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One of the greatest physicians of all time, I have come across , is my professor Dr.T.K.Ganesan from Coimbatore medical college.
A man who taught medicine to generations of doctors.During those years (1980-1990) learning medicine was simple and also not contaminated with commerce . Dr TKG made it so lively .He infused passion in the subject.
Myself and Dr K.A.Sambasivam (Son in law of DrTKG at his residence in Coimbatore )
* Dr K.A .Sambasivam was my class mate during both my under and post graduation . He is now a senior Interventional cardiologist in GKNM Hospital Coimbatore .
This post will be updated.
Posted in dr s venkatesan -Personal | Tagged coimbatore medical college, dr s venkatesan, dr t k ganesan, professor t.k ganesan | 1 Comment »
A.Blood
B.Oxygen
C.Glucose
D.High energy ATPs
E.Free fatty acid
Answer : A will be considered by most , as correct answer . A can provide B to E . But it is also a fact heart can survive without A.
Myocardium requires energy first ! it does not in fact bother about from where it is coming at the time of crises.It may be right if you restore the coronary blood flow all other components (B-E) are made available to the heart .
The heart can survive off the coronary circulation with only chemical support during cardiac surgery and also a during heart transplantation explanted donor heart survives on a ice box during transit and till it is transplanted into the recipient heart
But ironically we spend much of our energy and efforts in restoring blood flow.One need to spare a thought about the quality of blood also . This is especially important in the setting of ischmia where a metabolic centric approach will add further benefit.
Heart is a fascinating mechano biological organ pumping millions of gallons of blood .Fuel for this is self generated on a continuous basis from the circulation blood .So the key to human survival is the coronary blood flow that supplies the fuel and nutrients to the heart. When this key supply line is under threat during acute coronary syndrome cardiologist have the only option of restoring the compromised blood supply by any means . But during chronic ischemia there is no urgency. There has always been an option of enriching the blood with energisers like ATPs, glucose, hemoglobin etc .Providing energy support to the failing heart has never captured the imagination of cardiac physicians until recently.Still most are skeptical about the concept of biochemical ischemia.
Click to download full PPT presentation
Metabolic manipulation of CAD( Will be available shortly)
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Infrequently asked questions in cardiology (iFAQs) | Tagged acs, angina, atp, biochemical ischemia, cardiac failure, chronic stable angina, coronary, fatty acid, glucose, ischemia, ketoacid, metabolic modulation, mitochondrial energetics, myocardial energetics, ranalozine, trimetazidine, unstable angina | Leave a Comment »
Humans have roughly 5 to 6 liters of blood at any given time in their body . Out of this*
50% (2500ml) is located in the systemic venous compartment. 18% is within the pulmonary circulation participating in the vital oxygenation 12% (500-600ml) is within the cardiac chambers. 8% is in the arterial tree of the body. 5% is within the capillaries. 2% is in the aorta.Autonomic dysfunction and resultant orthostatic hypotension is directly related to venous reservoir dysfunction.Increasing effective circulatory volume by elastic stockings or administration of mineralocorticosteroids like fludrocortisone (.5mg/day ) can be useful in this condition
Posted in Cardiology - Clinical, cardiology -Therapeutics, Infrequently asked questions in cardiology (iFAQs) | Tagged autonomic dysfunction, blood volume, bmj, capillary, cardiac output, cardiology, drsvenkatesan, effective circulatory volume, fludrocortisone, heart, Hemodynamics, lnacet, lvedp, nejm, ortho static hypotension, pcwp, physiology of circulation, pulmonary edema, syncope, venous circulation, venous insufficiency, venous pooling | Leave a Comment »
Glucose is the molecule of life ,burnt every second inside the body at the energy store house called mitochondria. Heart , the most active organ in the body gets bulk of it’s energy supply from fatty acids, glucose and a little from keto acids. Under anerobic conditions this energy substrates shifts towards glucose .
We are rarely inclined to think that heart can ever suffer from hypoglycemia ! But hypoglycemia can have distinct direct and indirect effects on heart. In fact indirect effects due to activation of adrenergic activation is more obvious.An episode of hypoglycemia can precipitate an arrhythmia . Glucose potassium insulin infusion
Hypoglycemia , can be a trigger of ACS .This aspect is poorly recognised and studied.
Posted in Cardiology - Clinical, cardiology- coronary care, Infrequently asked questions in cardiology (iFAQs) | Tagged acs, acute coronary syndrome, angina, cardiac arrhythmias, cardiology, diabetes mellites, drsvenkatesan, hypoglycemia, jama, lancet, nejm, tiggers | 1 Comment »
Atrial fibrillation is relatively a benign arrhythmia especially when it occurs in isolation with structurally normal heart.This is sometimes referred to lone atrial fibrillation . Even otherwise, atrial fibrillation is rarely fatal except in few situations.But AF commonly destabilises the patient who have baseline valvular or myocardial disease.(Post MI, dilated cardiomyopathy etc)
There are few situations where AF can be life threatening
While atrial fibrillation is less likely to cause death , it is a highly morbid arrhythmia .It is one of important cause of stroke in elderly as well as young !
Posted in Cardiology - Electrophysiology -Pacemaker, Infrequently asked questions in cardiology (iFAQs) | Tagged atrial fibrillation, cardiac arrhythmia, cardiology, drsvenkatesan, ECG, electro physiology, heart rhythm, nejm, pace, ventricular fibrillation | 1 Comment »
Usually in the the vascular system both artery and vein go together .It is an irony in pulmonary circualtion these two never go together .Another paradox is that pulmonary artery carries the most deoxygenated blood and pulmonary vien carries the purest form of blood in the entrie body , probably God has kept them widely seperated as communication between them seriously affect the physiology.
Posted in cardiology-Anatomy, Infrequently asked questions in cardiology (iFAQs) | Tagged pulmonary artery, pulmonary vein | Leave a Comment »
Ventricular tachycardia is considered as one of the most dangerous cardiac arrhythmia .Rather , it is the label VT that spreads more fear than the arrhythmia itself. It is a fact many patients with VT walk into hospital , still VT will always be a sinister arrhythmia as long as it carries a risk of degenerating into ventricular fibrillation.
VTs originating high up in the ventricle( High septal VT,Proximal VTs) have more organised ventricular contraction and they are more stable.Distal VT originating in the myocardium away from the conducting system has chaotic myocyte to myocyte conduction.These are very unstable.
The term fascicular VT is nothing but VTs originating in the His bundle and it’s branches( Can also be termed Septal VT ).These VTs are also stable and some of them respond well to calcium blockers indicating that they are very close to the AV junction and carry the properties of junctional tachycardia. QRS width gives a rough estimate about the location of VT. Narrower the VT higher it’s origin.( But remember even in VT , qrs can further widen on it’s way downhill !)
This is probably the most important determinant of the outcome in VT. Patients with severe LV dysfunction (EF <30%) fare badly .Hence the land mark concepts from MADIT 1& 2 demanded ICDs in these patients.The most common clinical setting is dilated cardiomyopathy.SomE of them have bundle branch re entry(BBR).This particular VT can be stable for many hours.
Usually VT has a rate between 120-200.Higher the rate of VT more the chances of instability .This rule is also not always true as fascicular VT can be well tolerated at high rates.So location of VT focus and LV dysfunction usually over rides the impact of ventricular rate.
Proper left ventricular filling is the key to hemodynamic stability in VT. In proximal, septal,fascicular, LVOT VTs doppler studies suggest (ACC /AHA Type C evidence : Personal observations in CCU during VT) near normal preservation of bi modal filling of mitral valve inflow.In ischemic myocardial VT the mitral inflow profile is critically affected . There is no distinctive forward filling was observed .In fact at rapid rates a short pulsatile MR jets are noted instead.
It is obvious, aortic and mitral valve disorders can aggravate the hemodyanmic instability.
The clinical behavior of ventricular tachycardia is widely variable and dependent on multiple factors.
Associated LV dysfunction and structural heart disease ultimately determine the outcome.
Posted in Cardiology - Electrophysiology -Pacemaker, cardiology- coronary care, Infrequently asked questions in cardiology (iFAQs) | Tagged bmj, fasicular tachycardia, heart rhythm, Hemodynamics, ischemic vt, jama, lancet, lvot vt, myocardial VT, nrjm, pace, ventricular tachycardia, verapamil sensitive vt | Leave a Comment »
Even as cardiology community is preoccupied with systemic hypertension & CAD , pulmonary arterial hypertension(PAH) is a much neglected , still an important clinical cardiac problem encountered . The irony is self evident , there are half a dozen methods to grade systemic hypertension not even a single stadardised grading available for pulmonary arterial hypertension. The WHO working group defined pulmonary hypertension few decades ago and was not clinically graded .The only grading available is based on the pulmonary vascular biopsy changes (Heath Edwards)
Currently PAH management has gone through revolutionary changes. There is an urgent need for grading this entity .This will facilitate to diagnose , manage and assess the efficacy of the currently available treatment.
Developing countries like ours have a great number of PAH due to rampant rheumatic heart disease. A simple study was done in 100 patients with PAH .Bulk of the study population had RHD .Few had primary pulmonary hypertension .Systolic , diastolic, and mean pressure was assessed by doppler echocardiographic analysis of tricuspid regurgitation (TR) and pulmonary regurgitaion(PR) jets. TR jet provided the systolic PA pressure , PR jet provided mean as well as diastolic PA pressure .TR jet was available in all patients. PR jet was available only in 60 patients .Hence the diastolic andmean PA pressure data has been extrapolated in some and was plotted in a scatter diagram. Five equal quintiles were divided. Patients in first and 2nd quintiles were graded 1 and third and 4th quintile were graded 2 , 5 th was graded 3 respectively. From this cut off points for various grades of PAH were identified .The top 3% of patients with highest PAP were graded as grade 4 and all of them had supra systemic PAH.
*This is a preliminary attempt to grade PAH. This could be applicable mainly in rheumatic heart disese and primary pulmonary hypertension .Further refining of methodology is required.PAH grading may be little different in congenital left to right shunts.
Posted in Cardiology - Clinical, Infrequently asked questions in cardiology (iFAQs) | Tagged annals of internal medicine, bmj, cardiology, chest, drsvenkatesans, eisenmenger, grading of pah, grading of pulmonary hypertension, jama, lancet, lungs, mitral stenosis, nejm, pah, pulmonary arterial hypertension, pulmonary hypertension, rabinovitch, rubin | 1 Comment »
By definition palpitation is abnormal awareness of ones own heart beat. Heart is a mechanical organ with multiple mobile anatomical structures. There is constant blood flow in multiple directions . Apart from this the heart has it’s unique translational, rotational movement . These intrinsic movements combined with proximity to chest wall generate vibratory motion signals .These signals are generally dampened by the encircling pericardial space .The neural signals responsible for perception of palpitation is not clear. If the heart hits against the chest wall it is the somatic nerves from the chest wall that carries the signal. Vibrations generated within the heart chambers, and and the valves are carried by the myocardial and intravascular sensors.( Autonomic) * Mitral valve prolapse, a very benign condition, over diagnosed in the last few decades raised considerable anxiety and palpitations for the patients (mainly after the diagnosis ! ).Now the cardiology community has sought to underplay this entity with strict diagnostic criteria.( Thickened mitral leaflet ,presence of MR both must be present to label a patient as MVPS)
“Patients with dilated cardiomyopathy or CHF rarely feel their heart beat during exertion , instead they have dyspnea as the LV force of contraction is less”
Posted in Cardiology - Clinical, Tutorial in clinical cardiology | Tagged anxiety state, asd, bmj, bradycardia, cardiology, clincal cardiology, drsvenkatesan, hyper kinetic circulation, lancet, nejm, palpitation, Tachycardia | Leave a Comment »
Dr.S.Venkatesan MD 
