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 Cardiology - Clinical, pericardial disease, Uncategorized | Tagged constrictive pericarditis, constrictive vs restrictive cardiomyopathy, mayo clinic reviewconstrictive pericarditis | Leave a Comment »
Coronary collateral circulation is probably the most poorly understood circulation than any other.This is ignorance at it’s best , in spite of the life saving potential of this circulation. A popular (mis )perception is coronary collaterals can support only resting blood flow and it would struggle to compensate at times of exertion. This is based on few case studies and not based on large , authentic scientific data.
Does this reasoning mean , coronary collaterals can never / ever be complete ?
If we believe so . . .we are grossly underestimating the power of nature .(In fact , mankind was humiliated by the nature time and again !)
Lessons from a unique patient we have encountered.
Here is an example of total LAD/LCX occlusion with good collateral from RCA. He was having stable angina on medical management . This patient was not only asymptomatic and was also negative for exercise stress test at moderate work load .
There was an intense debate about the management when this angiogram was presented in the cath meeting .
Any answers . . .
He ultimately went on to receive CABG (By popular opinion ) , but the point here is the collaterals were good enough to support exertion.We have documented quiet a few similar patients with collateral circulation supporting exercise.
What happened to the collaterals and (of course ) the patient after surgery ?
I will post you the curious story soon . . .
Final message
Coronary collateral circulation , if well developed can provide hemo-dynamically useful support even at times of exertion *
* The existing literature is biased against this concept. It generalizes all grades of collaterals into a single entity. It is better if we spend more time to understand the nuances of coronary collateral circulation .
This is the message from our observation. Do not ever believe whatever is published as facts in scientific literature. Observe, analyse , create your own inference , and concepts. Mainstream cardiologists would brand it unscientific , Simply ignore it . Many times it is rewarding to our patients.
Posted in cardiac surgery, Cardiology -Interventional -PCI, cardiology -Therapeutics, Infrequently asked questions in cardiology (iFAQs) | Tagged chronic total occlusion, coronary collateral circulation, idoe coronary collaterals support exertion, importance of coronary circualtion | 9 Comments »
It is often said optimism is key to success . From the patient’s and physician’s perspective it is the willpower that has saved many lives. Positive minded patients do not die without fighting. We know self belief can do wonders in medical care !
If self belief is the ultimate healer , trusting the doctor and the hospital are equally important . Patients believe in doctors and doctors believe in science . Science is not sacred .It is man-made .Those men who create science need not be holy either !
Can we trust modern medicine in the current form ?
I am afraid the answer is too tilted towards . . . “No” I am not a pessimist in the strict sense . However , the future looks bleak in most places ! unless some strong remedial measures are under taken.
Statistics suggest , patients are rapidly losing the belief in their physicians , considering the track record of our health care management in recent times . Global trends in the last 5 decades indicate the health care delivery system has gradually been hijacked from the Govt to the private hands.
It is quiet a shocking revelation , the private sector health care has done more damage than the state driven health care . How foolish our expectation can be ! For fulfilling the millennium goal ( Health for all ) most countries have handed over the baton to the greedy corporates .
How on earth , one can expect the private / corporate sector to provide equitable health for all . It would be wealth for all those involved in this flawed medical care system at the cost of poor !
Read this book . . .To understand the nuances of how our health care industry is bulldozing , like an army tank into the population and most of us is a victim or a partner to this .
Click here for the Book review
From The Hindu January 2011
Final message
Entry of capitalism into health sector is probably the worst infliction man kind has suffered , than all those deadly viruses and bacteria over a last few centuries !
Medical science is a phenomenal gift created , nurtured and grown by the sixth sense of our ancestors .Their only aim was to provide relief to the sufferings. Now their dreams, vision and goals lie shattered .
No hospital has a specialty called “humane care” , while many have a separate department to do a neuro metabolic imaging for a depressed man with Alzheimer disease in his nineties and a Bio – Robot driven fuzzy logic lab to predict cardiac events in a soon to die rich man . Absolute waste of resources !
There is no doubt , we have become a sort of salves to science . . . (Irrational science to be precise ! ) It is a man-made monster. Even a most conservative person (including the author ) could be causing some damage as we are forced to follow the unruly scientific publications . Probably . . .yes . . . we can’t eliminate it but identify futility of modern science try to get rid of it . !
A related article
Those were the days . . . When doctors practiced medicine . . .and much more . . .
A wonderful piece of writing by Dr Susikaran Thangasamy from the open pages of India’s national newspaper
‘The Hindu” http://www.thehindu.com/opinion/open-page/article1137935.ece
What is the remedy ?
First of all , every one should answer this question to their conscience
What ails our health care system today ?
Do not be part of it . . . solutions will come automatically !
Posted in bio ethics, medical quotes | Tagged aggressive medicine, arrogant science, conservative management, evidence based medicine, health care, hippocrates, humane care, medical ethics, medical science, modern health care, randomised controlled trial, what ails medical care, why patients suffer | 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 cardiac surgery, Cardiology - Clinical, cardiology-Anatomy, Uncategorized | Tagged coroanry anatomy, left main, trifurcation and quadrification | Leave a Comment »
Life cycle of PTCA : Let us hope it do not become extinct !
Does PTCA , a great Innovation for mankind, is facing a threat of extinction ?
It seems so . . . the stents are losing its shine in most situations. A simple evidence . . . for that . . . can be found in answering the following question
What drives the extensive research in biodegradable stents now ?
The simple answer is , we are fed up with the metals inside the coronary artery. We want to get rid of it !
Too much of knowledge , often blunts our senses . Our track record clearly reveals this fact. We needed a major study INTERHEART to tell the world that ,exercise is good and tobacco is bad for heart ! Now ,we forgot a simplest solution for getting rid of metal inside the coronary artery , which is “not to implant the stent” at all ! (Instead we do billion dollar research for making bio – absorbable stents , which in the first place may not be required in the majority !
Read the related article . Does POBA has a role now ? in my site
The only situation , where PCI may withstand the test of time could be in ACS (Both in STEMI and high risk NSTEMI !) PCI is cosmetic in most of the chronic coronary syndromes .
Final message
Our fight against human atherosclerosis will have to be , by medical means .PCI at best will provide a supportive role in selected patient group. It requires lots of common sense and scientific ignorance to achieve this. Risk reduction , prevention , optimal medical therapy will have to play a dominant role in the next few decades . This is something similar to the environmental issues we face in protecting our planet .No amount of green industry will protect the earth . It requires better social and behavioral ethics from mankind and their rulers !
Posted in bio ethics, Cardiology -Interventional -PCI, cardiology -Therapeutics | Tagged pci, poba, ptca, stents | 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 Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology-Anatomy, Uncategorized | Tagged left main coronary artery, ramus intermedius, true trifurcation | Leave a Comment »
Few web sites provide free cardiology service. This one from cardiomath beats all ! It makes the job easier for all those cardiologists who spend lots of time in echo lab . It provides simple online tool for all common calculations in clinical echocardiography
Here is the link to the website of cardiomath
With due Courtesy to
Author: Dr. Chi-Ming Chow Developer: Edward Brawer Illustrator: Ellen Ho
Sponsored by Canadian society of echocardiography
Posted in echocardiography | Tagged best web site for echocardiography, canadian society of echocardiography, cardiomath, echocardiography, mitral valve orifice, myocardial performance index, pisa mitral, stress tests | Leave a Comment »
Nothing in this world is black and white. In fact, most events are in between . The irony is , our brain always wants to view things in two distinct entities !
So it is no surprise ! cardiologists also travel in the same boat !
They classified the events after thrombolysis into two dogmatic categories . Successful thrombolysis or failed thrombolysis . . . as if no other event can occur in between .
Traditionally 50% regression of ST segment is called successful . What about 30% and 40 % ST regression ?
Further , there is an important caveat in the timing, as we traditionally assess , 90 minutes of thrombolysis .
Consider the following situation :
So, without finding answers to some critical questions , we have defined the success of thrombolysis with half baked data .
This is exactly , is the reason we are unable to do a valid study on failed thrombolysis, rescue PCI etc . We know the results of rescue PCI , always been contradictory to the general logic !
It is estimated a substantial number of STEMI patients following thrombolysis fall into a category of partially successful thrombolysis implying partial restoration of blood flow and salvage. The correct definition for successful thrombolysis and reperfusion should be at the myocardial mass level , and not at the level of coronary artery.The ECG is the best available indicator.
Implication for having a poor definition of failed thrombolysis
It is not a rare sight to wheel in , a patient to a cath lab with label of failed thrombolysis dangling in his neck who is clinically stable (Has a less than required 50% ST regression , but a definite, favorable trend with a 30 % ST regression at 90 minutes )
How many cardiologists will be willing to abort a CAG/PCI , as a repeat ECG just before puncturing in the cath lab reveals successful thrombolysis ? (little delayed though !)
If only we have better methods to risk stratify patients following thrombolysis , we can avoid
Final message
Classifying thrombolyis into success or failure is a skewed way of looking at this important issue .
It is an irony , cardiologists often triage LV dysfunction , valve disease , cardiac failure etc into 4 grades ( minimal , mild , moderate or severe ) . It is still a mystery , why thrombolysis is never graded like that , and it is always considered as all or none phenomenon !
There is a substantial number of patients with partially successful ( or shall we call partially failed !) thrombolyis .This group must be given adequate attention or inattention . There is a urgent need for a through review of how we look at the post thrombolysis status . It is better to use the newer imaging modalities like PET/MRI more liberally to identify exact sub group of failed thrombolysis who will benefit form revascularisation .
Posted in Cardiology - Clinical, cardiology -ECG, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology-ethics | Tagged failed thrombolysis, successful thrombolysis | 1 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 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 | Leave a Comment »
Manuals are not only for doctors . There are few heart maintenance manuals for patients as well.
This one from Philadelphia , is worth reading and of-course following thereafter !
Posted in Best books in cardiology, Cardiology - Clinical | Tagged BARI 2D, courage study, heart repair manual, MASS 2 study, medcial vs pci, pci stent, zerbini foundation mass 2 study | 1 Comment »
Dr.S.Venkatesan MD 
