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Archive for June, 2024

June 2020

Let me go back … 4 years in time-line, to the dark COVID duty days in 2020 at one of the largest COVID facilities, Madras Medical College, Chennai.India.I still feel a sense of unease when I reflect on those harsh days, with bed-less patients gasping for breath and waiting in the long ambulance queues in our esteemed hospital.

I can’t recall how many times I was disrupted by the silent, final journey of body bags being transported to the mortuary ward. The fatigue and sickness affected doctors, fellows, nurses, and ward boys. Still, the hospital did a mind-boggling job of saving and caring for hundreds and thousands of patients through the agile administrative team.


June 2024

Putting those tough years back, I have since retired from my hospital. Now, why should I stumble upon this video from Dr Campbell. It shook me again. This is not an all-pervasive, fake, or exaggerated video clip from YouTube. It is, in my opinion, an uncontaminated truth. It took a 5-year chase to catch the truth, red-handed.

Dr John Campell don’t need any Introduction. He was the only comforting voice and his daily briefing right through the pandemic was watched by millions. Now, in June 2024, he has to say this. Watch it fully if you can. You will learn in 15 minutes, the lifetime lessons of how biomolecular & viral laboratories work. Also, be aware of the dangerous game of making gene sequences of these microbial monsters proprietary.

Also, don’t miss the thundering statement, by the ex CDC director, that has a huge implications for humanity, (Who himself is a virologist) The summary of the video seems to convey a strong message. Let us pray for no more pandemics. If at all it happens, let it be a natural one that will definitely be less virulent for sure.

Final message

The title of this post is intentionally provocative, However, there is no evidence to disprove it. One thing is clear. Hundreds of virulent viral RNA and DNAs are waiting in unknown labs, at various stages of mutations and gain in function, itching to get into an animal or human domain.

What a pity, “My dear world” I thought, our esteemed scientists are working day and night to weaken the viruses but they are using all their energy, and do just the opposite.

It looks like, the world is no longer a safe place to live in. We are adding more things to worry about than, War, Poverty & climate change. The solution is never going to come from the Governments or WHO. It is in our minds, in the ability to resist fear-mongering. Let the Almighty give us the capacity, to identify and avoid the evil design, that has encircled us, with deceiving kindness, topped up with sweetly poisoned science. (How can we forget those nearly 100 billion Dollars worth of senseless RTPCRs, CT scans Remdesvirs, and their clones, that went down the drain without any purpose.)

Further watching

More sinister truths are hidden in the widely open corridors of WHO headquarters.(Watch this video link)

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Technically and also realistically, Jugular veins can be referred to as live, non-invasive biological catheters, that transmit the hemodynamic data of the right heart, 24/7 free of cost. JVP reflects RA pressure in systole and the combined RA, & RV chamber in diastole. It is left to our clinical acumen, to use it in whatever manner, that is beneficial.

One such thought is described in this animation.

Please go to the full-screen view and freeze the video to read the text.

The usefulness of JVP in a cardiac emergency like acute pulmonary embolism may appear superfluous. But, the fact of the matter is, a persistently raised JVP with good waveform, without systemic hypotension, may not portend a bad outcome. Sometimes, the Echo parameters are alarming, but a patient may be just fine. Here, is a real challenge. In these situations, the humble neck veins can assist us in the decision to thrombolysis or the need for any newer intrapulmonary Interventions under RV assist system.

Limitation is endless

Whenever we talk about RV dysfunction, by default we mean RV systolic dysfunction. It is critically important to understand the RV diastolic function is silently and strongly coupled with its systolic function. Impaired RV diastolic function impacts JVP in a significant fashion. We are not going into those complexities. However, tricuspid annular motion is independent of the diastolic relaxation properties of RV. If you want to go one step further in this topic, try to find out the true mean pressure of JVP, and its relationship with RVEDP.

Reference

To be created.

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Like coronary blood flow, intra-cardiac electricity must flow in a pre-designated path at a specific time interval with absolute  discipline. Any deviation or trespassing results in arrhythmia. While, minor aberrations are accepted, major deviations due to structural or functional reentry within the ventricles presenting as VTs (Scars, Infiltrates, etc) need immediate or at least early attention.

The term, VT mapping has been in vogue in clinical electrophysiology for more than half a century, right from Dr.Josephson and Wellens’ days. While , treating VTs with drugs is still a choice, permanent solutions by defining the VT circuit and ablating them, is the new norm. However , the difficulty is, demarcation of the VT circuit is still a tough job, especially since the VT circuit plays a mysterious hide-and-seek game during diastole. The current challenge is to draw the complete blueprint of the VT, especially the diastolic VT circuit.

The tracts that carry the diastolic electrical flow are located sub-endocardially, sub-epicardially , over right ventricular aspect, or finally through the ubiquitous concealed intramural paths.

Unless, we eliminate the entire circumference of the circuit the chances of recurrence is higher (This is contrary to the past belief that a one-time interruption of the VT circuit at some point of the circumference was considered good enough. (This is what DC shocks do for temporary reversion to sinus rhythm )

How to localize the diastolic pathways?

We must thank the technological innovators in the electro-anatomical mapping system, who are continuously upgrading and providing the best to us. The following image and video clip is one such demonstration of ablating hidden diastolic paths between the entry and exit points.

Diastolic blind spots between the entry & exit points of VT can be deep & dark


The final message

It’s very clear, that I can never be able to understand the technology and nuances behind the mapping and ablation. But, just wanted to share a simple thought with the general cardiologists after going through the above article. Like hemodynamics of blood , an “electro-dynamic” flow cycle exists that is critically important both in physiology and pathology . The learning point is that, in VT ablation, looking for anatomical diastolic tracts and its electrical activity becomes a key exercise.

How can we remember this EP lesson easily ?
We can take a cue from the vintage clinical auscultation classes, where we ask the medical students to look for MDM (mid-diastolic murmur) in mitral stenosis in the left lateral posture in expiratory phase. Now in modern electro-physiology, it is time to teach young cardiology fellows a new rule of thumb, always look for the (mid )diastolic electrical flow in any scar-induced VT.

Reference
Alexios Hadjis , Antonio Frontera. Luca Rosario Limite , et al Complete Electroanatomic Imaging of the Diastolic Pathway Is Associated With Improved Freedom From Ventricular Tachycardia Recurrence Circ Arrhythm Electrophysiol. 2020;13:e008651. DOI: 10.1161/CIRCEP.120.008651

Next question in the queue

Can a VT occur without an exit point ? (I have been looking for a long time for an answer)

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This is a condensed video version of PPT slides of my recent presentation.Please pardon, there is no audio as of now. Will make a voice-over and post soon.

Topic : AI in cardiology

Occasion: Prof Rathnavelu Subramanian memory oration. Cardiological Society of India Chennai.

Date : 8-06-2024

Acknowledgment & Courtesy: Images and videos from open source

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