Aorto ostial stenting requires extra caution and special technique. It always worry us what if few mm of metal might project into Aorta when we stent a RCA or left main ostium.
To prevent this ,Merit- medical has innovated a catheter that help us position the stent exactly at the ostial level .It is done with a help of an octopus like buttressing arm that support the aortic wall when the stent is deployed .
Watch the video.
Reference
Posted in Cardiology -Interventional -PCI, Cardiology -Therapeutic dilemma, Cardiology -unresolved questions | Tagged aorto ostial lesion, aorto ostial stenting, coronary ostial stenting, merit medical ostio pro stent system, ostial dissection in rca, ostio pro coronary stent system, proximal left main disease, rca stent projecting to aorta, stent, stent lost in aortic root, stent migration, stent projection in aortic root, stenting, tips and tricks cath lab left main stenting, tips for aorto ostial stenting | 1 Comment »
Mohandas Karam Chand Gandhi , father of my country , India , made these observations in year 1925 about the fundamental constituents of violence in society . These words of monumental wisdom came when he was addressing young Indians in a country- side rally .
Note, his finger points to , what exactly is relevant to our profession ! He emphasized this nearly 100 years ago, when medical science was at its infancy .One can only guess what would be Mahatma’s comment about our profession in it’s current form !
Should we include moral, behavioral and ethical classes right from the first year of medical school along with Anatomy , physiology and bio chemistry.Medical council of India obviously need to burn more mid night oil , I wish it happens in my life time. !
Posted in bio ethics, medical quotes, Two line sermons in cardiology | Tagged brainy quotes, cardiology ethics, evidence based medicine, great medical quotes, mahatma gandhi quotes, medical quotes, medical violence, principles of medicine, science quotes, sensible medical practice | Leave a Comment »
One of my patients with atrial fibrillation recently developed a fairly moderate sized right MCA stroke that resulted in dense left sided hemiplegia .He was on warfarin , but the stroke was confirmed to be ischemic,the etiology was fixed as cardio embolic .After a smart recovery he asked this question.
Why did the clot from my heart preferred to enter the brain doctor ? Is there no other place for it to go ?
I told him in simple terms , “It is your destiny and the clot’s wish”. In fact , you are some what blessed as the clot did not enter the left side of the brain .If it had gone, your speech would have severely affected and you may not be asking this question to me ! It is true the clot do have other options to embolise , however they are still trouble some !
What is the diameter of internal carotid artery , and cerebral artery ? The common size of LA appendage clot almost match with this !
It can go straight down to your leg , kidney , intestines or upper limbs .All are equally dangerous and present dramatically . Very rarely it can enter coronary arteries bringing a heart attack rather than a brain attack .If it is going to the legs you are at risk of acute monoplegia instead of chronic hemiplegia .Peripheral embolism are very painful .Intestinal ischemia evokes a most excruciating pain one can ever encounter ! Luckily stroke is not painful.God is kind enough ,he foresaw cerebral ischemia to be more common and hence made it pain-free ! (There is no cerebral angina equivalent !)
Having said that , I felt we should get a scientific answer to my patients query .
What determines the destination of these emboli in transit from heart ?
A large clot often fails to traverse the Aortic arch branches and invariably reach the periphery .
The dynamics of a cardiac emboli hitting the cerebral arteries can never be known in live human vascular tree. The following factors might play a role.
Variations in Aortic arch anatomy
Image courtesy : Anatomy Atlases by Michael P. D’Alessandro, and Ronald A. Bergman, from university of Iowa. http://www.anatomyatlases.com
It is surprising, human beings can have as many types of Aortic arch as English alphabets . Then,there are innumerable ways for cardiac clots to embolise too !
Posted in Atrial fibrillation, cardiac source of embolism, stroke | Tagged aortic arch type and embolic risk, cardiac emboli, cardiac source of emboli, carotid artery origin angle and risk of stroke, clot deflection in stroke, embolic stroke, fate of clot from heart, Ischemic stroke | 2 Comments »
Caring shall be an inbuilt character in the Noble profession ,need not be a value added service or a separate medical specialty !
Posted in Cardiology quotes, cardiology-ethics | Tagged caring, ethics in medical profession, venkat quotes | Leave a Comment »
Your clock starts now !
Chronic stable angina : Most can be effectively managed by optimal /intensive medicines and life style Interventions .About 10% will require PCI/CABG.
ACS – STEMI: Primarily managed with rapid and competent pre-hospital care with prompt thrombolysis in or out of hospital .Patients with large STEMI who develop complications (Again about 10 %) require PCI and few additional lives can be saved.
ACS-NSTEMI : This is the group that demand an important role for PCI . All true high risk UA/NSTEMI patients should receive urgent coronary angiogram and critical lesions should either be stented or sent for CABG (If the lesions are multiple and complex ) The field of interventional cardiology is expected to play a major role in this category of patients for the simple reason , we not only give dramatic relief from angina and also prevent a potentially a huge MI that is waiting to happen !
* It is vital to emphasise the “Aim and objective” in NSTEMI management is critically different from other two. We know , in CSA the aim is to give relief symptoms and improve excercise capacity . Both PCI/CABG are unlikely to prevent a future MI in CSA..In STEMI it has already occurred .The aim is to salvage myocardium and prevent future events. While PCI can do the former , it can’t do the later . In STEMI scenerio ,we have very good alternate modality called thrombolysis which can easily beat the pPCI in , cost , availability and time (and hence efficiency as well in most countries !)
Counter thought
The above suggestion is too simplified ,generalized , misleading , and unscientific, should strongly be disagreed. For those people who disagree , I provide an alternate scheme .It is ultra short ,comes in 5 lines .Very practical and scientific too !
In any patient , who is suspected to have either acute or chronic coronary syndromes ,take them to the cath lab in an urgent or semi urgent fashion .Do an angiogram and stent all lesions that you feel important . If stenting is not possible manage with optimal medicines and /or send them to the surgeons.
Final message
The essence of catheter based coronary care is simple.We complicate it. To understand this concept 100’s of cardiology journals and as many conferences and infinite number of books are churned out every year !
Posted in Cardiology -Therapeutic dilemma, cardiology -Therapeutics, Cardiology -unresolved questions | Tagged csa, ethics in cardiology, interventional cardiology, management of pci, pci ptca in a nutshell, priamry pci vs thrombolysis, stemi vs nstemi | 1 Comment »
TVI (or VTI) is a hemo-dynamic echo parameter measured from Doppler spectrum across the valves ,usually in the outflow.This parameter is used to calculate cardiac output .VTI times the cross sectional area gives the stroke volume.
A correction: TVI is multiplication of velocity into time not division as suggested in the cartoon
Time velocity Integral
Summary
*VTI is a Doppler parameter described in cm , it can be referred to as Stroke distance.This stroke distance when multiplied by valve area gives the stroke volume from LV/RV (or flow volume across AV valves or through any conduit)
Posted in echocardiography | Tagged tvi, tvi by echo, tvi in doppler, tvi unit is cm, What is the unit for TVI ? Echocardiography, what is time velocity integral |
When a patient comes with angina at rest , it could mean two things .Either a STEMI or an NSTEMI .This , we can diagnose only after seeing the ECG .
Can we differentiate these two by the character of chest pain alone ?
Very tough task isn’t ? But there are some definite clues .
Infarct pain
Unstable angina
Mechanism of the difference : Epicardial vs Endocardial angina
The pain of UA is due to subtotal occlusion and endocardial ischemia , while STEMI is sudden total occlusion and the resultant transmural ischemia . In STEMI epicardial surface is always involved (Which lifts the ST segment in ECG .).We know epicardium is same as visceral layer of pericardium which is well innervated .Hence pain of STEMI acquires more of somatic character than a predominately visceral type pain that occurs with UA/NSTEMI where epicardial ischemia is absent.
Clinical importance
The demarcation between unstable angina and Infarct pain becomes vital when we calculate the time window for thrombolysing STEMI .Many of them have a phase of pre infarction angina which is a type of unstable angina. If we mistake it for Infarct pain then one may falsely calculate a prolonged time window and deny re-perfusion therapy.
Post -amble
It is tricky issue to differentiate the chest pain of STEMI and NSTEMI .A significant overlap can occur in real coronary care scenario . We know chest pain that occurs in both pre and post infarct phase is considered as unstable angina .(With infarct pain sandwiched between them!) Hence differentiating them may even be termed as futile.
Still,clinical cardiology can be made fascinating by indulging in such exercise !
Posted in Cardiology - Clinical, Cardiology -Clinical signs, Cardiology -Mechnisms of disease, cardiology- coronary care, Clinical cardiology | Tagged angina vs infarct, difference between stemi and nstemi, epicardial angina vs endocardail angina, heberden angina, how is chest pain different between nstemi and stemi ?, rca vs lad angina | Leave a Comment »
I got this alert from World health organisation yesterday .Click over the image to read more .
Why should a cardiologist affected about this ?
When we are fighting in cath lab day in night day out to extinguish the myocardial fire set by coronary thrombosis and the resultant STEMI . . . the solemn attempt to salvage whatever myocardial cells we can !
See . . . what is happening elsewhere every 40 seconds a healthy heart in toto is executed by weak minds !
What should the WHO do ?
Just publish these data and forget . No,they should organise the world leaders to take a resolve !
Either , we should prevent these unnatural deaths or else we should have world organ net work. Why can’t we use these weak hearts for those courageous men and women who lose their life daily with end stage cardiomyopathy who long for living !
Is this possible ?
Why not ? Ain’t the world leaders group together periodically to impose a sanction or bomb other countries for personal reasons !
Posted in Public Health, Public health issues | Tagged better world, brain death defintion, cadaver organ sharing india, ethical medicine, future of man kind, heart transplantation in India, humane medicine, kidney transplantation india, net work for organ sharing, organ transplant act india, role of who health, sucide and cardiology, sucide victims as heart donors, unos, who, world health issues | Leave a Comment »
I stumbled upon a TV reality show where a mother of a child was crying inconsolably ,whom she lost when it fell into a open bore-well pit .She was blaming it as her fate and the hole was sent by Lord Yama (God of death )
I just got curious ! This article was written in a flash.
I used to get questions from anxious parents of children with holes in the heart .(Asymptomatic small VSDs or ASDs who come for periodic echo-cardiograms) .I reassure and convey the message , most of these holes are tiny and will close automatically and they need not worry.Even if it doesn’t, it poses little problem.
But .after watching that haunting TV show, I have started to warn the parents that holes in the heart may not be that dangerous but be wary of holes in the roads and unclosed bore wells in our country !
Every single parent was amused with my statement ! Some how it appeared sense to me !
I made a mini google research. It is estimated thousands of bore-wells are dug every day and kept open in allover the country side .It is like live land mines . Some press reports suggest at least one child dies in India every day due to uncovered bore-wells and man holes ! (May be really true !)
The following are some of the samples.
One
One more
Two
You can understand the gravity of the problem , one engineer has devised a special child retrieval Robot for such accidents.
Three
A news report in Times of India .What shall we do about these ?
It is a horrific truth in this civilised world .Nature creates holes in the heart due to defective gene in some . It appears less dangerous to me. After all a hole in the heart threatens only one life,while a hole in the road kills many people.
As a cardiologist , I am saying this with anguish as our team along with surgeons work over time to close intra-cardiac holes with device , the holes in the road are often callously kept open forming death traps for our children .The men responsible for such things deserves no pardon.
The story is never ending . . .
Posted in Public health issues | Tagged asd vsd pda, bore-well deaths in India, congenital heart disease, hippocrates oath, hole in the heart, hole in the heart and hole in the road, Indian association of pediatrics iap, public health issues, safety issues for children, who child safety | Leave a Comment »
As the medical care advances human care has taken the back seat. It is said super specialists read more and more about less and less ! In the process they fail to see the patients as a single biological unit instead as collection of organs .
While organs in turn are looked as pile of data.Hence the treatment they provide lack the soul !
In the prevailing circumstances , how do we ensure modern medicine does not interfere with these vulnerable souls,either to live in peace or leave in peace ?
Image : Source and Courtesy of http://illuminationstudios.com
It appears doctors are not at fault . The system is biased towards raw science .Highly trained doctors are tied down by both true and pseudo scientific Intellect .Often times they are compelled to do some procedure or interventions just to justify the premier status of the hospital .While few do it to show off their expertise or to impress their peers others are simply bound by rigid and obsessive protocols and guidelines . Few others do it for the burning desire of scientific accomplishment .
One can offer hundred reasons for doing a procedure . . . but we always struggle to justify with a valid reason for not doing a investigation or procedure !
In fact , the concept of appropriateness criteria came out with good intention .But , it had failed miserably.
The irony is . . . we need to indulge in something to avoid something.
Example 1 If homocystiene and hsCRP vanish from the CAD screening industry Adiponectin and Vitamin D3 comes in with a thunderous applause like a new Hollywood movie !
Example 2: In cath lab for leaving alone an insignificant coronary stenosis , we have to do another procedure called FFR to satisfy scientific ego ! (I know one senior doctor , who left a 80% LAD lesion for medical management without FFR ( with all his clinical acumen ) was ridiculed for being unscientific !)
Here is a recent perspective article NEJM has discussed this important issue that plague us
Why should big Tertiary teaching hospital are flooded with super specialists which by default shun basic human care ?
Read this article*
*The article I have quoted may not be completely relevant here . . . It answers few of the queries raised!
Posted in bio ethics, Cardiology -Emerging technology, Cardiology -guidelines, Cardiology -Interventional -PCI, Cardiology -Patient page, Cardiology -Therapeutic dilemma, Cardiology -unresolved questions, medical quotes | Tagged father of modern medicine, medical ethics, primary health care in tertiary health centre, primary secondary tertiary health care | Leave a Comment »
Dr.S.Venkatesan MD 