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The incidence of stroke during TAVI up to 5 % (minimum ). Stroke risk reduction during TAVI is a critical requirement that can be a deterrent against this wonderful Intervention.

Many devices are being considered

  1. EmbolX (Edwards life science)
  2. Emrella
  3. Sentinel (Claret medical)
  4. TriGaurd (Keystone)

1-s2.0-S1050173818300112-gr2

 

TriGaurd 3just got the approval from CE and appear promising. (REFLECT trial) It is inserted through the transfemoral route , deflects embolic material to descending aorta since it covers all the three branches of Arch.What happens to these deflected particles? Any bodys guess.

So , in my understanding it converts potential brain embolisation to peripheral microemboli , wh

This image has an empty alt attribute; its file name is triguard-3tavi-tavr.jpg

A nice descriptive animation .https://player.vimeo.com/video/232995629

While, these innovative aortic arch filters reduce the risk of periprocedural embolic stroke, please mind, TAVR patients continue to be at significant risk for stroke over a long period. This is due to other late causes like TAVR leaflet thrombosis, atrial fibrillation, arch atheromas, and bleeding due antiplatelet agents.

Reference

1.WienekeVlastra, JeroenVendrik,  Karel T.Koch et al Cerebral protection devices during transcatheter aortic valve implantation  Trends in Cardiovascular Medicine  Volume 28, Issue 6, August 2018, Pages 412-418

2.(REFLECT trial) 

 

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Can you guess how many drugs a busy physician on an average writes in their prescription in his office ?

Three ? , Five , Six ,  . . . . Nine,? There is no specific study available for this non-academic query. I have got stunned to see a maximum of 18 drugs in one prescription. So, it should be anything between  1 to 18. May be a mean around 6 or so (Make your own guesstimate)

There is strong evidence to suggest writing a drug prescription has become a (un)conditioned habit-forming act. My professor* used to say generally 2 to 3 drugs are sufficient for most of the common illnesses we encounter (Only in extraordinary situation one may need to go beyond this )

One evidence less estimate though a random observation  among  the physicians suggested the bottom half of any long list of drug prescription is redundant and it doesn’t really address the specific problem the patient is suffering. Meanwhile ,the concept of poly-pill is making drug compliance easier in many cardiovascular and diabetic diseases.

*William Osler

Final message

Number of drugs human body can handle simultaneously without any harm is  often an ignored chapter in the Principles of clinical pharmacology and therapeutics.

Let us mind the length of our prescriptions and ensure less harm to our beloved patients.

Related material

This was my old presentation made about polypharmacy in CHF :Perils and pearls

PDF format of the presentation

 

 

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Its almost like playing a billiards game in absolute blindness.

It is not an unusual scenerio, to see the balloon catheter delicately bending at IAS puncture site , dodging and deflecting with random jerks as it tries to steal a entry in a few diastolic milliseconds time window when the fish mouthed mitral valve opens in sub square cm areas of MVO trembling in fast atrial fibrillation.

Agree ?

Gathered some tips to cross a difficult mitral valve during PTMC.

This is a PPT presentation taken from archive (Made in 2012)

Please pardon , it lacks audio.

PDF version : Prof SV PTMC mitral valve crossing

Final message

Often times Its noted we tend to struggle more at the mitral valve crossing than at IAS puncture during PTMC. Experience prevails over Image assistance. Assessment of LA size , IAS plane , and sub valvular disease seem to be critical. Probably the secret of success which I found out was , smart guys never hesitate to repeat IAS puncture site for optimal trajectory .Over the wire technique is not forbidden.

Unfortunately, TTE guidance is of little use to cross the mitral valve. Co-registration of fluro/3D TEE is promising , but most cardiologist continue to rely on their experience.

This always Intrigues me ! why we have abandoned retrograde crossing through the Aortic valve that avoids the dreaded IAS puncture. (Refer Dr V.K.Bahl AIIMS Newdelhi in a large series from Greece : Retrograde PTMC J Am Coll Cardiol 1998;32:1009–16)

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I don’t know whether you have seen this before. Surely , I haven’t seen a presentation such as this one.

Place: Annual scientific meet ASE 2013. Minneapolis

Presentor:Dr.Partho Sengupta, Mount Sinai hospital, New york.

Its a 3D presentation in “space” without a screen by Holography.

The stunning 15 minutes lecture take us into the myocardial architecture, with speckles , flow vortex echocardiography and fluid kinetic energy mapping.

Don’t miss, a dramatic live teleporting of ASE president on to the stage. 

 

Can you Imagine , where does this technology take us to the future ?

Patients may reach doctor’s offices by holographic teleport for a medical examination or vice versa. Yes, it’s all going to happen someday.

 

 

 

 

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Coronary collateral circulation is one of the major determinants of symptoms and outcomes in chronic CAD. But, we generally shrug off the value of coronary collateral circulation in acute coronary syndrome. The fact is, it has a myocardial mitigating effect following sudden total occlusion.

When does it appear? We did a small analysis (PDF version)

We found it is noted in 25% of patients. With reference time of appearance,  6% had it within 12hrs and in few, it was noted as early as 6 hrs. One caveat is,  we may not know whether its preexisting collateral due to chronic multivessel CAD. I am sorry to note this study did not address the outcome analysis. We however documented patients with good collaterals had negligible wall motion defect and near-normal function post PCI. Some of you can pursue research in this area. 

Potential role of collaterals in ACS

  1. It limits the infarct size
  2. Keep the myocardium alive and give us time to intervene
  3. Can converts a potential Q-MI to non-Q MI
  4. Possibly prevent primary VT/VF and hence dreaded sudden death in early STEMI
  5. Prevent early adverse remodeling of the left ventricle.

When these points appeared just my assumptions, Dr. Ali Aldujeli, (Lithuanian University of Health Sciences, Kaunas) in his presentation, at TCT 2020 confirms many of them are  Indeed true

Final message

I agree, in the era of instant gratification with primary PCI,  relying on coronary collaterals may appear a lesser professional virtue. Still, we may need to respect nature. Many times it bails us out.

Current update 2020

Alsanjari, O., Chouari, T., Williams, T.,  Angiographically visible coronary artery collateral circulation improves prognosis in patients presenting with acute ST segment‐elevation myocardial infarction. Catheterization and Cardiovascular Interventions.  Volume96, IssueSeptember 1, 2020 Pages 528-533

 

 

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Covid has struck hard and this time it has consumed one of the Doyens of Neurology, from Coimbatore, India –Dr.M.B.Pranesh. Privileged to have him as my professor in Coimbatore medical college, my alma mater, watched him in close quarters during my undergraduate and MD days in the late 1980s.

Still recall, how he empathizes with the patient and their family in distress, practiced medicine in the best scientific manner at the same time with a humane and philosophical touch. I can’t forget, how the little genius standing beside the comatose patients In IMCU and tells so precisely the difference between metabolic vs structural coma without even asking for a CT or MRI scan.(We learned with awe, for the first time, how hyponatremia can cause havoc to the brain)  I have seen him so tired in many days and sleeping in the ward chair for a few minutes and comes back fresh for the rounds. He used to say sleep is a luxury in our profession. What a statement to make for our generation next.

His favorite quotes are from William Osler and ask us to read the life history Harvey Cushings. He encouraged us, to learn the history of medicine. He was so emphatic to say “Unless we know how our past physicians toiled with their astuteness and hard work, we will not understand the value of clinical medicine”

 

One of the pure souls who showed us what is the true meaning of teaching, learning, and caring. Got this small clip, wherein he continues to wish us good.

Let his legacy live forever. 

 

 

 

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Got it? One clue, you are part of these numbers! It crossed  5 million reads recently across 160 countries. Thanks. I know,It amounts to self-promotion. Such boosters are required when energy level sags. Sorry.

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Truely a great demonstration of life saving Mitra clip procedure.

Found this from

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Can a bedside echocardiogram help rule out STEMI in patients with suspicious ECG?

No, it can’t  (Though, it may be tempting to use a rapid echo to look for wall motion defect to rule out ACS ) 

If your answer is No, probably you don’t need to read any further in this post.

Diagnosis of STEMI* is based on

  1. Clinical
  2. ECG
  3. Bio-Markers

*Please note, two of the most popular investigations namely Echo and Coronary angiogram are missing in the list.

A middle-aged man with  chest pain.  Can an echocardiogram help you confirm  STEMI here? Most likely not. It may still be an evolving STEMI. But, observation, serial ECGs, and Troponin is the answer. (ECG -Source http://www.emdocs.net/hyperacute-t-waves/ )

Though, echocardiography, a great noninvasive imaging tool at the point of care, it stands almost helpless in the diagnosis of the commonest cardiac emergency ie ACS. It can be called as mother of all paradox even visualizing the myocardium directly with high-quality imaging will not tell you, whether there is ongoing ACS or not. 

Relying on wall motion defects without diagnostic ECG changes to diagnose STEMI  can be misleading for the simple reason, both unstable angina and old MI can be a 100 % confounding effect. Similarly, absence of WMA doesn’t rule out an evolving STEM(Apart from the bizarre behavior of   Ischemic cascade,  In the early hours only subendocardial wall stress is noted, that is not good enough to cause visible WMA)

Role of CAG in the diagnosis of STEMI

Urgent CAG is an easy way out in confusing coronary conundrums. But, unless you know the background info even a CTO can be mistaken for ATO/ STEMI . So it is essentially new ST/T  shifts (corroborated with CAG) will be the guiding force. 

Final message 

The humble Clinical examination and ECG will prevail over all other modalities in the diagnosis of ACS. Mind you, ECG findings are built within the diagnosis of myocardial infarction ie STEMI (ST-segment) so can’t diagnose it with  Echo. Further, an indication of thrombolysis or PCI goes with ECG finding only.

Counterpoint

*Having said that, there is a key role for echocardiography in the ER to diagnose alternate cardiac emergencies like Aortic dissection, Acute pulmonary embolism or ACS mimickers like HOCM, etc. Further, echocardiography is used in a big way,  in the risk stratification or identifying complication during the ACS management.

Exceptions

In patients with atypical presentations, pacemaker rhythms, LBBB, especially elderly, comorbid, ECG can be quiet normal or non-diagnostic. Here, echo and angiogram may have some adjunct diagnostic roles.

What about newer echo Imaging modalities?

** There has been a suggestion, that regression of Global longitudinal strain(GLS) or new-onset regional loss of myocardial strain, detected by speckle tracked echo is a powerful and the earliest sign of myocardial ischemia.

A potential tool to rule out ACS by Echo -Global /Regional longitudinal strain (GLS) still trailing behind ECG.

 

GLS is proposed to be used in coronary units to rule out ACS. In spite of its Initial promise, we understand it has not been accurate enough to be included as criteria to diagnose ACS . So, as of now, it appears unlikely for echo criteria to be included in the  diagnose of STEMI.

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Who is a doctor?  Where are they made?

I haven’t clearly understood the true meaning of customary Dr tag, my name carries for more than 3 decades, till I saw this. Wish, this video is played to all young medical students on their graduation day.

             I am realizing with guilt, it requires a Holywood movie buff to remind us the true meaning of the famous WHO – definition of Health, done in the most holistic fashion in the year 1948. 

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

So, technically, whoever serves to improve these three components and alleviate human suffering becomes a doctor. 

Happy to share this on July 1st, the official Doctor’s day in India in memory of the Bharat Ratna Dr.B.C.Roy of Bengal. 

Reference

The clip is from the movie Patch Adams, Directed by Tom Shadyac.  A Hollywood celebrity movie maker, Virginian professor of communication turned philanthropist, now retired to a minimalist life. He is also known for his famous documentary I am that talks about the problems faced by the world. Though his works are much appreciated, I  must say, they are underrated. Deserves more than an Oscar for communicating his thoughts on the medical profession perfectly and for social equality.

 

 

 

 

 

 

 

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