17)
    • October 2011 (17)
    • September 2011 (17)
    • August 2011 (21)
    • July 2011 (20)
    • June 2011 (17)
    • May 2011 (15)
    • April 2011 (17)
    • March 2011 (25)
    • February 2011 (20)
    • January 2011 (20)
    • December 2010 (18)
    • November 2010 (21)
    • October 2010 (21)
    • September 2010 (25)
    • August 2010 (20)
    • July 2010 (10)
    • June 2010 (11)
    • May 2010 (19)
    • April 2010 (16)
    • March 2010 (14)
    • February 2010 (22)
    • January 2010 (18)
    • December 2009 (20)
    • November 2009 (20)
    • October 2009 (3)
    • September 2009 (21)
    • August 2009 (19)
    • July 2009 (12)
    • June 2009 (12)
    • May 2009 (11)
    • April 2009 (15)
    • March 2009 (21)
    • February 2009 (4)
    • January 2009 (12)
    • December 2008 (13)
    • November 2008 (9)
    • October 2008 (22)
    • September 2008 (20)
    • August 2008 (16)
    • July 2008 (14)
    • June 2008 (7)
  • Blog Stats

    • 5,961,212 hits
  • Please give your feed back .

  • Click below to see who is watching this website live !

  • This site will never aim for profit. Still ,this donation link is added at the request of few visitors who wanted to contribute and of-course that will help make it sustainable . Donate Button with Credit Cards
  • Please Note

    The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
  • Live 3D global traffic map Stats

WPThemes.


  • Follow Following
    • Dr.S.Venkatesan MD
    • Join 820 other followers
    • Already have a WordPress.com account? Log in now.
    • Dr.S.Venkatesan MD
    • Customize
    • Follow Following
    • Sign up
    • Log in
    • Copy shortlink
    • Report this content
    • View post in Reader
    • Manage subscriptions
    • Collapse this bar
 

Loading Comments...
 

    %d bloggers like this: