Dr.S.Venkatesan MD

Archive for the ‘Anatomy of heart’ Category

Learning targeted IAS puncture in 20 minutes

Posted in Anatomy of heart, Uncategorized, tagged anatomy of heart, ias puncture, right vs left atrial anatomy on March 10, 2023|

The main reason for all those jitters, we cardiologists, get every time we puncture the IAS is not due to a lack of expertise and experience perse. There are two more reasons. First and foremost, it is still largely a blind* procedure. (Even in this era, where drones with HD vision shoot one-meter targets from a 1000 KM range )  *TEE and ICE are there, but they rarely give enough confidence. 

The second reason is more important and is rectifiable. It is the perception error in our anatomical cognition, that is fed to us from first-year medical school. We are made to believe (at least to people like me ) The right atrium is aligned like a perfect box on the right side, sharing a wall called IAS, and the left atrium is obediently placed left of the right atrium. Please realize the heart is such a complex twisted single tubular organ, the venous end, in a stunning backward loop brings the LA  most superior and posterior to the right atrium overriding the left-right relationship.) 

The right atrial terrain and IAS with multiple bumps and holes. Note the true IAS constitutes only 20% . This is where our punctures need to be.

Development of IAS 

IAS development and the number of layers it sandwiches, the tortuous tracts of PFOs, the fossas, and its variable limbus is a big topic. Further, It is worth recalling, the true IAS hardly forms 20 % of the area of the interatrial contact surface.

(the differential regression of sinus venous,  along with infolding of the roof and along with curious septum spurium , the ubiquitous septum secundum make the texture, area & shape of IAS, a fascinating creation, though troublesome for the cardiologists ! ) Whoever named that part of vanishing  IAS  as spurious, (I think it is Henrry Grey ) has much fore-vision.

 

Forget about all this. Tell me how to cross this difficult terrain 

Coming to the real world of interventions,  we need to do targeted punctures in different spots of IAS in various interventions.(Mitra clips, LAA device, PTMC, PV abaltions, Mitral paravalvular leaks , TMVR etc) This has made this task even more tricky. Experts are always there to help us out. Like swimming, it can never be learned in books.

This 19-minute clip from. Seoul, South Korea is an excellent resource. Thanks to  Dr. Sang Weon Park 

 

Along with sound anatomical knowledge, improved hardware, and imaging like deflectable sheaths, TEEs, and ICE (intracardiac echo ), let us hope, it will soon become an easier task for everyone.

Final message

 Understanding “attitudinal cardiac anatomy” with fluoroscopic overlay is the key. Again, it needs to be stressed, “Right is not right, and left is not left” when it comes to true atrial geo position. LA is equally posterior, superior, and of course to the left of RA. Some of my colleagues are blessed with a special 3-dimensional skillset  (Inherited ?) I failed miserably to understand this, till very late. I am sure, Dr. Park’s video will help all our youngsters to cross the difficult gateway to the left side of the heart. 

Reference 

One more good read

B. O’Brien et al. / International Journal of Cardiology 233 (2017) 12–22

 

Rate this:

Read Full Post »

Does the Aortic root contract or relax during ventricular systole ?

Posted in Anatomy of heart, Uncategorized, tagged aortic root dynamism, cardiology research topic on October 1, 2022|

Does the Aortic root contract or relax during ventricular systole? Some time back, I asked this question in one of my classes for the fellows and found no takers. Not even a guess? I realized later, it was indeed a tough question. The heart is not the only dynamic organ, as we generally believe. The entire aorta which is an extension of the left ventricle has to be dynamic according to the physics of ventricular-arterial coupling and the momentum of blood flow.

What happens to the aortic dimension with systole?

Even prior to systole, there is evidence, the aorta gets ready to receive the blood from the LV. So, the Aortic root must be larger at the onset of systole. (Ref 2 ) It is been generally agreed now, that the systolic dimension is slightly more by a few mm. That is why aortic dimensions are measured in peak systole as per the American society of echocardiography.

There has been an opposite argument as well. The diastolic aortic dimension could be larger, as the aortic valve is in the closed position and the aortic root distended, & becomes a reservoir of blood that’s meant to be distributed during diastole. What determines the aortic dimension on a moment-to-moment basis?  Is it the, LV contractility, pressure, or volume, or the compliance of the aortic wall that determines the aortic dimension and pulsatility? How does a prosthetic valve alter this?

So, what exactly happens to the aortic dimension during the cardiac cycle ? 

A wonderfully done study from University Medical Center Utrecht, The Netherlands throws some important facts with their analysis of ECG-gated CT scans in 108 Aortas.(Ref 1)

Clinical implication of aortic pulsatility

The implication of knowing (or not knowing )the dynamism of the aorta can be huge.

• Age-related stiffening and onset of systolic hypertension
• Aortic diameter, pulsatility, and shear stress are the key parameters in initiating dissection and its propagation
• Choosing the right sized valve for AVR
• Current interventional heart-throb TAVI involves just a passive placement of the valve in the aortic root. Imagine what will happen, if the foundations are excessively dynamic and shaky   

It is surprising, even after decades of vascular research, we lack clarity on what exactly happens to aortic root during various phases of the cardiac cycle. (Currently, paravalvular leak, & migration of TAVI remains a major worry, which has a direct relationship with pulsatility of the aortic root ) One thing is obvious,.Young cardiologists have a lot of work to do in this arena.

Final message

 Though the aorta is a direct extension of LVOT, its vaso-motion doesn’t seem to be in complete sync with the cardiac cycle. It tends to have an independent behavior, out of phase with the heart. 

As per available evidence, the aortic root dimension can either increase, decrease, or be static in response to LV contractility.

Reference

1.de Heer LM, Budde RP, Mali WP, de Vos AM, van Herwerden LA, Kluin J. Aortic root dimension changes during systole and diastole: evaluation with ECG-gated multidetector row computed tomography. Int J Cardiovasc Imaging. 2011 Dec;27(8):1195-204.

2. Pang DC, Choo SJ, Luo HH, et al. Significant increase of aortic root volume and commissural occurs prior to aortic valve opening. J Heart Valve Dis. 2000;9:9–15. [PubMed] [Google Scholar]

3. Vesely I. Aortic root dilation prior to valve opening is explained by passive hemodynamics. J Heart Valve Dis. 2000;9:16–20. [PubMed] [Google Scholar]

 

 

 

Rate this:

Read Full Post »

Wrong-way catheter during radial angiogram : An Illustration

Posted in Anatomy of heart, tagged aberrant right sub clavian artery, aortic arch anomalies, arteria lusoria ptca, brachio cephalic artery aortic arch angle, radial angiogram tips, radial pci on January 19, 2021|

The commonest cause* for repeated entry of right radial catheter to descending aorta is not due to any anomaly. Most times,it is just a skewed angle between right brachio-cephalic artery with Aortic arch, that deflects the catheter to the descending aorta . Just make sure, aortic root is entered with a deeply held inspiration.

*Anomalies of the aortic arch, aberrant right subclavian, Kommerell’s diverticulum, vascular ring must be kept in mind.

 

Postamble: A true abnormal course

Though, It might appear prudent to avoid the radial route when encountering anomalous subclavian arteries, the reality is different and adventurous. We have acquired great expertise and successful PTCAs have been done through these tortuous vascular highways.

This is a case report from Dr H.S. Isser, Gunjan Garg, from Safdarjung hospital New Delhi. 

 

Rate this:

Read Full Post »

What exactly constitute posterior wall of heart ?

Posted in Anatomy of heart, Cardiology - Clinical, tagged Anatomy of the heart, inferior vs posterior surface of heart, posterior stemi, posterior wall of heart, what is the posterior surface of heart on August 24, 2017| Leave a Comment »

Heart is not like a rigid structure built with  bricks . . . . so , its too architectural mindset to describe cardiac chambers to be made up of walls. Rather , Its a four chambered muscle mass moulded together in a complex 3D interface with distinct surfaces rather than walls. It’s also important to realise, since the heart is positioned (rather hanging )delicately in the middle mediastinum resting on the diaphragm , its subjected to one more dynamism due to respiratory motion blurring the definition of surfaces as well. (Vertical vs Horizontal)

Posterior surface is now referred to as infero-posterior

The posterior aspect of heart contains essentially the venous channels and the atrium (LA in particular)pulmonary veins and coronary sinus.  This happens right from 8 week heart open stage when venous end of lower straight heart tube folds up and posteriorly .

It should be recalled only a small portion of lower aspect of posterior wall is alloted to left ventrilce.Instead the Infero diaphragmatic surface is formed by two-thirds  the LV and one-third Right ventricle.

Image courtesy : From the great Netter

Nomenclature  issue 

The term posterior wall is now abandoned in most Echocardiography texts its replaced by inferior .The implication is more for Electrophysiologists with reference to accessory pathway localization

What is true posterior wall MI ?

As discussed before ,posterior surface of heart is different from posterior aspect of left and and right ventricle.

What does leads V7 V8 V9 record ?

It actually records electrical signals arising from posterior  aspect  of heart.  Left atrium,  pulmonary vein along with insulatory  effect of lungs dampens the potential . This makes the sensitivity of ST elevation  in posterior MI is low.

Blood supply of posterior surface

It’s highly variable.Both RCA and LCX arteries contribute with its  posterior left ventricular branches (PLV)

It can be inferred , LCX has more territorial rights than RCA in this unique zone of heart as the artery covers more posterior areas.

Read a related article

Back pain from anterior MI : Is it possible ?

 

Rate this:

Read Full Post »

Where does Bronchial veins drain ?

Posted in Anatomy of heart, Bronchail arterial and venous circulation, bronchial arterial and venous circulation, tagged bronchial circulation, bronchial vein rupture hemoptysis in mitral stenosis, bronchial venous drainage, clincial antomy research topics, research topics in basic sciences anatomy, where does bronchial veins drain ? on June 28, 2016| 2 Comments »

One casual question in my class led to this search for an anatomical mystery. When we were discussing why left atrial oxygen saturation never reaches 100 % ? , it was attributed to desaturated bronchial venous blood draining into pulmonary vein.

How does this bronchial vein enter pulmonary venous circulation ? How many bronchial veins are there ? What anatomical plane it runs ?

Surprisingly, even in this hi-tech era of academic excess, literature is sparse for this basic anatomical question. It is reported (In Greys anatomy ? ) Bronchial veins are two in number and both drain to Azygos and Hemiazygos veins (systemic) rather than pulmonary veins.

So is our assumption wrong ?

May not be.We realise these are only two visible and named bronchial veins .It is learnt they probably carry only about 13 % of bronchial venous blood to systemic venous circuit.

Image showing right and left bronchial veins draining to Azygos and hemiazygos veins.

It is assumed , remaining 87 % of bronchial venous blood drains to pulmonary venous circuit in an invisible fashion (By unnamed twigs ?) desaturating the LA blood by about one percent from 100 to 99 %. This is our current understanding. I haven’t come across any specific human research that quantifies the bronchial venous channels and it saturation . It’s gratifying to find one study specifically looked answer this question in sheep study .(Charan H.B et all Reference 1 )

True physiological bronchial venous drainage seems to be different from anatomical bronchial venous circuits .

Clinical implication of bronchial venous circulation.

In physiology it may not be important . However bronchial circulation (both arterial and venous) can take many anatomical tracts when pulmonary micro vascular bed is structurally and functionally altered as in COPD, , pulmonary atresia with aorto-pulmonary collaterals , congenital left to right shunts,post Fontan circulation pulmonary AV malformations,lung tumors etc .

Hemoptysis in acute pulmonary venous hypertension is thought to be due to rupture of these bronchial veins as elevated pulmonary venous pressure reflect into bronchial veins (As in mitral stenois and other conditions. ) This again would vouch for bronchial veins draining to pulmonary veins.

Final message

As on today , it can be concluded bronchial vein drainage goes both systemic and pulmonary venous circuit.Bulk of them appear to end in pulmonary veins though clear anatomical evidence is lacking.

Postamble

Exploring human anatomy appear a grossly unfinished agenda even today, especially the micro and histo-anatomy. Teachers of basic sciences should impress upon youngsters entering the medical school to pursue translational research relevant to specific clinical problems.

Students may contact <drsvenkatesans@yahoo.co.in> for specific areas of clinical cardiac anatomy topics that still requires answers.

Reference

1.Functional anatomy of bronchial veins. Charan NB¹, Thompson WH, Carvalho P. Pulm Pharmacol Ther. 2007;20(2):100-3

2.Baile EM The anatomy and physiology of the bronchial circulation.J Aerosol Med. 1996 Spring;9(1):1-6.

3. Melachrinou M¹, Alexopoulos D¹, Dougenis D¹ .Experimental studies in the bronchial circulation. Which is the ideal animal model?J Thorac Dis. 2014 Oct;6(10):1506-12 (Free full text )

Rate this:

Read Full Post »

Anatomical encounters of Aortic valve with bundle of His : An Illustration

Posted in Anatomy of heart, Complete heart block, tagged anatomy of complete heart bock, aortic root valve stress, aortic valve calcification, aortic valve sclerosis, calcific aortic stenosis, mechanism of complete heart block, tavr stress on his bundle on October 17, 2015| Leave a Comment »

Car tyres warrant  replacement  every  20,000 km or so .Its batteries do require periodic attention. Human heart , which runs non stop from womb to tomb . . . deserves how much ? Unfortunately no one (What about your cardiologist?) can  provide  a flawless lifetime maintenance contract to this restless bio-mechanical pump ! Fortunately still, God has  created this wonder organ ,that can with stand the stress of life for nearly 10 decades . . . if we live a proper life !

However ,there are many areas in heart that are prone for mechanical stress even if it’s structurally normal .These are  the zones where the relatively fixed parts  rub against the dynamic zones .The joint between inflows ,outflows to the respective ventricle are at risk . Aortic root, along with the leaflets and annulus  formed by the fibrous skeleton is delicately close to the critical part of the conduction system namely the branching portion of AV node and His Purkinje.The process of degeneration is linked to age, valvular abnormality and genetic and  systemic metabolic profile also seem to matter in few .(Hypercalcemia and cardiac calcification ?)

Importance of the interface between Aortic valve and  AV conduction system in the current Era 

Degenerative aortic valve disease along with  the adjacent conduction system  of elderly is going to be a key cardiovascular disease in the future as the population is aging .We have made a big step forward in tackling this with innovative percutaneous aortic valve implantation  (TAVI) . However ,the artificial valve  is positioned vulnerablely  close to conduction system and incidence of complete heart block either during implantation or follow up is  high and a permanent pacemaker seems to be an integral part of this procedure for many.

Heart seen from behind , Mitral annulus to left and tricuspid valve ring to the right .

Rate this:

Read Full Post »

Physiological Interventricular de-synchrony : Right ventricle contracts like an Intestine !

Posted in Anatomy of heart, Right ventricle, tagged best articles on right ventricle, cardiac peristalsis, physiological inter ventricualr desynchrony, Right ventricle anatomy and physiology, right ventricular sequential peristaltic contraction on May 5, 2015| Leave a Comment »

Right ventricle,being a venous chamber has distinct anatomical and physiological features to carry out this function.RV has a complex shape, its triangular in long axis and  crescent like in short axis , thin (<5mm)  more distendable  .Contraction of RV begins slightly early but ends later than LV  (30ms )

RV receives blood from RA and ejects in to PA in a sequential manner .The inflow, body and outflow contract somewhat like  intestinal peristalsis. This is facilitated  by the incremental  delay in the electrical depolarization of right ventricle.In physiological conditions, the later half of QRS  is  responsible for RV activity and RVOT is the last to contract. (This intrinsic electrical and mechanical  delay in RV contraction is a physiological inter ventricular  desynchrony . One  should be aware of this when planning cardiac resynchronisation therapy in cardiac failure.  )

Click over the image for an animation of RV contraction.

Image courtesey Oxford spcialist hand book in cardiology :Echocardiography Paul Leeson , Second edition ,.Oxford university press 2012 Multi media .

Note:LV is  a fairly   elliptical and strongly  muscular pump and contracts in a  single go with maximum force.(dp/dt).

Final message

Though both right and  left ventricle originate from same  straight heart tube , developmentally the right ventricle evolves for a different form and function . Now,we realise there are lots of sharing of parental muscle fibers that engulfs and bonds both chambers.(Mind you ,This is the fundamental mechanism of ventricular interdependence.Of course ,IVS is a common wall shared lifelong by both chambers  without any (sibling related?)  hemo-dynamic dispute !

3D echocardiography and MR imaging has helped us to understand the RV morphology better and exciting articles written by pioneers are available  free for those who are interested.

Reference

1.Ho  S.Y., Nihoyannopoulos  P.; Anatomy, echocardiography, and normal right ventricular dimensions. Heart. 92 2006:i2-i13.

2.Foale  R., Nihoyannopoulos  P., McKenna  W.; Echocardiographic measurement of the normal adult right ventricle. Br Heart J. 56 1986:33-44.

3.Contemporary Reviews in Cardiovascular Medicine.Right Ventricular Function in Cardiovascular Disease, Part IAnatomy, Physiology, Aging, and Functional Assessment of the Right VentricleFrançois Haddad,Sharon A. Hunt,David N. Rosenthal, Daniel J. Murphy

 4.Contemporary Reviews in Cardiovascular Medicine. RightVentricular Function in Cardiovascular Disease,Part 2.Pathophysiology, Clinical Importance, and Management of Right Ventricular Failure François Haddad, Ramona Doyle Daniel J. Murphy, M Circulation. 2008; 117: 1717-1731

5.Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American

Society of EchocardiographyEndorsed by the European Association of Echocardiography, a registered

branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

Lawrence G. Rudski, Chair, Wyman W. Lai, Jonathan Afilalo, Lanqi Hua, , Mark D. Handschumacher, Krishnaswamy Chandrasekaran, Scott D. Solomon,, Eric K. Louie, and Nelson B. Schiller,,(J Am Soc Echocardiogr 2010;23:685-713.)

Rate this:

Read Full Post »

• Search for:

• Categories

  Categories Select Category acute coroanry syndrome acute coronary syndrome acute pulmonary embolism acute rheumatic fever admixture lesions in cyanotic heart disease Alcohol and heart disease Anatomy of heart angina anti platelet drug aortic aneurysm Aortic diseases Aortic regurgitation aortic stenosis Aortic stent grafing Aortic valve replacement ASD device closure atherosclerosis Atrial fibrillation Auscultation Awards in medicine baloon aortic valvotomy Basic sciecne Basic science -Physiology bav vs tavr Best books in cardiology Beta Blocker bifurcation pci bio ethics Blood pressure Breakthrough technology Bronchail arterial and venous circulation bronchial arterial and venous circulation Brugada syndrome CABG CABG for Ischemic DCM CABG Indications CAD in HFpEF cardaic pharmacology cardaic physiology cardiac anatomy Cardiac biomarkers cardiac cycle cardiac drugs cardiac electrophysiology cardiac embryology cardiac failure Cardiac MRI Cardiac myxoma cardiac physiology cardiac radiology cardiac resynchronisation cardiac source of embolism cardiac surgery cardiac tamponade cardiac volume cardiac X ray cardinal symptom in cardiology Cardio Nephrology cardio pulmonary resucitation Cardiologt women Cardiology – Animations Cardiology – Clinical Cardiology – Electrophysiology -Pacemaker Cardiology – Pioneers Cardiology -Clinical signs cardiology -congenital heart disease Cardiology -Coronary collateral circulation Cardiology -Criteria Cardiology -Definitions cardiology -ECG Cardiology -Emerging technology Cardiology -Funny events Cardiology -guidelines Cardiology -Hemodynamics Cardiology -Interesting videos Cardiology -Interventional -PCI Cardiology -Mechnisms of disease Cardiology -Non coronary Interventions -PTMC Cardiology -Pacemakers and ICD Cardiology -Patient page cardiology -pregnancy cardiology -Preventive cardiology -Sexual health Cardiology -Technology Cardiology -Therapeutic dilemma cardiology -Therapeutics Cardiology -unresolved questions Cardiology classics cardiology congenital heart disese Cardiology hypertension Cardiology Illistrations Cardiology Illustrations cardiology innovation Cardiology Innovations cardiology journal club Cardiology journal links cardiology journals Cardiology lipids /dyslipidemia Cardiology Outcome analysis Cardiology Patho physiology cardiology physiology Cardiology quotes Cardiology research topics cardiology research topics for fellows Cardiology Risk assesment Cardiology teaching websites cardiology thesis topics cardiology wisdom cardiology women cardiology- coronary care cardiology-Anatomy Cardiology-Arrhythmias Cardiology-Coronary artery disese Cardiology-Echocardiography Cardiology-Electrolytes cardiology-ethics Cardiology-Land mark studies Cardiology-Statistics cardiomyopathy carotid interventions Cath lab Hardware cath lab tips and tricks Centre for cardiology unlearninng cerebral circualtion stroke cerebral circulation stroke Chest pain Chronic total occlusion chronic total occlusion (CTO) Clinical cardiology Clinical cardiology Clinical cardiology -Cyanosis Clinical cardiology -JVP clinical cardiology -Murmurs clinical lipidology coarctation of aorta Comparative efficacy Complete heart block congenital heart disease constritctive pericarditis contrast induced nephropathy Coronary angiogram Coronary collateral circulation coronary sinus anatomy and physiology coronary sinus filling and emptying time drsvenkatesan coronary veno occlusive disorder coronary venous circulation cost effectiveness in cardiology Criteria and Nomenclature critical care ccu cto chronic total occlusion Diabetes and Heart Diastolic dysfunction Dilated cardiomyopathy Dissection coronary dr s venkatesan -Personal dynamic auscultation dyslipidemia early repolarisation syndrome ECG -Basics Echo library and gallery echocardiography Echocardiography – LV dysfunction Echocardiography -Normal measurement Echocardiography-hemodynamics Echocardiography-Limitations of LV EF % Electro physiology Electrocardiography-ECG Electrocardiology -Basics Electrolyte and Heart Electrolytes and heart Embryology : Heart valve development embryology of heart emotion and cad Ethics in Medicine evidence based cardiology excercise stress test .EST fame study ffr Fracional flow reserve Future cardiology gadgets future of cardiology Futuristic cardiology Gender issues in medicine general medicine great cardiologists great illustrations in cardiology Great Men in cardiology Great men in Medicine Great websites in cardiology Hadwares in cardiology Hardware techniques tips health economics Heart failure with preserved LV EF Heart transplantation Heart valves Hemodynamics Hemodynamics hemodynamics during Labor Heparin HFpEF HFrEF vs HFpEF Hippocratic oath history of cardiology Histroy of medicine hocm hcm hyperlipidemia Hypertension hypertrophic cardiomyopathy ICD ICD -Tips and Tricks ICD and Pacemakers infective endocarditis Infective endocarditis : Pathology Infrequently asked questions in cardiology (iFAQs) innovations in cardiology Interesting case study Interventions -Structural heart disease ischemic cardiomyopathy ivus IVUS /OCT/NIR Jugular venous pulse JVP -Jugualr venous pulse Land mark articles in cardiology Left atrial enlargement Left main disease Left main stenting -Tips and tricks lipid metabolism lipids lipid metabolism Long and Short QT syndromes LSCS for heart disease LV dilatation is diastolic dysfunction LV function Medcal research Medical education Medical ethics medical quotes medical satistics metabolic support of heart failure Mitral annulus -Functional mitral regurgitation Mitral balloon valvotomy Mitral regurgitation Mitral stenosis Morality in medicine Multimodality Imaging MVPS My favorite quote My presentations myocardial disease Neuro cardiology New hardware Newer cardiac Imaging Newer hardwares in cardiology Newer technology NSTEMI obesity open artery hypothesis opening snap oral anticoagulants warfarin acitrom Pace maker Tips and tricks Palpation Pathology-Vulnerable plaque PCI PTCA Hardware pericardial disease pericardial effusion Pericardium perioperative risk assessment: Non cardiac surgery Permanent pacemaker platelet function post dilatation prasugrel Pregnancy and heart pregnancy and heart disease Preoperative evaluation Preventive cardiology Primary -PCI Primary PCI Primary prevention of CAD Primary prevention studies prosthetic valve dysfunction prosthetic valves PTMC PTMC -Tips and tricks Public Health Public health issues Pulmonary arterial hypertension Pulmonary circulation pulmonary embolism pulmonary hypertension Pulmonary vascular resistance pulmonary vein ablation quantitative coronary angiogram Quotes radial coronary angiogram PCI Radial Interventions RBBB vs RVH RBBB/LBBB Reperfusion rf ablation rheumatic heart disease Right atrial appendage Right ventricle RIsk factors Science and Religion side branch jailing Social medicine stains and ldl STEMI STEMI -Managment STEMI-Primary PCI stress doubtamine echo stroke Syncope systemic hypertension Systolic decapitation in aortic stenosis TAVR TAVR /TAVI tavr tavi Teaching points Technology Technology Emerging TEE-Transesophageal echocardiography Tetrology of Fallot Thesis/Research topics for cardiology fellows Thrombolysis Thrombolysis -Tips Tips and tricks in cath lab Top ten in cardiology Tutorial in clinical cardiology Two line sermons in cardiology Uncategorized valvular heart disease Venkat quotes Venkatesan -Presentations Viability assessment vulnerable plaque Wintage cardiology wisdom in cardiology WPW syndrome X ray

• Archives

  • March 2023 (3)
  • February 2023 (2)
  • 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

  • 6,005,087 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 .

• 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