Posted in Echo library and gallery, echocardiography, Uncategorized, tagged diastolic dysfunction video, super normal diastolic dysfunction, tissue doppler in diastolic dysfunction on February 8, 2011| Leave a Comment »
We have thousands of medical videos.When I stumbled upon this one ,from you tube which I thought will be immensely useful and is crisply made.
It proposes a 5 simple rules to diagnose diastolic dysfunction .There is also a new concept* discussed in this video .
* What is super normal diastolic function ? How can it be mis- interpreted as a pathological ?
Over to the video clip from (123sonography 0
http://www.youtube.com/watch?v=qdLkbcFe_DI&feature=related
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, Uncategorized, tagged contraindication for doing coroanry angiogram, coronary angiogram, drug eluting stent, ectasia, guidelines for doing coronary angiogram, indications for coronary angiogram, pci, ptca, reporting a coronary angiogram, stents on February 6, 2011| Leave a Comment »
Coronary angiogram is probably the commonest invasive cardiac investigation done world wide. It should run into millions every year. The procedure once thought dangerous is now performed in few minutes in day care centers . While doing a coronary angiogram has become a minuscule task to most cardiologists, interpreting it correctly remains a huge task !
Many of the young cardiologists get fascinated in doing a coronary angiogram and hardly spend enough time and mind in interpreting it.
Most of us succumb to the popular occulo coronary reflex and describe a coronary artery lesions as though it is a number game . It is very rarely we use the quantitative angiography tools available in the machine. We need to meticulously analyse the length , morphology , distal flow, thrombus , collaterals etc . (FFR a new avatar tries to do some justice )
Calling atherosclerois by numbers alone, such as 50 % LAD and 70 % diagonal 20 % left main is a huge insult to the deadly & diffuse disease process of atherosclerosis .We are paying the penalty for it .This is the fundamental flaw in our reporting , that makes every coronary intervention redundant.We must first remember we are looking at the lumen not the wall of coronary artery.
Coronary interventions is not about removing obstructions but regression of atherosclerosis load within the coronary artery , prevent progression of it and ultimately reduced cardiac events and improve survival. It is obvious, it can not be achieved by wires and catheters alone . At best they can be adjuncts.One can easily understand why medical therapy scores over wires as it can take care of the overall disease process.
But still , most* of the learned cardiology community considers medical therapy to be an adjunct to coronary intervention , which is a gross ignorance at it’s best !
* This is my perception. If I am proven wrong , I am happy our patients will be benefited !
Final message
Do not reduce the importance of coronary angiogram to a farce number game !
Do not get excited by visualizing your patient’s coronary artery. It may make you richer by few thousands. Realise , what you are seeing in a CAG is a fraction of coronary circulation.
It is estimated coronary circulation we visualize daily in cath lab as epicardial coronary arteries is less than 2 % of entire cross section of coronary circulation.
This means we are 98 % blind ! ( or 2 % wise !) .Spend adequate time and mind to interpret it correctly , so that logical and useful ( non ) interventions can be done .This only can make you a true cardiac professional and your patients will respect you.
//
Posted in Uncategorized, tagged healthy heart syndrome, modern medicine, prevention is better than cure, when prevention becomes a disease on February 5, 2011| Leave a Comment »
Healthy heart syndrome (HHS) . This is essentially a state of mind , being in constant worry that something will happen to their heart , in spite of having normal parameters.
HHS is a new age medical entity of the mankind . Here the heart suffers because of excessive knowledge , affluence and entry of market forces into health care .
Final message : Let us suffer from disease not from health !
While , many patients with multiple blocks , bye -pass surgeries and half- functioning hearts , lead a near normal life , it is ironical , a substantial number suffer with HHS and inappropriate interventions .
Let us hope , modern medicine which goes deep into Nano medicines and bio Robotics look into this issue also !
Posted in Cardiology - Clinical, pericardial disease, Uncategorized, tagged constrictive pericarditis, constrictive vs restrictive cardiomyopathy, mayo clinic reviewconstrictive pericarditis on February 4, 2011| Leave a Comment »
A must read for all clinical cardiologists and fellows . A comprehensive review on pericardial diseases.
It also highlights a new diagnostic parameter in cath lab to differentiate constrictive pericarditis from restrictive cardiomyopathy .The area subtended by RV pressure curve and LV pressure curve moves discordantly in constrictive pericarditis while it moves concordantly in restrictive cardiomyopathy
Source : Mayo Clin Proc. 2010;85(6):572-593
Posted in cardiac surgery, Cardiology - Clinical, cardiology-Anatomy, Uncategorized, tagged coroanry anatomy, left main, trifurcation and quadrification on January 30, 2011| Leave a Comment »
Left main divides into two. Some times into three . Very rarely into 4
Look at this angiogram , This looks like a quadrification, if not quadrification equivalent
Clinical implication
A 4 way division invariably means the OM and diagonal or going to be diminutive.These people are expected to have favorable coronary hemodynamics during ACS , and left main lesions are less likely to occur
Reference
This article is from Singapore medical Journal
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology-Anatomy, Uncategorized, tagged left main coronary artery, ramus intermedius, true trifurcation on January 28, 2011| Leave a Comment »
God creates life with infinite variation . The heart gets bulk of its blood supply from the left coronary artery , which divides into two after a short course. Bifurcation is the rule . Left main becomes left circumflex and LAD in about in 85-90 %.
Note the left main divides into 3 equal caliber vessels.very lucky to have such a branching pattern !Distal left main is unloaded by three large ostia . This makes stasis of blood in left main very unlikely . LAO caudal view
Note : The OMs are small in these people. RAO caudal view
Few men and women are blessed with three branches from LCA . The anatomical and physiological importance of this branching pattern is not well analysed in the literature .There could be few advantages of having a trifurcation instead of bifurcation .
Disadvantage of trifurcation !
* A related blog elsewhere in my site . The explanations offered above are based on personal observation .
Posted in Uncategorized, tagged abnormal coronary artery origin, absent leftmain, anomalous coronary artery, coronary angiogram, lad and lcx, lcx from right sinus, left anterior descending artery, left circumflex artery, left main artery, rare coronary angiograms, split left main on January 26, 2011| Leave a Comment »
Is it not , boring to see normal coronary arteries every day ! There need to be surprises in cath lab to make our time lively and keep our brain alert . Have a look at this angiogram in RAO caudal view.One of our junior cardiology fellows thought it was a split left main artery .
How can an artery split . . .of course the image indeed looks like that !
It was indeed an absent left main. Also called as separate origin of LAD and RCA.
Note : There can be three types of absent left main.
* Some books mention about a left main of 0 -5mm .
** Very difficult to delineate and is rare
Zero mm left main is nothing but single ostial origin of both LAD and LCX. A very short left main , say 1 0r 2 mm will practically mimic an absent left main.
Here is the the dynamic angio image. It is surprising how a catheter in left sinus is able to visualise the LCX from right sinus so well !
Note the separate origin of LAD and LCX.The LCX was originating near the right sinus.It is intriguing to note even though they originate in different sinuses , the main stem of LAD and LCX wants to maintain a close parallel relation.
Advantages of having absent left main .
Implications for interventional cardiologists
Guiding catheter selection and positioning could be difficult.
Posted in Cardiology - Electrophysiology -Pacemaker, cardiology -ECG, great illustrations in cardiology, history of cardiology, Uncategorized, tagged atrial pacing through esophagus, emergency temporary pacing, medtronic transesophageal lead, oesophageal pacing, over drive pacing through esophagus, pacing electrode within ryles tube, pacing the esophagus, pacing threshold in esophageal pacing, pacing via nasopharnynx, sinus braducardia, temporary pacing through esophagus on January 20, 2011| Leave a Comment »
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.
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*
* 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
Posted in Cardiology - Clinical, Cardiology - Electrophysiology -Pacemaker, tagged aai mode, can single cahmber pacemaker be physiological, david study, dual chamber pacing, floating atrial sensing lead, medtronic, mode switching, non physiologcal pacing, pacing modes in sick sinus syndrome, pathologicalpacing, physiological pacing, rate adaptive pacemakers, single vs dual chamber pacing, sinus node dysfunction, st judes, triple cahmber pacing, vdd mode, vvi mode, wahat is a physiological pacemaker on January 18, 2011| Leave a Comment »
In pacemaker science , any pacemaker that maintains AV synchrony is often referred to as physiological pacemaker. This is of course , a wrong reasoning .None of the pacemakers available today can be claimed to be completely physiological .All pacemakers which paces the right ventricle induces IVS dysynchrony (Including the modern DDD)
Single chamber physiological pacing
AAI
Paradoxically , the most primitive of pacemakers AAI can be the near perfect physiological pacemaker . The simple explanation is , In AAI mode , expect for the origin of pacemaker impulse the entire depolarisation and repolarisation is through the normally existing physiological conducting system .(AV node, HIS, Purkinje etc)
(It not only has atrio ventricular synchrony but also has ventriculo ventricular and intra ventricular synchrony )
So, technically AAIR is most physiological pacemaker possible .But the practical utility of such a pacemaker is limited.It can be used only in isolated sinus node dysfunction with intact AV conduction . (The problem is the AV nodal conduction can develop later ) To over come this DDDR pacemaker can be programmed to AAIR as a default mode.
VVIR
This rate adaptive pacemaker , to a certain extent can be termed physiological as the heart rate can improve with exercise . (Still it is unphysiological as it paces the RV )
VVD
This is based on the concept , for pacing to be physiological , it requires atria to be at least sensed not necessarily paced.This mode which has a floating sensor attached to the lead as it crosses the atria.This facilitates atrial sensed ventricular pacing .But many believe the atrial sensing is not consistent in VDD mode.Currently this mode is not popular.There is scope for improving the atrial sensor technology .
Dual chamber physiological pacing
DDD, DDRR
Both these are the prototype dual chamber physiological pacing modes.
Bi-Ventricular or triple chamber pacing ( one atria two ventricle) are our elusive answers for attaining perfect physiological pacing . it need to be realized, we simply , can not mimic the natural cardiac conduction system.It is estimated to be more than 10 miles long specialized fibers .
Final message
In our quest for physiological pacemaker we often forget the fact , AAI is the most physiological pacemaker mode available .(It even has VV synchrony ! )
We should use it liberally whenever possible .Of course ,we cannot use it in complete heart block .Still 50 % the permanent pacemaker we implant is for sinus node dysfunction. Many of them could be candidates for AAI mode .If current generation cardiac physicians feel out dated to insert a AAI pacemaker, at the least they should program the DDDR into AAI mode with a mode switching to ventricular pacing modes whenever required.
In spite of all advantages , why atrial based pacemakers are not gaining popularity ?
Dr.S.Venkatesan MD 
TRANSFER-AMI study : Transfer with caution . . . bumpy roads ahead !
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology journal club, cardiology journals, Uncategorized, tagged comments about transfer ami, facilitated pci, FAILED THROMOLYSIS, journal watch transer ami, letters to the editor transfer ami, nejm transfer ami, REACT STUDY, rescue pci, routine early pci, stemi, tenecteplase failure, time window for pulmoanry thromolysis, TRANSFER -AMI STUDY on January 14, 2011| Leave a Comment »
Preamble
The much published TRANSFER -AMI study has few important queries to ponder about.It was supposed to test the role of routine PCI following thrombolysis. In other words it compared rescue only strategy with routine strategy.The caveat is , even among failed thrombolysis, the rescue strategy has not convincingly proven superior to medical management (if the time is lapsed ) as much of the damage is done .
Will the investigators share their experience ?
Finally
Why the title of the paper says it is about “Routine angioplasty” and the conclusion emphasizes it is indeed “high risk subsets ofangioplasty” (While the study itself involves a 92 % least risk Killip class 1 ) . Why this double dose of confusion ? (Is it deliberate ! Which i think is unlikely )
NEJM please take note of this . . .
All that glitters are not natural glitter . . .some are made to glitter !
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