Posted in Uncategorized, tagged bbc trial, bifurcation pci, distal vs proximal strut crossing, dk crush cullotte, final kissing balloon inflation, lcx ostoium compromise, mini crush, pot technique, provisional single stent strategy, single vs double stent, tap t technique for pci, upfront two stent strategy, which cell to cross proximal or distal ? on April 30, 2025|
I am neither an active or inactive Interventional cardiologist. But, I have sat through numerous sessions of complex PCI workshops. I used to wonder why they give so much importance to the side branch crossing. Obviously, it must be for some good reason. I did this brief write-up, trying to comprehend some sense. Hope the experts would agree with this.
Posted in Uncategorized on April 29, 2025|
It is an unusual study on STEMI ,yet profound, in adding clinical wisdom in this techno era. The study is titled : Symptoms Predictive of Acute Myocardial Infarction in the Troponin Era: Analysis From the TRAPID-AMI Study . Kudos to the Henry ford hospital team, for thinking to produce such a study .
This study looked into the clinical characters of STEMI presentation and correlated with various aspects including Troponin levels with reference tothe clinical factors.
Reproducing just one sample data about the character of chest pain. Please go through the complete paper.
Few observations need a comment
The pull or catchining type of pain has 0% likelyhood of STEMI.The last in the list is mentioned as dyspnea is of great importance.It is the angina equivalnet ,which is reported to be 50 % is quiet high.
One observation, and an unlikely miss I could found, is the incidence of epigastric pain and rare abdominal pain in some of those pateints with inferio posterior MI where it direct intimacy with diaphgram and whcih can radiate downwrds.We have missed some cases as acute abdomen, as pancreatitis , later on proven to be RCA STEMI.
Final message
We keep talking at length, dozens of listless trials fighting between single or two stent strategies in bifurcation lesions in every compulsive interventional workshop. Currently, I don’t think any conference would give a stage space to discuss trials such as TRAP-AMI which can infuse fresh thoughts in youngsters’ minds. It is an unrealistic wish though; any cardiology scientific committee should be mandatorily instructed to allot at least 30% of time to clinical cardiology that can bring back the field of cardiology, on the righteous track again.
Reference
Posted in Uncategorized, tagged coronary autoregulation, coronary perfusion pressure, ffr, iapb, ifr, lad flow, qfr on April 12, 2025|
1.Is systemic HT an advantage ?so that high pressure head aids in pushing the blood across the lesion. ?
I don’t know whether I can say Yes*, physiologically, the high proximal pressure and low distal pressure help maintain the flow. The distal drop happens due to the tightness of the lesion itself, but that is counterproductive, unless tone of the distal microvascular bed is intact and dilates fully.
*Mind you, IABP during cardiogenic shock, essentially does this – keep the coroanry diastolic pressure high.
However, there are significant caveats.
There is law of diminishing Returns : In a 90% lesion, the resistance is so high that even elevated Pa may not substantially increase flow due to the fixed obstruction. Hypertension increases left ventricular afterload, raising myocardial oxygen demand. In a 90% LAD lesion with compromised flow, this can worsen ischemia, outweighing any flow benefit from higher pressure.
2.What happens to trans-lesion flow during hypotension ?
This has direct implications when a patient with a significant lesion develops hypotension due to a systemic cause like dehydration or postoperative hypovolemia. We have often observed transient ST/T changes in a postoperative patient that may or may not lead to full-blown ACS.
To know what exactly happens across a lesion, we need to understand coronary autoregulation and its limits. Coronary autoregulation maintains stable myocardial blood flow despite changes in coronary perfusion pressure. Its limits and range are as follows. .
The famous dog experiment on the coronary flow on depressurisation (Ref 2)
Range of Autoregulation: In healthy coronary arteries, autoregulation operates effectively between perfusion pressures of approximately 50–60 mmHg to 120–140 mmHg. Within this range, vascular smooth muscle in coronary arterioles adjusts resistance to maintain near-constant blood flow.Lower Limit: Below 50–60 mmHg, autoregulation fails, and blood flow becomes pressure-dependent. This can lead to ischemia, especially in the subendocardium, which is most vulnerable due to higher oxygen demand.Upper Limit: Above 120–140 mmHg, maximal vasodilation is reached, and further increases in pressure do not significantly increase flow.
However , we don’t know how this autoregulatory biological servo control, is tampered in the presence of a single or a tandem lesions.
3.How does FFR gets altered during exertion in such lesion ?
We have very limited data available on this and are essentially ignorant . FFR during exertion typically decreases compared to rest due to the amplified pressure gradient across the stenosis driven by increased flow demand and limited reserve.However collaterals can mitigate this fall in FFR.
Final message
Putting a stent across 90% lesion surely is a childish task, when compared to understanding complex hemodynamic vortices that happen across it.
Reference
Posted in cardiology -Therapeutics, Ethics in Medicine, tagged dr s venkatesan, dr venkatesan sangareddi, ethics, optimism, optimism vs pessimism, optimist, positive vs negative thinking, venkat quotes, venkatesan sangareddi, widom quotes on April 9, 2025|
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology therapeutics on April 9, 2025|
Cardiologists have been trying for the last two decades to prove PCI is superior or at least equal, to CABG in multivessel CAD. We desperately needed studies to prevail over FREEDOM and SYNTAX which favored CABG.
FAME series , though never had an intention to compare PCI vs CABG , now we have used the platform to upend it to take on the CABG in multivessel CAD. ( FAME 3)
FAME 1 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation)
Purpose
The FAME 1 study aimed to compare the efficacy of FFR-guided PCI versus angiography-guided PCI in patients with multivessel coronary artery disease (CAD). The goal was to determine whether using FFR to identify functionally significant stenoses (FFR ≤ 0.80) for stenting, rather than relying solely on angiographic appearance.
Inference
Established that FFR-guided PCI is superior to angiography-guided PCI in multivessel CAD, reducing unnecessary revascularizations and improving outcomes.
Purpose
FAME 2 sought to evaluate whether FFR-guided PCI plus optimal medical therapy (OMT) was superior to OMT alone in patients with stable CAD and at least one functionally significant stenosis (FFR ≤ 0.80).
The study concluded that FFR-guided PCI is beneficial in stable CAD when ischemia is present, reducing the need for subsequent urgent revascularizations compared to OMT alone, though it did not significantly reduce rates of death or MI
Purpose
FAME 3 aimed to determine whether FFR-guided PCI using contemporary drug-eluting stents was non-inferior to CABG in patients with three-vessel CAD. The study sought to compare these two revascularization strategies in terms of clinical outcomes, testing the hypothesis that FFR-guided PCI could achieve similar results to CABG by targeting only functionally significant lesions.
Conclusion
At 1 year, FFR-guided PCI did not meet the criterion for non-inferiority compared to CABG for the primary endpoint of MACE (death, MI, stroke, or repeat revascularization), with event rates of 10.6% for PCI vs. 6.9% for CABG.
5 years later in 2025
FAME 3 : 5 year follow up data , released in 2025, tries to confirm the non inferiorty of PCI over CABG in a larger sense.
The study concluded that in patients with three-vessel CAD, FFR-guided PCI is not non-inferior to CABG, with CABG remaining superior for reducing MI and repeat revascularization. However, FFR guidance still refined PCI by limiting interventions to functionally significant lesions.
Did the FAME 3 study compare FFR guided CABG vs FFR guided PCI ?
No, none of the FAME studies (FAME 1, FAME 2, or FAME 3) directly compared FFR-guided CABG versus FFR-guided PCI. Each study had a distinct focus involving FFR-guided PCI, but none incorporated FFR guidance into CABG as a primary comparator. Here’s why this comparison could be meaningless.
Final message
Truths express themselves. We can’t force it to happen.
Reference
Posted in Uncategorized on April 6, 2025|
We know, stress tests can give false positive results suggesting ischemia in at least 20% of patients for various reasons . It can occur with systemic (Anemia) and cardiac conditions such as HT, LVH, baseline ECG changes, or myocardial disease.
Here is a middle-aged man who went for an annual health check and ended up with this TMT. His exercise capacity was good at 11 METs, stopped at early stage 4 standard Bruce. He was asymptomatic, and every other parameter was normal.
Images: Resting, Peak, severe positive response, in lead V5 and V6. Every cardiologist advised some form of CAG. Opinions were so diverse, ranging between silent left main, tight proximal LAD to innocuous false positive.
What is your inference ? The patient seeked by advice It was indeed an academic stress test. There is a frightening ST depression I said. yes the rest is very likely to be false positive but I don’t have the courage to commit so. Mostly, you can’t escape from a coronary angiogram” . Next option is CT angiogram, Thallium or dobutamine stress.
It was indeed an academic stress test. There is a frightening ST depression . Very difficult to Ignore. May be, it could be false positive but I don’t have the courage to commit so. Mostly, you can’t escape from a coronary angiogram” .Other options are CT angiogram, Thallium or dobutamine stress.
He smiled and said, “You are absolutely right, doctor. Out of 5 cardiologists I consulted, 4 asked me to go for an immediate angiogram. Still, I escaped because of one Egyptian cardiologist.”
I was eager to see what he did . This is the test he did.
Yes. It was indeed a smart move. The shrewd cardiologist did a bicycle ergometry and simultaneous echocardiogram without any drugs or injections. He could confidently rule out significant CAD (by absence of any wall motion defect). Hats off to him. Lets earn some courage from such truely learnt cardiologist.
Final message
Most of us (Cardiologists) find it difficult to trust the physiological data that come from history, ie excercise capcity . We are obsessed with anatomy. Though, we eloborately debate about physiology-based intervention inside cathlab in every conference.
Our flawed intellect keeps asking this question: How can I trust physiology (Flow) without documenting a good anatomy? In fact, truth is the other way around. A good epicardial anatomy rarely guarantee good physiology. (It is worth recalling, CAG, the investigation we celebrate as the gold standard, images only about 2% of the entire coronary vasculature.)
A well-documented near physiologically flowing coronary circulation, negates the need to document anatomy through whihc it flows,however shabby or good it may be. (For the FFR & iFR guys, it must be mentioned that a negative stress test implies a net combined three-vessel FFR of > 0.9.)
Postamble
There was a well-accepted holistic, yet scientific concept roaming around in cardiology academic circles in the 1990s. (Of course, now it is thrown to the dustbin.) It said, if anybody crosses 10 METs in TMT, he or she is unlikely to harbor a significant lesion; even if there is one, it usually doesn’t require a metallic fix.
Posted in Uncategorized, tagged cardiac indication for lscs in pregnancy ceserain section in heart disease, cardiocascualr disease complicating pregnancy, cardioobstetrics team, epidual anesthesia during heart disease carpreg, esc acc pregnancy guidleines, heart disease in pregnancy, hemodyanmicstress of lscs vs natural delivery in heart diseae complicating pregnancy, lscs risks during heart diseas, mitral stenosisin pregancy, obsterical anesthesia, obsterical indication for lscs, which is safe lscs or vaginal deliver y in heart diseae, who pregnancy on April 4, 2025|
In pregnant women with significant heart disease : A quick LSCS or a potentially prolonged natural delivery,which is more safe ?
In pregnant women with significant heart disease, the choice between natural vaginal birth and a cesarean section (LSCS) depends on several factors, including the specific type and severity of the heart condition, the overall health of the mother and fetus, and the recommendations of a multidisciplinary medical team (typically involving obstetricians, cardiologists, and anesthesiologists). There’s no one-size-fits-all answer.
Hemodynamics of normal delivery
Natural delivery involves the physiological stress of labor, which includes increased cardiac output, blood pressure fluctuations, and oxygen demand, peaking at 50-80% above baseline during contractions and pushing. For women with significant heart disease (e.g., severe mitral stenosis, pulmonary hypertension, or cardiomyopathy), prolonged labor could strain the heart excessively, potentially leading to decompensation, heart failure, or arrhythmias. The unpredictability of labor duration is a key concern, as it might delay intervention if complications arise.
A planned C-section, on the other hand, offers a controlled environment with predictable timing and monitored anesthesia (often regional, like spinal ,graded spinal or epidural, which can minimize hemodynamic shifts compared to general anesthesia). It avoids the prolonged cardiac stress of labor and allows immediate access to surgical intervention if needed. However, it’s not risk-free: C-sections increase the risk of bleeding, infection, and fluid shifts post-delivery, which can also challenge a compromised heart. Recovery might also be tougher on someone with limited cardiac reserve.
Evidence leans toward individualized decisions rather than a universal preference. For example, women with conditions like Marfan syndrome and aortic dilatation (>4 cm) or Eisenmenger syndrome often have C-sections recommended due to the risk of aortic rupture or acute heart failure during labor. In contrast, women with well-managed, less severe conditions (e.g., repaired congenital defects) might safely attempt vaginal delivery with careful monitoring and a low threshold for intervention.
The American Heart Association and European Society of Cardiology guidelines suggest that for high-risk cardiac patients (e.g., WHO Class III or IV), a planned C-section under controlled conditions is often safer, especially if labor could become prolonged or unpredictable. Epidural anesthesia and assisted vaginal delivery (e.g., forceps) can sometimes bridge the gap, reducing labor strain while avoiding surgery, but this requires a stable patient and skilled team.
Is LSCS really more safe ?
Ultimately, “more safe” hinges on the specific case. A quick C-section in a monitored setting often edges out natural delivery for significant heart disease because it minimizes uncertainty and prolonged stress—but it’s not without trade-offs. The medical team would weigh the patient’s cardiac function (e.g., ejection fraction, symptoms), fetal status, and delivery logistics. If you’re asking about a specific scenario, feel free to give me more details, and I can refine the answer further
Dictums can’t dictate
Is the generally accepted dictum, that ceserain section is meant only for obsterical Indication, still valid in most cardiac patients?
It is true , cesarean section is reserved for obstetric indications—like fetal distress, breech presentation, or failure to progress in labor, has historically been rooted in minimizing surgical risks and prioritizing natural delivery when possible. However, in the context of pregnant women with cardiac disease, this principle isn’t universally upheld as a strict rule. For cardiac patients, the decision often shifts from purely obstetric factors to a broader risk-benefit analysis that includes maternal cardiac safety, sometimes overriding the “obstetric indication only” guideline.
In women with significant heart disease, the physiological demands of labor (e.g., increased cardiac output, blood pressure spikes, and oxygen consumption) can pose a direct threat to maternal survival, even if the pregnancy itself is obstetrically uncomplicated. Conditions like severe pulmonary hypertension, advanced heart failure, or critical aortic stenosis carry high maternal mortality risks during labor—sometimes 30-50% in extreme cases like Eisenmenger syndrome. Here, a planned C-section isn’t just about the baby; it’s about keeping the mother alive. This makes maternal cardiac status a valid indication for C-section, challenging the traditional obstetric-only framework.
However, the dictum still holds some relevance for cardiac patients with milder or well-controlled conditions (e.g., WHO Class I or II, like a repaired atrial septal defect with normal function). In these cases, vaginal delivery is often preferred if obstetric factors don’t demand otherwise, as it avoids surgical risks like bleeding, infection, or anesthesia-related complications that could still tax a less-severe cardiac condition. Assisted vaginal delivery (e.g., with forceps or vacuum) and epidural anesthesia can further reduce labor strain, making natural birth feasible and safe.
Current guidelines, from the American College of Cardiology and European Society of Cardiology, reflect this changing perception . They recommend individualized plans rather than blanket rules. For high-risk cardiac patients (WHO Class III or IV), a C-section is frequently favored—often scheduled around 34-36 weeks if preterm delivery is tolerated—regardless of obstetric status, because the controlled setting trumps the unpredictability of labor. For lower-risk patients, the obstetric indication rule still guide us, unless cardiac monitoring suggests otherwise.
It must me emphasised , the discipline of the multidisciplinary team , especially the egoless ineractions of all members is the key. Type of anesthesia and their cooperation and expertise will be a defining factor many times.
Final message
So, the dictum is no longer valid in all cardiac patients” anymore—it’s just sort of entered our minds and refuse to go away. (There are set of contions and absolute indication for LSCS in heart disese. Every one agrees on that) The purpose of this write up is to look beneath those established Indications.
There is an urgent need for some “academic tinkering” to this decades old, much revered dictum, for the beenfit of mother and baby May be , It applies where cardiac risk is low and obstetric needs dominate, but for severe heart disease, maternal cardiac indication alone can justify a C-section. The shift reflects better understanding of cardio-obstetric interplay and prioritizes outcomes over tradition.
Counterpoint
Guidelines are still dilly-dallying between choices of delivery , based on tradition, technology, expertise & experince (Ref 2 : vouch against LSCS), I think, the obstetrician who is the captain of the multidisciplinary team along with her anesthetist and intensivist are the best persons to take the call. Cardiologist’s role is generally minimal in most situations except for that critical moral support , few management advices and ofcourse for legal protection.
Reference
1 https://doi.org/10.1093/eurheartj/ehy340
Dr.S.Venkatesan MD 