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Archive for the ‘history of cardiology’ Category

In the early  20th century , Waller invented the ECG machine. Wilson  created  leads and  methods to record it. Eienthoven  formulated the concepts the electrical theory behind ECG.

Between 1940-197os one man ruled supreme in the world of electro cardiography .   He is Dr Sodi pallares from Mexico. His deep insights revolutionised  and helped  us  understand how the cardiac electricity is generated  and propagated  in various pathological states that is the beginning new age electrocardiography! It adds much to his  credit , as in those days scientists  from non American and European countries   were hard to come  in the  global limelight.

Some of his thought processes and Inventions

  • He laid the foundation  for deductive electrocardiography.
  • Applied  vectorocardiographic  principles to scalar  ECG and helped  understand mechanism of ventricular chamber enlargements
  • He was instrumental  to analyse  the genesis of current from the myocardium . He tried to reason out  the contribution  of  cell metabolism, hypoxia, electrolytes to the current genesis.
  • Polarising myocardium with GIK infusion STEMI was proposed by him
  • Finally he tried to incorporate the laws of thermodynamics into electrocardiography .

Please remember , Sodi pallare’s  conscience  is still largely unexplored .There are lots of hidden truths .We now know fever can influence qrs voltage and febrile illness can trigger  ventricular tachycardia as in  of Brugada syndromes.

Today’s youngsters can take a  few cues from this great man and enlighten the field of electro-cardiology

DOCTOR DEMETRIO SODI PALLARES

Demetrio Sodi Pallares (1913-2003 )

If  modern-day cardiologist is able to  interpret the  ECG by a cursory 3 second scan of  strip of waves  , we are greatly  indebted to the knowledge imbibed by this great man from Mexico !

Sodi pallares

Reference

http://onlinelibrary.wiley.com/doi/10.1002/clc.4960110616/pdf

Sodi-Pallares D,Medrano GA, Bisteni A, Ponce de Leon J:
Deductive and Poly-paramerric Elecrocardiography.Instituton acionalde
Cardiologia de Mexico, Mexico,DF1970,VII,VIII
Sodi-Pallares D, Testelli MR, Fishleder BL, Bisteni A, Medrano GA, Friendland C, De Micheli A. Effects of an intravenous infusion of a potassium-glucose-insulin solution on the electrocardiographic signs of myocardial infarction: a preliminary clinical report. Am J Cardiol. 1962;9:166–181

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I guess ,the art of delivering medical lectures is gradually deteriorating . This is not because of lack of young brains in teaching profession .It is primarily due to onslaught of technology  and multiple  scattered source of knowledge . I do remember some of my physiology  professors take class  in  the first year medical school  in the early 1980s  .

I wonder  I  could go back in time machine to hear the voice of Dr Kieth who delivered this grand lecture of anatomy of heart in the year 1918 .in the famed auditorium of  Royal college of surgeons . We should profusely than the BMJ for providing the text of that lecture free to us in  almost 100 years later.

By the way  . . .  for those who do not know  ,  Kieth is one of the inventor of SA node the pacemaker of the heart .

\

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2340034/pdf/brmedj06937-0003.pdf

Highlights

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This man enters your cath lab  every morning !  . . .  He is Mr Stent !

Endo-prothe`ses coronariennes autoexpansives.”

    “Endo-prothe`ses coronariennes autoexpansives.”  This is the official name given to coronary stents  when it was first used in man in 1986 in France . The first  stent in human coronary artery was implanted by Puel . Followed by Sigwart  ,Puel combine .

Later on  , the name Stent came into vogue . Surprisingly stent is not a technical name . It is a name of British dentist. To know more about the historical aspects of coronary stents read the following review from Circulation.

References

http://www.fauchard.org/history/articles/jdh/v49n2_July01/charles_stent_49_2.html

1 .Puel  J, Joffre  F, Rousseau  H;  et al.  Endo-protheses coronariennes auto-expansives dans le prevention des restenoses apres angioplastie transluminale, Arch Mal Coeur 8 1987 1311-131

2. Sigwart U, Puel J, Mirkovitch V, Joffre F, Kappenberger L. Intravascular stents to prevent occlusion and restenosis after
transluminal angioplasty. N Engl J Med. 1987; 316: 701-706.

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Some scientists are  known for their discovery ,  few are known for their vision  few for their character .Here was a man who  had  all of them  can be termed as father of modern medicine .

Rudolf Virchow - German pathologist( 1821-1902)

Unfortunately the current generation knows him for his concept and theory of blood clotting  or  lymph  node in the neck .

Here is a  reviews about this man who single handedly   taught  the world

He  insisted  , caring  the sick and treating illness  is  more of a social science than medical one

We  have probably  not  learnt  a single lesson yet , from this master  teacher is a different story !

Avid listeners to Virchow in Berlin university

My  Virchowian thoughts

This man’s understanding of medicine was much . . .  much sharper than us –  100 years ago  , when  cardiology was practiced  with out  even an  ECG and   X-ray chest  . ( Is itn’t  true   today  we struggle with  loads of  3 dimensinal  gadolinium enhanced  cardiac MRI ! images )

Virchow’s  concepts  are most relevant in today’s world  , where the corporate and capitalist  culture  has  hijacked the  noble profession . Inhabitants of this planet are  threatened with eccentrically blown up  healthcare  system   where  the  development of   modern medical   modalities is completely out phase of with what  is required for the people .

We will pay a heavy penalty  if  this world  continues to witness   people die  for as  flimsy  reasons  like lack of oral re-hydration fluids   , while the other section of society is  marketing an exotic  mitochondrial DNA  slicers  for prolonging a  cancer victim  life by few months .

In a global society  where  social , economic  and environmental  responsibilities  and liabilities  are shared ,  it would be disastrous if  one country is simply not bothered about what is happening in other country.


WHO the world health organization came into being exactly for this reason .

We know  .  . . how it functions .  It is the  most abused united nation body . It has  neither the required  power nor the will to  tell the world  and insist them the  righteous  route for human health !

If the rich  are  not bothered about poor ,  it is certain  the rich will  also be eliminated  from the planet  for the same reasons  . . . it’s  just  a matter of time   !

Reference

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305179/pdf/westjmed00323-0041.pdf

http://en.wikipedia.org/wiki/Rudolf_Virchow

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We do come  across ,  even  senior  cardiologists , who  tend to undermine  the importance  of  poster  presentations in scientific  conferences   (I know a  few ,  who  ridicule it as well  ? ) .

                      Is  it not a meanly  job   for  a  cardiologist  to paste a  poster  and stand  beside  it  for hours  , waiting for scientifically motivated audience !

But , what really matter is the thoughts ,  concepts  and often the hard work   that brings  these  posters to  big league  conferences .

Please remember   abstract posters  must cross the hurdle of  the conference peer review  committee’s scrutiny . Often times   the poster arenas   has  launched  some crazy ideas  ,  transform  them to  great  discoveries.

If   only  , Gruentzig had shied  away from the poster  he famously  pasted on lawns of   ACC  , Annual scientific sessions ,Florida

1975     .  .  .  the    revolutionary  concept  of  PTCA   would still be  in utero  !

Final message

I argue the young  fellows in cardiology to send as many  scientific  abstracts as  possible   in their  national or international  meets  . This is  where the  the future of cardiology lies ! Simply don’t  bother about the critics  .

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Who is the father of interventional cardiology ?

William Rashkind a cardiologist from Children’s hospital, Philadelphia in 1966  probably is the first person who thought it was indeed possible to use a wire and balloon as cardiac therapeutic intervention .When surgeons were groping in dark with  sick cyanotic new borns with dTGV , He along with Miller executed their idea.

It was published in JAMA

How the Rashkind  has revolutionized  our approach to congenital  heart disease  is evident from the current guidelines in 2011.

The procedure has since evolved with improving hardware and we are able to ferry a blade into the IAS for cutting .

Current  recommendations for Atrial  septostomy

It is primarily useful

1. Atrial septostomy  to enhance atrial  mixing (eg, transposition of the great vessels with restrictive/intact atrial communication) or to decompress the left atrium
2.During Extra corporeal membrane oxygenation (ECMO)   to decompression   of left atrial hypertension

3.If there is poor cardiac return from ECMO  circuit  low venous saturations  (Class 1 Evidence  C)
It may also be tried in  (Class 2 )
1.  Hypoplastic left heart syndrome  with  restrictive atrial communication.

2.  Static balloon dilation of  l synthetic / bioprosthetic  IAS  (eg, Gore-Tex)

3. Tricuspid atresia with restrictive atrial  communication

4 .Pulmonary atresia with intact IVS

5. TAPVC with  restrictive atrial communication.

6. Primary pulmonary hypertension / Eisenmneger VSD/PDA .(Occasionally useful )

Reference

http://circ.ahajournals.org/content/123/22/2607.full.pdf+html

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Medical science has grown ( and growing )  in an  astonishing pace. Many of the  inventions  which were  considered as  major break throughs   have fallen on the wayside over the years . Of course ,  quite a few  withstood the test of time .

One of  the great inventions  of last century  is per-cutaneous interventions  inside the human coronary artery .

The concept was first conceived and executed by Andreas  Gruentzig  of  Germany in year 1977.  Now , at-least a  million PCIs  are done every year to tackle  CAD  with greatly  improved knowledge base, evidence ,  hardware,  techniques and expertise .

PTCA  is  an  invention worth a Nobel prize . . .well , that’s what we cardiologists feel. The Nobel committee  seems to think otherwise .

What could  be the reasons ?

  1. PTCA is  simply an extension of an old invention. Already the  inventors  of the  cadiac catheterization were  conferred with  Nobel prize (Forssman, Cournand,Richards)  . Hence , it is a sort of duplication of  invention . If Gruentzig is conferred a Nobel prize  the man who discovered the  coronary  stent (A plaque scaffolding device)  will  argue he too deserve  a  Nobel !
  2. What Gruentzig  did  was  in-fact a fundamental  human  response  by Instinct !  .When you encounter  a mechanical obstruction on the road   just try to overcome it . “Here is an obstruction impeding the blood flow , let  me  remove it”  . He did this  with  a wire and balloon . There is not much intellectual  innovation . It was  delivery of a mechanical force through a wire  .   But what the  Nobel  committee should take it to account is , he did this  in live human beating heart  and  cured of his illness most dramatically avoiding a need for surgery.
  3. Finally  comes the vital question. What is the impact of this invention in the health of mankind. ? How  many lives have been  saved when compared to other modalities to treat the   coronary artery disease ? *.This again is not convincingly answered  especially in    stable angina  , for which Geuentzig  originally developed this modality  . One popular argument  is , in terms of life saved and sufferings  relived oral rehydration  fluid  or penicillin  would beat PTCA most convincingly !

* Another possible reason is ,  the  Nobel medical committee is probably well aware of the  perennial  controversy  about  role of  Medicine vs Surgery vs PCI on the outcome   CAD  and  the  superiority of one over the other !

Final message

Whatever  be the reasoning  ,  Nobel committee has to  rethink .  Cardiologists  all over the world   would definitely  agree  if one man who have  made a  huge difference in their patient’s  life ,  it must be  Gruentzig  .

It is well-known  Nobel prize  is given  for path breaking  research that  break  new grounds like  decoding  cosmic mysteries ,  expansion of universe  , cell signalling ,  molecular mimicry  and the  stuff  like that .

Still ,  Gruentzig  definitely  deserves  a Nobel  solely  for  the novelty  in his  procedure  and in the process it helped  avoid  surgery in vast majority of heart patients.

Reference

http://www.nobelprizemedicine.org/

http://circ.ahajournals.org/content/93/9/1621.full

http://www.nobelprize.org/

Video

http://www.angioplasty.org/video/aghero.ram

http://www.angioplasty.org/video/agcomplex.ram

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One of the greatest medical sermon of our times  is   “Doctors must   constantly update their knowledge , Continuing medical  education is as sacred as their profession  !  If you are not updating your knowledge you cease to a doctor “

It is fashionable , but true  to state  modern medicine lacks humane  care . Modern medicine  is  challenged by a huge  technological ,  commercial  onslaught  where common sense takes  the back seat

Hence , doctors need to renew not only  their  academic competence   but also  their ethical  fitness  every  year !

Aggression  could be the other  name for  modern medical care . For every  new  invention , treatment   or guideline that  is  approved  an equal number  is shelved after few months or years  for safety reasons.

Bulk of  medical updates  for  current age physicians  is nothing , but asking   them to forget  all those wrong things that has been meticulously uploaded in their brains in the recent past  ( Recall the classical story of drug eluting stents )

If this is the  case . . . then  . . .  what for  we  are  updating ?   and  for what  we are  learning and forgetting  ?  and  . . . how frequent we need to forget ?  Of course  , there is a big chunk of   human tribe  who  can never master the art of forgetting ! Some mistakes are permanently etched in their terra byte hard disks .

Is there a place  for backdating and discontinuing  medical  education  ?

What  man- kind needs  at times of  medical  crisis  ,  is  not  the current  treatment  but the correct  treatment    .It is our duty  to  find  all those  trustworthy  drugs  & treatment modalities  that were  sent  to  the gallows by the modern medical forces   for various reasons !

If  some of  the gems in  medicine are  left behind in  past  “time domain”  ,  it is  mandatory  for us  to go  back in time and   catch it , adopt it and disseminate it !

Further ,  whenever  the  hyped   “medical updating sessions ”  turns out to be  synonymous with adding nonsense (It is  becoming all too common these days   !) we should resist   it by all means !

For many . . . Hippocrates and his medicine sounds dirty now !

If  only we back-date  our knowledge   .  .  .

Todays  youngsters  can learn a secret that liver enlargement can be diagnosed easily  with their  hands ,  without  waiting for a  CT scan report !

If only we back-date  our   knowledge  . . .

We can realise  Aminophylline can save so many  lives of cardiac  failure  , which  our newer inotropic agents are struggling to accomplish .

If only we  back- date  our knowledge  . . .

We can calmly manage  acute MI with lignocaine  even in a country side  .  Amiodarone unfairly replaced  this  efficient  anti  VT  molecule  for no academic reasons !

If only we back- dat our knowledge  . . .

We  can  advice simple non pharmacological intervention for  stage 1 HT   than prescribing the  glamorous  sartan molecules  form a  multinational  ARB shoppe.

If only we back- date our knowledge  . . .

We can  promptly recognise  cardiac failure  without  ordering  for the error prone   BNP . Back dating also  helps us to under stand  that post infarct angina is a  glaring sign  for presence of   viable myocardium  and prevent us from undertaking a  2000 $ PET  excursion !

If only we back- date our knowledge  . . .

We can  send  all our uncomplicated , asymptomatic   STEMI  patients ( in class 1 )  straight to  their  home rather than to cath lab  play grounds !

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God has created  and arranged every organ in an order  with a purpose .  The unique  relationship  of the food tube and  the heart which run silently , posterior  to the heart has evoked much interest for the cardiologists.

Whenever LA is enlarged it pushes the Esophagus back .We also know  the vintage clinical entities   of cardiac  dysphagia that occurred with rheumatic mitral stenosis.

Since the  lower end of  esophagus just hugs  the left atrium , this anatomical concept was successfully exploited   for imaging heart in TEE.Now cardiac  anesthetists routinely use the esophagus as an imaging port during complex mitral valve surgeries.

How  esophagus can be utilized to resuscitate the heart at times of emergency ?

Note , the esophagus does a friendly hug as it crosses the heart posteriorly .It is a perfect anatomical sense , to Image and pace the heart from within the esophagus !

 

In a  cardiac  arrest  situation , when we need to   rapidly   access to heart  , we have  multiple  options  .Each has some  advantage and few draw backs.

  • Trans-venous pacing   is the standard method,   but even for experts  it needs   few minutes to reach the heart for pacing
  • Trans cutaneous pacing (Zoll)  is  a viable option , but  not widely  popular for some  unknown  reason (Patient discomfort ? High threshold ?)
  • Emergency trans-thoracic  needle pacing option is  a primitive method still can save a life or two on it’s day !

It was in 1980 ,  a dramatic  concept was conceived  . Why not    use the  esophagus as an access   for pacing  the  heart

after all ,  it  reaches as close as possible to the heart !

How to convert  a  Ryles tube into a  a  trans – esophageal  pacing lead ?

There was a certain article on this topic , which I read , when I was cardiology resident. It answers the following. Distance form mouth ,  Discomfort of  the lead ,   Pacing threshold ,  Esophageal burns .

I am unable locate that article. Will  post  it  once I get it.

Limitations of trans-esophageal pacing*

  • The most important limitation is it can pace only the atria with high degree of success.
  • Ventricular pacing is not that successful for the simple reason esophagus is anatomically insulated by the atrial chambers.
  • Tran gastric positioning  may reach  the basal aspects of Left ventricle , but the threshold needed  is too high that will invariably cause  discomfort.This can be used in a dying patient  when there is no  other option .

* Primarily  useful in acute SA nodal defects, sinus arrest or any other atrial electrical failure. Infra- nodal complete heart block trans esophageal pacing may not be effective .

Other potential uses  of trans-esophageal  leads

Over drive pacing

Overdrive entrainment of tachycardias ,  including resistant ventricular tachycardia is possible.

Trans esophageal ECG recording .

This can magnify p waves during supra ventricular tachycardias and aid in decoding narrow qrs tachycardias

Safety  Issues and Caution

Good earthing is necessary .Burns can occur.

Final message

Every cardiac physician is  expected to possess  the expertise to rapidly pace a heart  by trans jugular /subclavian access at times of  emergency .

Further , any modern CCU will have a defibrillator equipped with trans-cutaneous pacer as well. (The  disposable pads are too costly and is a deterrent in many hospitals  !).

This article  explores other possible way to pace the heart in dire emergency situations.

It has one more purpose !  It rekindles   the acumen , motivation  and hard work   of  our  cardiac  ancestors  (Which many of us are pathetically lacking !)

http://circ.ahajournals.org/cgi/reprint/65/2/336

Role of trans-esophageal lead during EP study  atrial fibrillation

http://cardiovascres.oxfordjournals.org/content/38/1/69.full

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In any field  , errors and mistakes  transform into   experience in retrospect. (Of course only  if we  realize  our mistakes !) . Many would argue prevention of such errors is the  only way to move  forward in science  , but ,the opposite could also be true.

In Medicine ,

  • Most errors are mild ,
  • Some errors  can   be fatal but it helps us prevent further fatalities.
  • Some errors create history  and  re-define the science.

That’s   what  happened on 1958 , to be precise on  October  3oth , 1958  in a lonely laboratory of Henry  Ford hospital/Cleveland clinic *

*A correction -This  invention actually happened in Cleveland.  ( Sones learnt  all his techniques in Henry ford)

When  Sones along  with his assistant were trying  to do an  Aortogram in a patient with RHD,  the entire dye meant for aorta went straight  into  the right coronary artery.When every one was stunned ,the  patient happily  survived the injection  with a few skipped beats.

The man behind  this horrendous medical mistake was   Mr . Sones . He   was guilty for many days ,  spent many sleepless nights  ( In spite of  the patient surviving  the episode ). In fact , he was much amused  about the patient’s  survival . At that point of time,  even a spill over of dye into coronary artery was considered forbidden.  He pondered over the incident for months  .

Had  two queries  lingering in his mind .

  1. How the  right coronary artery  was able to withstand the 40cc dye  injected with  force .
  2. If 40 m l was tolerated ,  well what about routinely injecting  3-5 ml for visualizing the coronary  tree   by intentionally  seeking the coronary ostium .

That was the moment , the concept of diagnostic coronary  angiogram  was born . He published his observation as an  abstract in Circulation journal. Later he did many experiments  with video  engineering at Kodak labs , X  ray  technology to improve the cine imaging .By 1964 , he devised a perfect protocol  for doing  selective coronary angiogram. Then along with Rene Favaloro he pioneered CABG surgery in USA.

Final message

Cardiac  catheterisation was invented by  Forssman , Cournand , and Richards ,(Nobel prize 1956 ). It was  Sones who took it into the coronary arteries  and thus it was  made possible  for a whole new specialty  of coronary  diagnostics  and therapeutic PCI  which was  conceptualized by another extraordinary human life called   Gruentzig. Sones along with Gruentzig definitely deserve a Nobel in medicine which i think will happen soon ! They lived a great life constantly thinking, innovating  putting  patients interest in the fore front .

Mean while , I argue our youngsters  to  portray  the images of  these giants in  every   cath lab they  work   .You may get their blessings from heaven  , provided you do your interventions with integrity and honesty without any conflict of interest in the patient care.

Do not cry foul when some genuine errors happen in cath lab.Few among us (like Sones ) may innovate those mistakes into glory !

Reference

http://en.wikipedia.org/wiki/F._Mason_Sones#cite_note-3

http://www.wired.com/thisdayintech/2009/10/1030first-coronary-angiogram/

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