Posted in Cardiology -Interventional -PCI, cardiology- coronary care, Cardiology-Coronary artery disese, tagged in stent restenosis, instent restenosis, isr, poba for instent restenosis, re stenosis in des on October 15, 2011| Leave a Comment »
Instent restenosis is a common problem.
Diffuse long segment instent restenosis is somewhat rare.
We encountered one such patient who had diffuse instent restenosis of RCA.
ISR is ssupposed to be rare in DES, but here ISR occured with a Cypher stent one year following implantation
He presented with angina which was relieved by plain baloon angioplasty.
link to a related article in this site regarding the mangementof ISR.
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, Cardiology-Coronary artery disese, tagged battered time window, primary PCI vs STEMI, time window for primary pci, time window in stemi on October 13, 2011| Leave a Comment »
We know primary PCI is a race against time both for the patient and his physician.
What is the upper limit for this unique race where the stakes are high and it involves human lives and big corporate warfares ?
Answer : 2
Please note there is only one exception . Cardiogenic shock has been given a extended lease of time window (Which can be technically up to 54 hours ) . PCI can be performed if the onset of shock is within 36 hours of STEMI and to be performed within 18 hours after the onset ! )* Even though we have a well set criteria for re-perfusion which bans primary PCI to be performed after 12 hours , cardiologists have enough technicalities to overcome this hurdle and keep doing the futile pPCI well after 12hours.
How they are able to indulge in these futilities without any ethical issue ?
The answer is very simple. Instead of calling it as primary PCI they refer to it as delayed PCI or rescue PCI ! Strict time specific guidelines are only for primary PCI . By changing the terminologies they make a mockery of the concept of time window which is vital for any intervention for STEMI !
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Cardiology-Coronary artery disese, tagged priamry PCI vs fibrinolysis, primary pci stemi on October 12, 2011| Leave a Comment »
Success of primary PCI is defined by different yardsticks by different cardiologists , in different institutions ! But , for the patient and his family, getting discharged alive with out symptoms is a huge success !
They do not bother even if they are charged Rs 3-4 lakh for their stay , as they believe surviving a heart attack is a God’s grace rendered thorough the hands of the doctor.
But we know the real success lies elsewhere. Cardiologist’s perception of success of pPCI should be based on scientific concepts. Unfortunately many physicians continue to think like their patients . This tendency to get self gratification with a patient’s frame of mind is common and needs introspection .
This is esepcailly true for primary PCI . It came with big fanfare a decade ago . Soon ,many cardiologists developed a habit of criticizing the practice thrombolysis for STEMI .If primary PCI is such a superior modality every patient should be prevented from significant myocardial damage following STEMI .
Primary PCI may be the the most logical method still , for reverting the STEMI process . But “A properly performed primary PCI as a concept ” lies mainly on paper , not been replicated in real world for various reasons.
Please remember , a successful primary PCI
Even if . . . we accomplish each one of the above . . . if the patient carries home anything equal to , or more than moderate LV dysfunction , primary PCI has deemed to have failed.
Final message
What is the reality check ? In one of the preliminary analysis out of 20 randomly selected patients who have undergone STEMI* within 12 hours , significant LV dysfunction was present in 12 patients making it pPCI only 40 % successful in real world .( Which would struggle to beat the outcome of promptly administered fibrinolysis )
* Primary PCI done in state of the art institutes .
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, Cardiology-Coronary artery disese, Infrequently asked questions in cardiology (iFAQs), Top ten in cardiology, tagged limitations of coronary angiogram, optical illusion in cath lab on September 26, 2011| Leave a Comment »
Coronary angiogram is a videographic snap shot of moving targets. Coronary arteries are dynamic , tortuous vessels of varying dimensions .Normal vessels sometimes appear as an illusion of lesions and tight lesions may appear innocuous at times. So the rule is never rely on a single view before reporting.
This is an angiogram of a patient , which one of my fellows referred to as “a black pearl inside the LCX !
The same patient,s angiogram showing origin of OM1
Final message
Beware of radiological artifacts in various angiograms. It can lead to erroneous interpretation and interventions !
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Cardiology-Coronary artery disese, tagged geographical miss, poba during stemi, primary pci, stemi, stents with radial strength, stentys apposition trial, wall stents for priamry pci on September 21, 2011| Leave a Comment »
During primary PCI , the weakest link for a cardiologist is , he is never sure whether the metal jacket has covered the entire disease segment with optimal apposition . (Geographical miss is another issue !)
This is because , even though the inflation pressure is uniform within the balloon , the required apposition pressure is not the same .This is obvious as the lesion surface has a varying consistency and uneven surfaces . It is a huge guess to quantitate the relative contribution of thrombus and plaque within the 100 % occlusion that has resulted in the STEMI. Hence some areas may get over apposed and others lesser apposed. Further , the stent -vessel wall interface in all likely hood enclose a layer of clot .This is almost certain during complex primary PCI. One can imagine the sequel if this thrombus layer dissolves later ! (Edentulous stent )
It is surprising , why cardiologists has so far not thought of a self expanding stent which can snugly appose the vessel wall in this setting . The radial strength from the stored potential energy can be used up future use. This is most important in first few days following STEMI , when the coronary arterial lumen can vary depending upon the
Cardiologists deploy a stent based on the morphology on day zero of STEMI .This may be totally irrelevant , since after a few days the lesion may change its morphology , thrombus may migrate , vascular dimension may change. In such a situation* , a self expanding stent can tackle these issues very effectively by constantly adjusting and fine tuning the luminal diameter and the apposition pressure . It does not give any chance for thrombus to form between the vessel wall and stent .
Here is a study that gives fresh insights regarding the role of self expanding stents during STEMI .
Animation
http://www.stentys.com/file_bdd/annexes/1284135580_video_stentys_en.swf
* Logically during primary PCI for STEMI , POBA and thrombus suction may be the best option in many as all stent related complication is instantly eliminated .But it is a battered concept , most of the current day cardiologists would feel guilty to come out of the cath lab without a stent in primary PCI scenario !
Final message
Self expanding stents during primary PCI : Is it a perfect solution for optimal stent apposition ?
It seems so . . . but the track record of current cardiology devices never fulfilled the initial promises !
Posted in cardiac surgery, Cardiology - Clinical, cardiology -ECG, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Cardiology-Coronary artery disese, tagged culprit vs non culprit, issues during priamry PCI, multivessel disease during priamry pci, non culprit vessel angioplasty during priamry pci, priamry pci in stable stemi, primary pci in cardiogenic shock on August 15, 2011| Leave a Comment »
Surprisingly it is common !
A .Abandon the procedure call the surgeon for an emergency CABG
B. Open the most critical lesion.*
C.Attempt to open and stent all possible lesions.
D.Send the patient back to CCU for a conventional thrombolysis or attempt a intracoronary thrombolysis.
Answer : All can be a right response depending upon the available expertise , time window, associated complication and hemodynamic stability etc .
* Please note ,the most tight lesion may not be the culprit artery. Though there is high chance for that being the culprit , it can be very deceiving especially when there is multi-vessel CAD with chaotic collaterals.
The site of lesion and site of infarct can unimaginably remote. (A traffic snarl at remote flyover can have its impact right on the busy commercial street due to diversions ! ).
What will happen if you open a non culprit artery first mistaking it for a culprit ?
This could lead to dangerous turn of events as whatever little perfusion the patient was getting through the ill-fated IRA will be challenged by the fresh diversion facilitated by non IRA angioplasty. Extreme caution is required.
Emergency CABG within 3 hours of MI even though advocated by few , is still considered a risky way to reperfuse the heart.(In India there is nothing called primary CABG!)
An energetic interventional cardiologist would vouch for opening all lesions . Only thing , he has to make sure is , the patient also has enough energy to withstand his onslaught. Never non culprit lesion if a patient is stable . 0ur aim is not that.If the patient is in shock or impending LVF one can justify opening few more lesions that improve total muscle function which can be vital.
What about fall back on thrombolysis?
This may be seen a defeatist attitude , but when the aim is in the well being of patient , there is no defeat or success. If severe CAD is encountered and both CABG / PCI or not an option, the cardiologist need not feel guilty or humiliated to refer him back for thrombolysis. (Of course , Intracoronary thrombolysis is an option !)
Final message
Primary PCI is often made to appear ” As a kids play” by many modern day cardiologists . It is not so. It requires a team effort. It is race against time. Feasibility depends largely on the coronary anatomy. The failure rate of primary PCI is often camouflaged .(Currently Success of pPCI is boasted at 95%) Logically it should include pPCI ineligible anatomy as well . Many still do not understand the real purpose of pPCI. The aim is to salvage the myocardium at risk , sure and fast. Never attempt for total revascularisation in an emergency situation however tempting it is !
In young persons with discrete single vessel disease the procedure is simple and outcome is straight forward. In elderly , diabetic , STEMI on preexisting CAD, diffuse multivessel disease , complex main left, bifurcation lesions , one requires lot of brain sense to provide optimal outcome . Many times that sense includes abandoning the procedure !
Please read a related article in this site Primary CABG
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, Cardiology-Coronary artery disese, tagged atherosclerosis, coroanry artery dilatation, ectasia coroanry, glaowian phenomenon on August 11, 2011| Leave a Comment »
Atherosclerosis is an inflammatory and degenerative disease of blood vessel.The common belief is (Of course , it is a fact ) it mainly causes vascular obstruction and compromise vital organ function(heart, Brain, Kidney etc)
Here is a different facet of atherosclerosis , A middle aged man surprised us with this coronary angiogram . Instead of obstructing the flow the coronary vessel begins to dilate. This is due to a medial weakness .(The media for some reason begins to give way rather than proliferate to the atherogenic stimuli.)
Same patient's RCA
One may wonder why he underwent CAG when obstruction is least expected in such a vessel ! It was paradox of sorts , this man in spite of his wide bore coronary artery , was prone for coronary thrombus and one such episode landed him in our CCU . ( Please note both faces of atherosclerosis “obstructive and dilatory” can manifest in the same vessel in different combination.)
This angiogram may be reported as any one of the following
These patients should get life long medium intensity (INR 2-2.5) oral anti coagulants for preventing coronary thrombosis.
Watch out for similar aneurysmal changes elsewhere (Renal, Cerebral, Aorta etc )
Counter point
How are so sure it is is due to atherosclerosis ? Can it be a congenital coronary medial weakness ?
Your guess is not my guess . . . My vote is for atherosclerosis .
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, Cardiology-Coronary artery disese, tagged contagious atherosclerosis, coronary ectasia, Coronary pre dilatation, geographical miss, ict, ivus, post stenotic dilatation, pre vs post stenotic dillatation on July 10, 2011| Leave a Comment »
Laws of fluid dynamics dictate there is a pressure drop across a point of narrowing and recovery thereafter . At recovery point if the vessel wall is weak it tends to balloon out .This is called post- stenotic dilatation .This is the anatomical equivalent of Bernoulli or venturi effect. This theoretically occur only distal to obstruction .
How do you explain the common observation of pre- stenotic dilatation?
How is dilatation different from ectasia ?
May be they are all related phenomenon. The definitions of ectasia , dilatation, aneurysm are more to do with semantics than with academics.
Clinical and hemodynamic implication in cath lab
Long term effects
Finale
Enlargement of vessel wall in both pre and post stenotic segments are possible . In small vessels pre- stenotic dilatation is more common , while in large vessels post stenotic dilatation is more prevalent .(Aorta, Pulmonary artery) The mechanisms are slightly different. Apart from the lesion tightness , hemodynamic and genetic factors are also responsible These dilatations are often labeled as ectasia in coronary artery and most cardiologists tend to ignore this finding especially if the margins are smooth.
But , newer imaging modalities like IVUS, OCT have given better insight about these dilatations.These are actually an expression of the contagious atherosclerosis . Pre- stenotic segments are prone for extensive disease than even the diseased segment due to more hemodynamic turbulence. There is some evidence atherosclerosis progresses proximally more than distally.Smooth margins within the pre -stenotic dilatation does not guarantee disease free status.
During PCI there could be an argument for covering the dilated pre- and post stenotic segments as well* . (We vouch for endovascular stenting when aorta is dilated why do we hesitate in coronary ?) .Careful selection of coronary stent size is recommended and allowance should be given for these two (Pre and post coronary dilatation ) patho -anatomic phenomenon.
* Stent missing a lesion is stylishly called geographical miss ! This should logically include dilated segments also.
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology-Coronary artery disese, tagged appedix and heart, appendectomy and cad, child hood risk factors for cad, dr s venkatesan, drsvenkatesn, ethics in medicine, first do no harm primum nocere, hippocrates, lymphoid tissue and heart, madras medcial college, newer risk factor for cad, tonsillectomy and cad on June 24, 2011| Leave a Comment »
Human body is a bundle of mystery. In an average life span of human beings, millions of afflictions come and go . Most are benign . Our body has a full-fledged defense ministry armed with sufficient weaponry in the form of , immune cells, thousands of regulating enzymes, hormones , cell service molecules etc .It can tackle most of the ailments our body encounters with out a doctors help (Jungle animals rarely die of disease!) .
Of course , the body needs external help when it’s intrinsic resources fail . There are few serious disorders that has to be intervened .However ,a big fraction of them will die in spite of whatever we do .
Is it not fascinating to know more than 100s of chemicals act day in, and day out , to prevent our blood from clotting and keep it flowing . If only the natural lytic mechanism fails for an hour , and create a vascular chaos we will realise importance of it !
Even as we debate appropriateness of medical care in this 21st century here is startling scenario ,
When a child presents with physiological hypertrophy of lymphoid tissue , as their body begin to learn and record the micro biological mysteries of our environment , it is often “cross labeled ” as tonsillitis or appendicitis and end up in surgical tables.
This article just released in European heart journal , tells us , how the rampant use of appendectomy and tonsillectomy in the early child hood may make them susceptible for CAD in later age group.
The role of medical professionals is identify the trivia ! and prevent unnecessary interventions.
Unfortunately or (Should I say dangerously) many of the professionals understood it in a diagonally opposite manner . Identify the trivia , instill fear in our patients and intervene , in the process injure our great biological system.This is also applicable to many cardiac interventions.
Final message
Heavens sake , youngsters , please remember , medical profession is all about removing suffering from patients . Do not fish out “non -existing” illness from your patients body ! Let me remind you , professional approach means , whatever you do it should be in the interest of our patients . The moment you deviate , you cease to be professional .
Also realise , good intentions can never be an excuse for inappropriateness !
Reference
http://eurheartj.oxfordjournals.org/content/early/2011/05/27/eurheartj.ehr137.abstract
Posted in Cardiology - Clinical, Cardiology-Coronary artery disese, cardiology-ethics, Cardiology-Land mark studies, critical care ccu, tagged clinical cardiology, mcq in clincal cardiology, medical ethics, outsourcing clinical examination on May 18, 2011| Leave a Comment »
Most important MCQ in clinical cardiology
Many cardiologists would love to do away with detailed clinical examination because . . .
Answer : All of the above can be true . The 6th response is likely to be more correct !
While cath labs can prevent few deaths occasionally . . . it is the general wards and OPDs that add life every day
Dr.S.Venkatesan MD 