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Archive for the ‘Left main disease’ Category

Was the past perfect ? I don’t know, but the future looks tense… welcome on-board, to automated ACS management.

Posted in acute coroanry syndrome, Clinical cardiology, Ethics in Medicine, Hippocratic oath, history of cardiology, Histroy of medicine, Left main disease, Medical ethics, Primary PCI on June 23, 2019|

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Charles river esplanade ,Boston* : A healthy middle-aged man who was jogging quietly, while his heart was under intense scrutiny by the bionic eyes of Apple i-watch’s smart patch electrode. Suddenly, it detected some bizarre ST segment fragmentation (Seems it can predict in advance , Ischemic signals 10 minutes prior to onset of ACS ) The built-in cosmos direct GPS instantly alerted & summoned a titanium powered Space X drone that pulled the patient from the riverside to the nearest human wellness port .

EHANG 184

It dropped him through a remotely accessed split glass roof right inside the hybrid heart lab, to find , men and women chatting with flattish Artificial intelligence panels who readily allowed the robotic arms to hug the patient which engaged the coronary artery pushing radiation free magnetic gas found nothing inside and what would become a perfectly normal human coronary artery .

An amused resident robot gently plucked the patient from the cath table with sheepish laughter and called for another drone to drop the patient exactly in the same place from where he was picked up.The healthy hearted patient thanked the doctors profusely and continued his routine evening jog across the Charles of course with a 16-minute delay!

Next day . . .

Event auditing firm medi-logic mind congratulated the entire cardiac team and its digital health hub for the quality of the network and completing this daring coronary rescue mission in 16 minutes. While the drone to hospital roof time was 3 minutes, the coronary artery visualisation time was perfect.The auditing team had a special mention about the astonishing capability of Apple time watch algorithm that made sure that the patient’s evening routine was unaffected in spite of this life-threatening non cardiac pseudo-emergency. The crowning glory was, the entire expenses amounting to 250000 dollors (after a special money back discount coupon for the first false alarm) were taken care by the patient’s virtual insurance blockchain payment gateway.

*You have just read the news that wasn’t – January 2030 AD

Now, back to reality,

Stumbled on this news clip from pages of Times of India, (20-6-2019) months after I wrote the above piece. I wondered the chase between fact and fiction is becoming  really a close race.

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Cathlab misadventures :”Protected left main” and . . , unprotected patient !

Posted in Left main disease, Left main stenting -Tips and tricks, Tips and tricks in cath lab, tagged , , , on February 26, 2017| 1 Comment »

It has become fashionable for many current generation cardiologists to stent the LAD   with proximal end  liberally extending into left main shaft  in Medina 0, 1, 0 or (1,1,1 )lesions involving distal left main often  jailing the LCX . This concept came into vogue as it helped bail  out few  hemo-dynamically  unstable patients with true left main bifurcation lesions during primary PCI .Of course , it’s potentially useful strategy in  emergency , if  extended into routine situations (like all stable proximal LAD/Bifurcation ) we are bound to create few problems.

the-only-thing-more-dangerous-than-ignorance-is-arrogance-quote-1

Rapidly protecting the left main with a long single stent down into LAD is an easy way out for tackling distal left main /LAD combined lesions.  Conceptually it asks you to forget the LCX outright.(Coronary outrage for some to call LCX as  a side branch of left main ! ).Of course, one can reconstruct the LCX  ostium by other means or a second stent if required.

Final message

Conquering  left main disease  with a long stent right from its origin or mid shaft to  LAD (Some times  from Aortic ostium ! ) may be an  interventional pride for the cardiologist. But , in no way it  imply we have crossed the  final frontier in LM disease.In fact,  putting a left main coil is the  easiest task among all  PCI since there is little expertise required to cross the lesion .Maintaining its patency   medium  long run and thus beating the CABG  is  true achievement  ! Achieving  an acute patency  of left main and wheeling out the patient live from cath lab can not  be reason for permanent rejoice ! One should realise his life is at the mercy of DAPT and its pharmakinetics which we know can be unpredictable !

“Protecting the patient is more important than a protecting left main” 

Just because a technique is easy to accomplish it doesn’t confer the right to misuse it .The argument “my patient” is doing fine with this type of stenting  is not an appropriate way of justification.

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Left main disease : How to add “Angle and Size”to Medina classification ?

Posted in Left main disease, Left main stenting -Tips and tricks, tagged , , , , on December 4, 2016| Leave a Comment »

Medina classification  is the most popular angiographic classification  of bifurcation lesions based on the presence or absence lesions at the three levels  of branching  (0,0,0 ) to (1,1,1). The popularity of this scheme is essentially due to its simplicity.

It can further be subdivided according to angle and size .Though there are three angles possible it is the angle of LM with LCX that matters most.

T shaped  left main. Angle of LM-LCX is around 90 Degrees

Y shaped left main. Angle of LM- LCX is > 120 Degrees

Three types of Y according to size of branch vessel size.

Y1 Large left main divided two equal LAD, LCX.

Y2 Left main and one of its branches are equal

Y3 All three are equal diameter.

Here is a series of  lectures on left main (Probably the best I guess  !)  from Dr.Boris Varshisky ,Hadassah University hospital  Jeruselam.He critically discusses about the   nuances of left main disease from pathology, technical and therapeutic considerations.

Spend some time on these videos , you should be able to learn about

  • Distribution of left main disease
  • The complexities in defining the true shapes of of left main ostia .(Ostial sharing between LCX and LAD ?)
  • Lesion based strategy
  • Carinal shift vs plaque shift
  • Stent sizing in Y 3 left main

and much , much  more !

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Left main disease : A classification and a simple strategy !

Posted in Cardiology -Interventional -PCI, Cardiology -unresolved questions, Left main disease, tagged , , , , on November 13, 2013| Leave a Comment »

Distribution of Left main disease.

  1. Ostial
  2. Ostio-proximal (Within 1 cm of  origin )
  3. Shaft -Discrete  mid left main
  4. Shaft -Diffuse
  5. Isolated distal shaft( 1.0.0)
  6. Bifurcation ( Medina 1.1.0 -LAD)*
  7. Bifurcation (Median 1.1.0-LCX)
  8. Bifurcation ( Median 1.1.1)*
  9. Trifurcation ( With ramus )

* These three locations account for nearly 75% of all left main lesions.

left main disease coronary angiogram

We know atherosclerosis is  a branch point disease .Normal left main measures 1 mm to 20mm.The shorter the left main lesser is the the incidence of LMD. Short left main can not engage the atherosclerosis much (No left main = No left main disease ) However ,very short left mains  may increase ostial lesions .

  1. The commonest left main lesion is distal left main with one of the branch involvement (1.1.0.LAD is more common )
  2. Least common entity is discrete mid shaft lesion.

Simple strategy.

First dictum : All complex looking LMDs should be referred to a good  surgeon.

Final dictum : Remember medical management for left main disease is still an accepted strategy in stable , non flow limiting situations .

Interventional  Cardiologists  feel they have the exclusive rights   to indulge between these two  spectrum of LMD .May be true! But extreme caution is required as we are playing  our game in the most critical  coronary high way .

Some suggestions and thoughts.

  • 50 % diameter stenosis is significant. But significance does not mean we should tackle the lesion by aggression.
  • Symptomatic flow limiting lesion only to be intervened . (Flow limiting means both angiographic and a stress test .FFR <.8 is also an index for flow limiting .Symptom means Angina on exertion )
  • IVUS, OCT, FFR,NIR ,SYNTAX  are not path breaking tools .They essentially  add  more glamor  to left main disease than anything .
  • Most bifurcation LMDs are  managed by single stent with stent jailing the major side branch (Yes side branch can be LCX !)
  • However ,two stent strategies is not banished .It can be vastly  superior in some selected cases .(Especially with huge plaque load at carina )But needs expertise .
  • In very small vessels two stent strategies are risky .

Reference (2012 update)

left main disease coroanry angiogram management Fajadet

PRECOMBAT left main disease south korea everolimus
Link to related articles in this site

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