Dr.S.Venkatesan MD

Archive for August, 2025

Pulmonary atresia with VSD : Is it a cono-truncal anomaly ?

Posted in Uncategorized, tagged collaterals in tof, cono truncal anomaly, mapcas, neural crest defects, pda in tof, pulmonary atresia with vsd, TOF on August 26, 2025|

There is a list of conditions that come under cono-truncal anomaly(CTA) in CHD. TOF is the classical example. CTA are group of genetically determined fusion defects between developing right ventricle , septum and the outflows .Many components of outflow are outsourced from cranially located neural crest . In fact, improper migration and fusion of this secondary heart field to the primary is most common cause of many complex heart disease. Microdeletion on chromosome 22, specifically in the 22q11.2 is a major documented gene defect. Traditionally CTA list often includes PA with VSD. This table compares the anatomical and embryological basis of TOF & PA with VSD. You can decide whether to call both as part of cono-truncal anomaly or not.

Add on content.

One important difference is missing in the above table. It is about presence and absence of PDA. In TOF true PDA may be present in early days or months . In PA with VSD , PDA or (MAPCAS mimicking a PDA ) can be part of collateral .A persistent controversy is, how to differentiate a PDA from MAPCAS .That can be challenging. Further, to label a vessel as PDA it should drain into normally formed left pulmonary artery, which is rarely likely.

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Normal BP recorded by an abnormal physician!

Posted in Uncategorized, tagged acc aha guidlines hypertension, british society of hupertension, defintion of normal blood pressure, esc hypertension guidelines 2024, hypertesnion grading, hypertesnion nomenclature, pre hypertension vs non eelvated bp, what is eelvated bp, world hypertension league on August 20, 2025|

This a transcript of a mini-cardiology consult happened in a routine office practice of a physician.

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I am Mr. S. I just went for a preventive health check, specifically to rule out hypertension . I got my BP checked by a physician who is also an experienced cardiologist.

“How is my BP doctor ?

“Its fine , It is 120/76 ”

I asked him, “Is my blood pressure normal doctor?

I thought, the doctor sort of frowned at me for a moment and said , “Oh sure, technically yes , it is normal BP , but academically it is not.” 

“Doctor, make a pardon , I didn’t get it . You mean to say my BP is abnormal ?

“No, not really, it is not abnormal either.”

“Then, why you said it is academically not-normal doctor ?

“I would love to call it normal, in fact it is normal .“

“I am confused doctor. What prevents you to call it as normal BP doctor ?

“Let me tell the truth .The current scientific guidelines (ESC) which we revere , doesn’t allow me to call it as normal BP . It wants to get rid of the term normal BP from the cardiology literature. It asks us to call you guys with perfectly normal BP as having non elevated BP. I want to be loyal to the science and also should not feel out-dated with my peers.“

“I understand doctor, the compulsion to respect science more than your conscience in your day to day practice and admit it too .You are a very rare & frank Doctor I have, ever come across “

Thank you, Mr S. for your complements very kind of you .But, let me go little personal. My colleagues consider me otherwise . They don’t consider me as a normal doctor , because I am frank.

Doctor, please don’t bring that normal curve stuff again. If you are called abnormal, then who is normal , doctor?

Sorry, I don’t have an answer .We shall meet on our next visit. Bye & thanks

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Those who want to dwell deep please go through this 107 page document.

Trying to find out the word normal BP in the latest ESC 2024  Hypertension  guidelines .

What is the logic for removing the term Normal BP in the new ESC guidelines ?

BP is a continuous variable . People with any level of BP can develop cardiovascular events. So there can’t be strict normal.

Why such a classification could be dangerous ?

By avoiding the word normal, are we trying to suggest non-elevated BP is also a potential risk factor? These guidelines misleadingly and unintentionally took a cue from the LDL analogy: i.e., lower is better. They conveniently forgot the J-curves and U-curve of BP. This classification is meant to keep every adult human being as a potential candidate to get ready for elevated BP or HT. Can’t suspect the true intentions, though, as these guidelines stress the importance of good lifestyle choices to keep the BP in control without drugs.

The fact that the new guidelines is avoiding the word normal , implies it hesitates to reassure our public .This, by itself, will make our public anxious, push up the BP, and end up as drug-consuming hypertensives later. Principles of the practice of medicine hinge on trust and reassurance. In the name of scientific preventive medicine, we are unable to call a normal person normal. That is the wages for the sins we pay for the explosive growth of knowledge (Pseudo) and technology.

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Post-amble

Who am I ? to question the credibility of a 107-page document prepared by the best of all experts in the field of cardiology? Just a reminder to mind , what happened to the term pre-hypertension and the fate of JNC across the Atlantic a decade ago.

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TAVR vs TMVR : The differential Anatomic & Scientific Principle

Posted in Uncategorized, tagged dailyprompt, dailyprompt-2033 on August 17, 2025|

Good bye to Gruentzig … the mercurial genius and the father of Interventional cardiology. The swag attached to PCI has become a bygone era. Percutaneous structural heart disease interventions, though in Infancy, is ruling the world today. Tans catheter heart valves is the new mantra. (THV).We can say Aortic stenosis has been conquered without surgery.(*Note : we means cardiologists, not patients) . Pediatric cardiologists have done the same in percutaneous pulmonary valve delivery in children. However, our quest for percutaneous AV valve implantation is facing tough challenges that sans meaningful outcomes.

It is heartening to witness huge technological innovations in arena of native TMVR*. Still, Mitra clip (TEER ) is the only non surgical solution for MR as of now. We know, It is a terrible alternative for an surgical MVR. The key issue with TMVR is the absence of good native foundation and tackling the extremely dynamic AV ring , which are in continuity with LV/RV muscle (unlike Aortic valve ) Mind you ,the AV valves should withstand the force of TAPSE/MAPSE for tricuspid and mitral valves respectively. May be a dysfunctional left ventricle might co-live with a TMVR with more peace. (Fortunately ,LV dysfunction is common in patients who are considered for TMVR)

*Valve in valve in TMVR is being widely used .The issue discussed here will be for TMVR . native mitral valve diseae.

Here , an attempt is made to differentiate the basic differences in the science of between TAVR vs TMVR . (Not comprehensive, but has compared three promising TMVRs , Intrepid, Tendyne, M-3 and Alta-valve.

Final message

Though TAVR and TMVR share a word ‘transcatheter’ they live in different anatomical and physiological worlds. TAVR is often successful because calcium is mostly friendly , the annulus is near circular, and landing zone is fairly predictable. Implantation of TMVR demands extreme diligence because the annulus is dynamic, calcium is an unstable ally, and of course there is always the fearsome LVOT nearby.

Post-amble

Meanwhile, the inability to dispose of the native disease leaflets is a the common issue in both TAVR and TMVR .( which our surgical colleagues will laugh at) May be we need to wait until an new avatar of BASILICA or LAMPOON, which might have a valve bioptome , to cut and extract native leaflet ,safely through a dedicated port without the risk of embolization.

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What are the various 3D-CT soft-wares available for pre-procedural TAVR Imaging ? How accurate they are ?

Posted in Uncategorized, tagged 3mensio, comparison of various ct scan tavi software, cvi42, free tavr tavi soft ware ct scan, heart navigator, horos tavi tavr soft ware, intution tavr planning, osirix md, partner, sapiens vs core valve, syngo vs 3mensio, tavi, tavi software, TAVR, vitrea ct scan tavr tavi on August 11, 2025|

TAVI is becoming like PCI equivalent of aortic valve. The procedure is nothing but stenting and plastering the aortic prothesis ,with all the native diseased aortic leaflet in-situ. Pre procedure CT aortic valve mapping (rather the entire Aorta) is the key to successful outcome.

While the calcium is the essential bonding force of the valve to the aortic annulus, it can also play some serious spoilsport, along with native leaflet debri . Many times, the hardened calcium are like like sharp 3 dimensional knife hanging over there in root of aorta.

Every TAVI operator has this ligering fear . Will that speck of calcium “ice berg”, hiding 2 mm above the NCC, hit the AV node, when I deploy the valve ? Will the distorted leaflet jump few mm above and hit the coronary ostia , however high it may be. (After all , the exact final landing zone is not determined by the operator , but by the ROC curve)

Every severely calcified valve experiences a Titanic effect , fortunately most valves escape.

Realise how important the accuracy these softwares are .It is just a matter of few mm error . . Apart form calcium distribution pattern , more fundamental parameters like the annular size, shape, and optimal imaging angle are critically important. Here is brief report on various software packages available for pre procedure planning of TAVR.

Image courtesy : Thoracic Key  Assessment of aortic valve calcification.The stretch view shows dense calcification of the right coronary cusp, noncoronary cusp, and left coronary cusp. The stretch view (A), angiographic overlay (B), cross-sectional view (C), and “hockey puck” view (D) allow quantification of the calcium in the aortic valve.

The following table was curated from the respective company websites. Any further details can visit them.

Software	Vendor/Developer	Key Features for TAVR Pre-Planning
3mensio Structural Heart	Pie Medical Imaging	Dedicated TAVR module for automated aortic root analysis, valve sizing, and access route planning. Provides 3D visualization, calcium scoring, and virtual valve implantation. Widely used for precise measurements and procedural simulation.
OsiriX MD / Horos	Pixmeo (OsiriX) / Open-source (Horos)	DICOM viewer with 3D multiplanar reconstruction (MPR) tools for manual valve sizing, annulus measurement, and aortic root analysis. Horos is a free alternative. Supports plugins like ProSizeAV for semi-automated sizing.
syngo.via CT Cardiac Function – Valve Pilot	Siemens Healthineers	Semi-automated workflow for aortic valve assessment, angulation prediction, and device sizing. Includes valve pilot tools for efficient CT analysis.
HeartNavigator	Philips Healthcare	Automated or semi-automated CT processing for TAVR, including aortic root segmentation, access route simulation, and procedural guidance. Often compared for reliability in measurements.
Valve Assist 2	GE Healthcare	AI-assisted tool for valve sizing, CT analysis, and planning efficiency. Focuses on automating measurements to reduce manual effort.
Mimics Enlight / Mimics Planner	Materialise	Cloud-based 3D modeling software with automated workflows for structural heart interventions, including TAVR-specific measurements, virtual valve implantation, and 3D printing support. Includes AI for segmentation.
cvi42	Circle Cardiovascular Imaging	Advanced CT tools for interventional planning, including TAVR, with automation for aortic valve assessment, flow quantification, and structural heart disease management.
Intuition TAVR Planning	TeraRecon	Comprehensive package for aortic root segmentation, centerline extraction, and pre-operative measurements. Supports advanced 3D/4D visualization for TAVR workflows.
Vitrea CT TAVR Planning	Canon Medical (Vital Images)	AI-leveraged application for automated TAVR assessment, including valve sizing, access planning, and post-operative evaluation. Integrates deep learning for efficiency.

Some questions

1.Which one is most popular ?

With out doubt 3mensio is top software because of its neutrality between various TAVR valve and wide spread usage and comparisons.

2.What is the cost of these software ?

They are substantial has a monthly subscription model. 3Mensio pricing starts at approximately $500/month for 1 user, $4,000/month for 10 users.

3.Is there any Freeware for assessing Aortic root ?

Yes . OsiriX MD / Horos is a free ware, but not getting sufficient attention.

4.What is the error rate of these software ? since they are offline and often images are machine extrapolated ?

Error rate in software are well not reported. (Can’t expect the vendors to do it !) However, It must be acknowledged they are real because of the offline nature of image processing .These tools process DICOM data, in pre-trained algorithms. Errors can arise from poor CT input (e.g., motion artifacts) or extrapolation in 3D reconstruction (e.g., interpolating between slices), but studies show minimal impact with high-quality scans.

Common Error Sources: User variability, calcium blooming artifacts, or phase-specific differences in dynamic CT.

Clinical Implications: Errors in sizing can lead to complications like paravalvular leak (if undersized) or embolism (if oversized), but validation shows risks are low (e.g., <2 mm differences rarely affect outcomes). Multi-reader or expert double check is encouraged to improve accuracy.

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Trying to become a truly Professional Physician !

Posted in Uncategorized, tagged bmj, ethics in cardiology, ethics in medicine, Hippocratic oath, jama network, lancet, medical ethics quotes, nejm, who is a professional cardiologist on August 10, 2025|

.

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Post-amble

Are you a professional physician doctor ?

Honestly I am struggling to become one , it is still a long way to go.

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How to differentiate the wall motion defect of LBBB from CAD ?

Posted in Uncategorized, tagged crt in lbbb, csp for lbbb, csp vs crt, dcm and lbbb, paradoxical wall motion defect in lbbb, septal beaking, septal flash, systolic wall thickening, wall motion defect in lbbb vs cad on August 7, 2025|

It is often said, If you are not able to answer a question, in a single line, or if the explanation is too long, then the answer is likely to be vague and difficult. So does this question.

It is a very practical probelm in day to day cardiology practice faced by every one of us. Still, it is often taken for granted during echo lessons in cardiology schools.

Here is a big table of differences listed. Read it if you have time.

There are only three words important. Find it out.

Final message

Look beyond septum, concentrate both systole and diastole. Normal systolic thickening and beaking in M-mode, clinch the diagnosis as LBBB

A query for advanced readers.

If LBBB and CAD /DCM co-exists, (a common scenario ) Which component of wall motion defect dominates ?

The answer to this question becomes important, as only the electrical component is correctable by CRT (or CSP now). No surprise, there is huge chunk of non responders, where myocardial component of de-synchrony prevails over the electrical LBBB,

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Why should we fall for PPG, amidst the onslaught of coronary flow Indices ?

Posted in Uncategorized, tagged coronary flow reserve, ct ffr, fame 1 2 study define -flair study, ffr, hyperemic flow indices, ifr, Intermediate coronary lesion, non hyperemic indices, ppg, pull back pressure gradient, qfr, rfr, swede heart study on August 7, 2025|

History beckons… once upon a time, assessing severity in valvular heart disease was gloriously simple. We used to just a pullback pressure gradient across the aortic valve . Now, history repeats itself, as the same philosophy returns to coronary arteries, offering a surprisingly elegant solution amid a chaos of physiological indices. That is PPG .

What Is PPG*?

Pullback Pressure Gradient (PPG) is a physiological mapping method that evaluates the pressure gradient across a coronary artery using a gradual pullback of a pressure wire . It helps to:

• Localize ischemia
• Differentiate focal from diffuse disease
• Guide a more logical PCI strategy

Rather than a strict binary verdict (ischemic or not), PPG gives us a gradient map — revealing how pressure falls, where it falls, and whether intervention makes sense.

*I would love to call it as plain old PPG. POPP-G . (Sort of POBA equivalent in PCI)

How to Measure It ?

1. Essentially it is a less glorified iFR or FFR .Same hard ware is used.
2. Pull back happens in both .But ,here thats is only that happens, that’s devoid of the clumsy Adenosine protocols, Incomplete hyperemia, patient anxiety, or microvascular dysfunction etc.
3. Apart from measurinng pressure drop the rate of fall the gradient slope is also analysed. PPG = ΔP / pullback distance (mm) .If the slope is steep the lesion is probably stentable . If the rate of fall is slow or flat we may avoid stenting.

PPG is a dynamic, localized, gradient-based insight into coronary disease. A focal ΔP over small length ΔL would be a perfect PCI candidate. A flat gradient over long ΔL , would suggest medical therapy .(May be CABG in few)

PPG in bifurcation Lesions

How do you FFR in bifurcation or trifurcation lesions . If you ask this question to any cardiologist, will try to get away from the scene. Such is the complexity involved. Here comes the savior. PPG helps you out in a smart fashion.

• PPG allows branch-specific physiological localization, Can be used selectively in each branch to map the true pressure loss. This is contrast to the crude FFR that may falsely elevate due to competitive flow or tandem disease.
• PPG can avoid the unnecessary double stenting and of course make the make the bifurcation club members unhappy in the process. PPG also can help detect ostial branch disease (by inching technique we do in cardiac auscultation,) by very slow pull back.

Image courtesy : Daniel Munhoz CARDIAC INTERVENTIONS TODAY MAY/JUNE 2021 VOL. 15, NO. 3

Is FFR really problematic ? Be aware of conflicting studies

FFR was a great concept when it came in. FAME I study adored It. FAME II questioned PCI’s benefit despite FFR-positive lesions. Then came DEFINE-FLAIR and iFR-SWEDEHEART, questioning the need for hyperemia at all. Still, residual ischemia post-PCI in up to 20% of cases (DEFINE-PCI) even when FFR said “normal.” Confused? So are most cardiologists.

Modern cardiologist’s dilemma: How to cross coronary jungle infested multiple flow Indices ?

The list is long . FFR , iFR, FFR-CT, QFR, RFR, dPR, NHPR, µQFR (there are few more I might have left ) . None are perfect. Some contradict. Some cost too much. Many need drugs. All add layers of complexity to what should be a simple clinical question: Should I stent this lesion? Now, we have the simple plain PPG.

Why should, we fall for PPG ?

Let’s be honest. PPG is not flawless. After all, we take pressure drop as a surrogate marker for restricted flow . Every Indices does that. But unlike other indices It’s intuitive. It’s visual. It tells you where to treat. It gets the pressure data on the spot from ground zero . It can bring reliable info without the need for intracoronary medication , or costly software. Finally, it restores some simple sense in us ,without great knowledge in coronary hemodynamics.

Reference

1. Kobayashi Y, Johnson NP, et al. “Physiological Assessment of Residual Ischemia After Coronary Stent Implantation Using Instantaneous Wave-Free Ratio.” JACC Cardiovasc Interv. 2019;12(19):1996–2007. https://doi.org/10.1016/j.jcin.2019.04.040
   PPG-based residual gradients predicted poor outcomes post-PCI even when angiographic results looked fine.
2. Collet C, et al. “Stress myocardial perfusion imaging vs coronary functional assessment with PPG and FFR: A physiologic map approach.” Eur Heart J. 2021;42(10):926–938.
   PPG superior in identifying focal lesions amenable to PCI compared to binary FFR thresholds.
3. van Belle E, et al. “DEFINE-PCI: Residual Ischemia Post-PCI Detected by PPG and iFR Pullback.” JACC Cardiovasc Interv. 2019;12(20):1991–2001.
   Post-PCI ischemia often missed by angiography alone — PPG reveals it.
4. Davies JE, et al. “Use of the Instantaneous Wave-Free Ratio or Fractional Flow Reserve in PCI.” N Engl J Med. 2017;376:1824–34.
   iFR non-inferior to FFR .Suggests resting physiology-based PPG.

5.Munhoz D, Collet C, Mizukami T, Yong A, Leone AM, Eftekhari A, Ko B, da Costa BR, Berry C, Collison D, Perera D, Christiansen EH, Rivero F, Zimmermann FM, Ando H, Matsuo H, Nakayama M, Escaned J, Sonck J, Sakai K, Adjedj J, Desta L, van Nunen LX, West NEJ, Fournier S, Storozhenko T, Amano T, Engstrøm T, Johnson T, Shinke T, Biscaglia S, Fearon WF, Ali Z, De Bruyne B, Johnson NP. Rationale and design of the pullback pressure gradient (PPG) global registry. Am Heart J. 2023 Nov;265:170-179. doi: 10.1016/j.ahj.2023.07.016. Epub 2023 Aug 21. PMID: 37611857.

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We know it is SCD , but, the question is , Did he die due to DID ?

Posted in Uncategorized, tagged brugada, delayed intrinsicoid deflection, did, id vs vat, LONG QT SYNDROME, ventricular activation time on August 6, 2025|

Recently , a young celebrity lost his life during gym session suddenly . The media erupted as expected .Every TV channel became a temporary schools of advanced cardiology . It seemed anchors knew more cardiology than us.

Among the peers, so many hypothesis were going around. The loudest one was prolonged QT. We are discussing a relatively new, (rather les popular ) entity for the potential cause of SCD. What is it ? DID is the new buzzword in electrophysiology . Next to Long QT, Brugada, DID is looked upon as a new marker for SCD in young as well as elderly .

What is DID ?

Delayed Intrinsicoid deflection. (DID) Mind you, Intrinsicoid deflection ( ID ) is nearly 100 year old concept, being rediscovered. ID is the time it takes for the electrical impulse to travel from the endocardium to the epicardium directly beneath the recording electrode.

Macleod, A. G., Wilson, F. N., & Barker, P. S. (1930). The form of the electrocardiogram; intrinsicoid electrocardiographic deflections in animals and man. Proceedings of the Society for Experimental Biology
and Medicine. 27(6), 586–587

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1.How to measure, what is the normal ?

Variable in each lead.

2. Which lead it is measure ? Is ID relevant in Limb leads ?

V5, V6. Normal less than 50 ms

3.When do you call Intrinsicoid deflection as prolonged ?

>50ms

4.What is the Ionic basis of ID ?

Sodium

5.Is there both congenital and acquired forms?

Yes

7.Is it different over RV vs LV ?

Yes

6.How does a DID trigger an arrhythmia ?

Not clear

Two more questions

7.Why it is called Intrinsicoid deflection rather than Intrinsic ?

Intrinsic was the original term coined by Sir Thomas Lewis in 1914, To get this “intrinsic” measurement, an electrode had to be placed in direct contact with the epicardium . Measuring it from surface ECG leds make it Intrinsicoid.

8. Is Intrinsicoid deflection and ventricular activation time (VAT) both are same ?

Yes. Both are used inter changeably , though one denotes time other the wave as such. While VAT is the same time , specifically look at time to R wave peak. However , ID can be applied to the leads where there is no R wave. Then it becomes time to peak of Q

9.Is it true, in every LBBB, ID is prolonged by default ? Then what is the risk of SCD in LBBB ?

For the first part of the question, the answer is Yes. The second part , we don’t know the true risk yet.

10. …………………………………………………………………..(Question left for the readers to ask)

Final message

As cardiologists, we have given disproportionate importance to the QT interval and gets the blame for many SCD. It is time, the 100 year old ECG parameter Intrinsicoid deflection (ID,) seems to be equally important. Much of the secret ionic codes, for many SCDs are believed to hide behind this eerie deflection.

Reference

Here is an important review

1.Aiken AV, Goldhaber JI, Chugh SS. Delayed intrinsicoid deflection: Electrocardiographic harbinger of heart disease. Ann Noninvasive Electrocardiol. 2022 May;27(3):e12940. doi: 10.1111/anec.12940. Epub 2022 Feb 17. PMID: 35176188; PMCID: PMC9107081.

Noninvasive Electrocardiol – 2022 – Aiken – Delayed intrinsicoid deflection Electrocardiographic harbinger of heartDownload

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