Dr.S.Venkatesan MD

Learning new lessons from a stressful “ST segment”

April 22, 2023 by dr s venkatesan

This is the Incidental ECG of an apparently healthy 50-year-old businessman, recorded while  applying for health insurance

How will you describe this ECG?

Let me magnify it for you 

Why this big fuss about this ECG?

 Such ECGs are so common. Looking at the ST segment, we are supposed to think of significant CAD,, LVH, Aortic stenosis or variants of cardiomyopathy, and sometimes electrolytic shifts. The fact that it is recorded at rest, and the patient is absolutely asymptomatic, it is very unlikely there is ongoing ischemia.It could be a myocardial origin or an unknown repolarisation pattern. But, one thing is clear, we can’t send this guy under the label of non-specific ST/T changes.

The Echo was done it was normal. No WMA,  LVH. The aortic valve was perfect. 

Is CAG indicated here?

Three responses came from three different cardiologists. Everyone agreed, the stress test is not going to be useful, as  baseline  is unstable

1. Absolutely not Indicated, since he is asymptomatic. I believe the history and Echo. Please follow him up
2. A definite yes for CAG. (Being a scientific cardiologist, without excluding CAD, I can’t be at peace. Will do at least a CT angiogram)
3. A third cardiologist said a CT angiogram is waste of time and wanted to do a radial CAG in 10 minutes in his newly opened hi-fi radial lounge.

What happened then?

Don’t know, whether he underwent CAG or not.  But, I can confidently say he will have a normal coronary angiogram.  How can you be so confident?  Confidence doesn’t mean I am correct. Look at the ST segment again. It is not true ischemic depression. It is neither non-sustained nor horizontal or downsloping*, This could be referred to as, primary T inversion with secondary ST segment dragging. Regarding the management,  the first response is ideal,

*Classical slope should begin at J point. Late downsloping has little predictive value as in this ECG.

Is Echo good enough to rule out structural heart disease?

Even after the echo was reported normal, few questioned the quality of the echocardiogram and asked to look specifically for apical wall motion with speckle track and GLS. ( I know, MRI is a must nowadays to rule out structural heart disease as Echo can’t rule out intrinsic myocardial disarray, infiltration, etc)

How is ST dragging different from ST depression?

                                                                Classical horizontal ST depression

ST dragging due to T wave pulling

 For ST depression to happen, the junction point needs to be depressed. Note here junction is held high, only the distal half of the ST segment dips rather dragged by the phase 3 repolarization process which corresponds to the proximal limb of T waves.  Our observation is, this type of ST drag is less sinister and usually indicates a myocardial ST defect, rather than an ischemic one. (Examples: concealed LVH or forme fruste of HCM or Infilitrative cardiomyopathy-related entities.)

Final message

The purpose of posting this ECG is, some ST segments create disproportionate panic than it deserves. The concept of  T waves pulling down the distal part of the ST segment which can be called ST segment dragging is being proposed here.

Some provocation for advanced readers 

Re-exploring the foundations of electro-cardiology is always welcome. Worth diving deep into mysterious terminology non-specific ST/T changes. ST  segment in the ECG  corresponds to the most stressful period since it represents the active part of mechanical contraction. Curiously, it Includes the entire electrical (Repolarisation) & most parts of mechanical relaxation. The true onset of LV myocardial mechanical relaxation we can’t be sure, It happens somewhere in late phase 2. I think it’s so difficult to decode that timing. But, what we can presume is ST segment behavior in its distal half is less specific for both ischemic as well as hemodynamic stress

The electro-mechanical continuity within the ST segment is so intimate, and the demarcation point between them is invisible in many clinical situations.   No surprise, we are largely in the dark about the true influence of the ST segment over T wave morphology and vice versa. (ie distal ST depression pulling down the T wave )  Though chronologically T must follow the S in timing,  it would seem impossible for “T” to go back in time and pull the ST down. (If QRS can precede P in a junctional rhythm, why not T do the same for ST? )  I am not sure whether there is any timing involved in antegrade vs retrograde repolarisation across endo-epicardial repolarisation dissociation.Further, we know very well, myocardial scars cause fragmented depolarisation in QRS. Can anyone guess effect of these scars in repolarisation vectors? (Fragmented ST segment ?)  I think it is worth pursuing this phenomenon. Let the young new age Sodipellares’ look into this.

Though the traditional rule of thumb, makes ST segment shifts more sinister, T-wave changes are largely benign, It is not an easy job to segregate benign from more serious forms of T-wave changes. Isolated new onset T inversion, can be an equally troublesome marker, especially mid-chest leads in the male population. 

It is interesting to note, not every T wave Inversion is empowered to drag the ST segment down. We don’t know why. It is something to do with the curvature of the shoulder zone of phase 2 /3 of the action potential. In this context, ST dragging could be an important concept to explore. 

 

. An example of isolated T inversion without influencing the ST segment. Try to compare this ECG with the one that is shown to drag the ST segment

Diastolic T wave stress

One more issue, which we are not yet clear is the timing of 2nd sound with reference to the T wave. It is a fact, a significant part of the T-wave will represent early diastolic hemodynamic stress* as well. 

 

 

 

 

 

Rate this:

Posted in Uncategorized | Tagged non specific st segment |

A non-relishable medical quote

April 19, 2023 by dr s venkatesan

Rate this:

Posted in Uncategorized |

Localising WPW : Take it EASY

April 15, 2023 by dr s venkatesan

If some body is struggling with same problem, say for over three decades , there is something seriously wrong with the way we deal with the problem. How do you localise accessory pathway in WPW syndrome from 12 lead ECG ? is one such entity, This question is asked exclusively in cardiology board exams. Now a 2023 paper from EUROPACE claims, it has come out with a simple algorithm bettering all the previous ones. Please check it for yourself.

One thing we can say with conviction is most of these embryological remnant pathways are posteriorly or laterally dragged in peri AV annular region or the para septal region. Very few appear anteriorly, if anterior it is more often placed on the right side.

Why should we take this question easy ?

Try asking any experienced EP specialist* to localise a pathway in given 12 lead ECG . Don’t get surprised by a long silence before they commit, because they know the truth, and how delicate this question might sound on quiet a few occasion, because of various anatomical and physiological reasons.

*Never fail to appreciate their hard long hours in cath lab to spot, analyse and shoot these tracts.(EP stuff is not like angioplasties, which, many can do even in half sleep!)

Final message

Yes, localising WPW can be either a fascinating or frustrating exercise depending on our understanding about the attitudinal cardiac anatomy, variable autonomic tone dependent morphological behaviour of delta waves, PR intervals, QRS axis ,the transition zones etc. Shrewd fellows may go through this 12 lead stress test. ,

For others just try to localise right from left , & then posterior or lateral Forget the anterior ones. This is more than suffice. Unlike drug trials, where statistics are often battered , here the Incident numbers are the key measure of truth. (Even without seeing a ECG you are likely to be correct in 80 % times, if you localise the pathway to posterior, para-septal or left lateral zones. )

Reference

Rate this:

Posted in Uncategorized, WPW syndrome | Tagged 12 LEAD ECG LOCLISATION IN WPW SYNDROME, arruda scheme, easy wpw algorithm, wpw syndrome |

Pre-operative cardiac fitness : No, it is not acceptable , you are not authorised to do this !

April 3, 2023 by dr s venkatesan

A 62-year-old man who is being scheduled for prostate surgery with no cardiac risk factors or comorbid status came for surgical clearance. I examined him and took an ECG, everything was fine and gave him clearance for surgery.

 I was surprised to spot him the very next day, waiting in the lounge of my office. He said, his anesthetist was not happy with my pre-op-cardiac assessment report, suggested it was incomplete, and sent me back for echocardiography to know the LV ejection fraction.

I wanted to clarify with the patient, what exactly happened when he met his anesthesiologist.

“I am not sure doctor, the moment he saw your report, he called my urologist. I overheard his call, they were discussing the need for an echocardiogram and they were also wondering,  how could a cardiologist give a  surgical clearance without even an echocardiography”.

I wasn’t really surprised by the turn of events and told the patient. 

“I am experienced enough to say, your heart is 100 % normal without an echocardiogram”.

“I understand doctor, but sorry to bother you. Can you please take it for the sake of my anesthetist and urologist, after all, right now I am worried about their peace of mind” 

“You are absolutely right. This is a topsy-turvy world. Investigations are dictated to me in my own field of expertise. Anyway, I am not a fool, to expect a patient’s help to guard my principles of practice. Please check in, let me do the echocardiogram as they wish” 

“Thank you so much, Doctor“.

I showed him, the vigorously contracting ventricle and taught the student trainee who was nearby, a simple clinical tip ie, a loud first heart sound on auscultation is good enough to tell you, the EF is beyond 60% in most situations. (A forceful AML movement is a direct auditory marker of EF %)

Final message

It is getting more & more clear,  physicians will face huge hurdles in applying their clinical skills to practice. They may even be unauthorized to do so. It seems, in our misplaced quest for perfection, we have fallen into a scientific trap, that every clinical decision must be authenticated by some objective lab-made obsession. The word clinical acumen could soon become a laughing stock, as AI-powered medical zombies are waiting to join our consultation suits.

(Meanwhile,  the guidelines are very clear. (Read below)  Do echo only in high-risk surgery, if patients’ functional capacity is poor. But, let me confess, at least in our part of the world,  we are happy to violate standard guidelines  without any degree of guilt )

Reference 

ESC Scientific Document Group, 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: Developed by the task force for cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC), European Heart Journal, Volume 43, Issue 39, 14 October 2022, Pages 3826–3924, https://doi.org/10.1093/eurheartj/ehac270

 

Download

Rate this:

Posted in cardiac surgery | Tagged Cardiac fitness for non cardiac surgery, preoperative cardiac risk assesment, surgical clearance and cardiac fitness |

AI, is not risk free in medical science !

March 25, 2023 by dr s venkatesan

Rate this:

Posted in Uncategorized |

Learning targeted IAS puncture in 20 minutes

March 10, 2023 by dr s venkatesan

The main reason for all those jitters, we cardiologists, get every time we puncture the IAS is not due to a lack of expertise and experience perse. There are two more reasons. First and foremost, it is still largely a blind* procedure. (Even in this era, where drones with HD vision shoot one-meter targets from a 1000 KM range )  *TEE and ICE are there, but they rarely give enough confidence. 

The second reason is more important and is rectifiable. It is the perception error in our anatomical cognition, that is fed to us from first-year medical school. We are made to believe (at least to people like me ) The right atrium is aligned like a perfect box on the right side, sharing a wall called IAS, and the left atrium is obediently placed left of the right atrium. Please realize the heart is such a complex twisted single tubular organ, the venous end, in a stunning backward loop brings the LA  most superior and posterior to the right atrium overriding the left-right relationship.) 

The right atrial terrain and IAS with multiple bumps and holes. Note the true IAS constitutes only 20% . This is where our punctures need to be.

Development of IAS 

IAS development and the number of layers it sandwiches, the tortuous tracts of PFOs, the fossas, and its variable limbus is a big topic. Further, It is worth recalling, the true IAS hardly forms 20 % of the area of the interatrial contact surface.

(the differential regression of sinus venous,  along with infolding of the roof and along with curious septum spurium , the ubiquitous septum secundum make the texture, area & shape of IAS, a fascinating creation, though troublesome for the cardiologists ! ) Whoever named that part of vanishing  IAS  as spurious, (I think it is Henrry Grey ) has much fore-vision.

 

Forget about all this. Tell me how to cross this difficult terrain 

Coming to the real world of interventions,  we need to do targeted punctures in different spots of IAS in various interventions.(Mitra clips, LAA device, PTMC, PV abaltions, Mitral paravalvular leaks , TMVR etc) This has made this task even more tricky. Experts are always there to help us out. Like swimming, it can never be learned in books.

This 19-minute clip from. Seoul, South Korea is an excellent resource. Thanks to  Dr. Sang Weon Park 

 

Along with sound anatomical knowledge, improved hardware, and imaging like deflectable sheaths, TEEs, and ICE (intracardiac echo ), let us hope, it will soon become an easier task for everyone.

Final message

 Understanding “attitudinal cardiac anatomy” with fluoroscopic overlay is the key. Again, it needs to be stressed, “Right is not right, and left is not left” when it comes to true atrial geo position. LA is equally posterior, superior, and of course to the left of RA. Some of my colleagues are blessed with a special 3-dimensional skillset  (Inherited ?) I failed miserably to understand this, till very late. I am sure, Dr. Park’s video will help all our youngsters to cross the difficult gateway to the left side of the heart. 

Reference 

One more good read

B. O’Brien et al. / International Journal of Cardiology 233 (2017) 12–22

 

Rate this:

Posted in Anatomy of heart, Uncategorized | Tagged anatomy of heart, ias puncture, right vs left atrial anatomy |

P wave spotting in AF is not forbidden

March 8, 2023 by dr s venkatesan

Fibrillation is a continuous, chaotic muscular activity. In AF, atrial muscle is expected to lose all coordinated contractions with fibrillatory waves replacing P waves. Have you ever spotted a suspicious  P wave in a strip of otherwise explicit AF?  If not, this write-up is not for you.

An evolving rare theme in Atrial fibrillation 

Have a look at this ECG 

Here is an ECG, that was reported as AF, multiple APDs, or Possible AF, Pre AF. I suggested the term AF in transition. While few agreed, many said it is a straightforward SR with APDs, making it appear irregular RR. 

But, the fact of the matter is, ECGs are insensitive to pick all fibrillatory wavelets. It can selectively pick a few coarse F waves and make them appear as P. I think, in this era, we should not diagnose AF by proxy, ie absent P waves. Rather, we need to look actively for fibrillatory wavelets. (Imagine all sinus arrests will qualify for f fine AF with a slow ventricular rate  is it not ?)

The semantics of AF nomenclature is long. Intermittent AF, and paroxysmal AF, are well-known entities. It is now clear, AF can occur for a few seconds and vanish too. It seems we need to play some more linguistics with the most common cardiac arrhythmia. (Non-sustained AF,  evanescent AF, etc )

Some thoughts on this hide &  seek P waves 

• Apart from the conventional list of absent P waves, one more example is repetitive APD can stun the atrial muscle for a few moments or minutes.
• Then, we always have the issue( eluded to earlier) of sinus node paralysis, with irregular junctional escape mimicking AF.
• Amiodarone can reduce fibrillatory rate, and (AF cycle length ?) Coarse F waves slow and stabilize it to mimic an organized P wave
• P on Ta waves (Like R on T ) can trigger a nonsustained AF for a few moments in a functional manner without real pathology in atria.

 

A funny memory  brings back an EP truth 

During our student days, my Professor used to trap us with this question, Which atria would fibrillate in mitral stenosis?  Many of us blinked, and few had no hesitation to say, it is the LA that fibrillates. Now, after 50 years we realize, how fascinating the secrets AF has unfolded. Some organized activities are often in the right atrium, even as LA begins the process of AF. It is possible it may take variable time for the left atrial chaos to spill over to RA*. During these electrical uncertain times, some of the right atrial P wave activity refuses to die down.  Even more dramatic one Atrium alone can permanently fibrillate and others completely insulated by blocking the signal in the Interatrial pathways. (Ref 1 ) Ndrepepa’s paper in the JCE 2000)

Final message.

True scientists rarely bother about questioning a dictum. The concept of non-uniform AF was first thought of by (Schrmp et al Ref 2) 100 years ago in 1920, and Zipes(Ref 3) hypothesized this in 1973. now, in the Year 2000, Ndrepepa confirmed it with EP studies. The spotting of occasional  P waves is not forbidden in AF if the contralateral atria decide to block the incoming AF signals and keep generating their own P waves 

Young EP guys, now that you are equipped with the sophisticated intracardiac GPS,  please pursue this provocation in AF. One more piece of evidence we observed in the echo lab. Try to look at Tricuspid doppler A velocity waves in full-blown AF patients. You can see the surprise for yourself. This is very good research work to do. This is one of the ideas I gave to my fellows at MMC. Now, it is free for all to pursue whoever wants to do this. The clinical implication* will follow.

* A lingering query, how common is RAA clot in mitral stenosis with AF and the possible threat of pulmonary embolism?

Reference

1,Ndrepepa G, Zrenner B, Schreieck J, Karch MR, Schneider MA, Schömig A, Schmitt C. Left atrial fibrillation with regular right atrial activation and a single left-to-right electrical interatrial connection: multisite mapping of dissimilar atrial rhythms. J Cardiovasc Electrophysiol. 2000 May;11(5):587-92. 

2.Zipes DP. DeJoseph RL: Dissimilar atrial rhythms in man and dog. AmJCardioi I973;32:6l8-628.

3.Schrumpf P: De 1’interference de deux rythmes sinusaux. Preuve  du dualisme du nodule de Keilh. Arch Mai Qwur 1920;l3:168-173

Postamble

The snapshot from Ref 1 . The term Isolated AF confined to one atrium could be a rare event, but, no one can deny we have plenty to learn from them

 

Rate this:

Posted in Uncategorized | Tagged cardiology research topics for fellows, causes of absent p wabes, p vs f waves in af, p waves in atrial fibrillation, research topics in atrial fibrillation |

LA volume assessment : A critical parameter with a time trouble !

February 8, 2023 by dr s venkatesan

LA dimension and volume have become vital parameters in recent times, especially, with the entity of HFpEF is becoming so common. LA not only acts as a live barometer, reflecting all that happens in LV, but it is also a chronic marker of LV diastolic function. (Funnily referred to as HBA1c of diastolic dysfunction) 

What is normal LA dimension & volume ? 

• Normal left atrial diameter < 4.1 cm in men or < 3.9 cm in women
• Normal left atrial volume indexed for body surface area (BSA) is 34 ml/m² for both women and men 

Which part of the cardiac cycle do we measure? 

Ever since Wiggers introduced the overwhelming concept of LV systole and diastole, most of us ignored the fact that atria do have a separate contraction relaxation cycle, independent of what happens in the ventricle. Of course, atria and ventricles act as a single chamber in diastole. In reality, atria lack true boundaries when it acts as a conduit. The LA dimension varies considerably during the atrial cardiac cycle. Look at the  LA pressure-volume loop, which can frighten anyone, with its horizontally lying figure of 8 pattern. During every cardiac cycle, the volume reaches atleast two troughs and one peak.

Don’t get frightened with this graph, spend some time, and you will get it right, Begin at  “3” o clock position with the onset of diastole with a downsloping green loop, that continues as the red line of atrial contraction to end up in systole. The entire black loop, that happens during ventricular systole depicts the true reservoir function. with MV closed. ,

 

As of now, we have a consensus, LA volume is measured typically in LV end-systolic frame. ( Rather, we measure it at maximum LA volume ) However, we have 4 different LA  volumetric components to assess, as this article excellently depicts. (Hoit BD. Left atrial size and function: role in prognosis. J Am Coll Cardiol. 2014 Feb 18;63(6):493-505.)

What could be the limitations of the traditional end-systolic measurement?

No single measurement will give an overall LA function assessment. But still, Somehow, we have measured the maximum LA  volume as a reference of true diastolic function. This happens in LV end-systolic point where atria reach the maximum size. But, here is a catch, we assess the left atrial function before its main physiological function of emptying takes place.

How about assessing  LA efficiency after it completes its job, ie end diastole? 

In LV function end-systolic dimension has pride of place as it is devoid of influence from loading condition. If applying the same logic, the “end atrial” systolic dimension(Which is the same as LV end-diastolic point/or post A ) should be perfect. It can also help measure the residual LA volume after its systole.

A potential advantage of LV end-diastolic dimension (The Heart & Soul study )

Maybe, this is less affected in the presence of MR systolic jet will spuriously elevate LA volume. In AF also this parameter is less likely to be influenced by LA preload.

Final message

Suddenly, we are debating a fundamental Issue, ie timing of LA measurement. While the end-systolic size/volume is the current standard, the LA dimension in the end diastole also provides useful info. There are at least 4 different LA volumes, at different parts of the LA cycle that need to be studied for a proper understanding of diastology (Unlike LV which has only two).

Now, we may need to ponder, if there is a mean LA volume, measured with the 3D volumetric analysis or MRI, that could be representative of the global LA function. 

Reference

Thadani SR, Shaw RE, Fang Q, Whooley MA, Schiller NB. Left Atrial End-Diastolic Volume Index as a Predictor of Cardiovascular Outcomes: The Heart and Soul Study. Circ Cardiovasc Imaging. 2020 Apr;13(4):e009746. doi: 10.1161/CIRCIMAGING.119.009746. Epub 2020 Apr 20. PMID: 32306763; PMCID: PMC8846436.

 

Rate this:

Posted in Cardiology Illustrations, cardiology physiology, Left atrial enlargement, Uncategorized | Tagged LA end diastolic dimension, la end diastolic vs end systolic dimension, LA end systolic dimension, la pressure volume loop, LA volume by mri, normal LA dimension, normal la volume, When do you measure LA dimension volume |

« Newer Posts - Older Posts »

• Search for:

• Categories

  Categories Select Category acute aortic dissection  (1) acute coroanry syndrome  (18) acute coronary syndrome  (24) acute pulmonary embolism  (5) acute rheumatic fever  (5) admixture lesions in cyanotic heart disease  (1) Alcohol and heart disease  (1) Anatomy of heart  (9) angina  (1) anti platelet drug  (4) aortic aneurysm  (1) Aortic diseases  (10) Aortic regurgitation  (3) aortic stenosis  (5) Aortic stent grafing  (2) Aortic valve replacement  (2) ASD device closure  (1) atherosclerosis  (2) Atrial fibrillation  (13) Auscultation  (2) Awards in medicine  (1) baloon aortic valvotomy  (1) Basic sciecne  (2) Basic science -Physiology  (3) bav vs tavr  (2) Best books in cardiology  (6) Beta Blocker  (1) bifurcation pci  (1) bio ethics  (83) Blood pressure  (1) Breakthrough technology  (1) Bronchail arterial and venous circulation  (1) bronchial arterial and venous circulation  (1) Brugada syndrome  (6) CABG  (1) CABG for Ischemic DCM  (1) CABG Indications  (1) CAD in HFpEF  (1) cardaic pharmacology  (1) cardaic physiology  (28) cardiac anatomy  (3) Cardiac biomarkers  (1) cardiac cycle  (1) cardiac drugs  (32) cardiac electrophysiology  (2) cardiac embryology  (2) cardiac failure  (10) Cardiac MRI  (4) Cardiac myxoma  (1) cardiac physiology  (31) cardiac radiology  (3) cardiac resynchronisation  (2) cardiac source of embolism  (1) cardiac surgery  (61) cardiac tamponade  (1) cardiac volume  (2) cardiac X ray  (1) cardinal symptom in cardiology  (2) Cardio Nephrology  (2) cardio pulmonary resucitation  (1) Cardiologt women  (3) Cardiology – Animations  (10) Cardiology – Clinical  (353) Cardiology – Electrophysiology -Pacemaker  (87) Cardiology – Pioneers  (2) Cardiology -Clinical signs  (4) cardiology -congenital heart disease  (40) Cardiology -Coronary collateral circulation  (1) Cardiology -Criteria  (4) Cardiology -Definitions  (3) cardiology -ECG  (147) Cardiology -Emerging technology  (3) Cardiology -Funny events  (1) Cardiology -guidelines  (21) Cardiology -Hemodynamics  (8) Cardiology -Interesting videos  (1) Cardiology -Interventional -PCI  (260) Cardiology -Mechnisms of disease  (15) Cardiology -Non coronary Interventions -PTMC  (2) Cardiology -Pacemakers and ICD  (5) Cardiology -Patient page  (5) cardiology -pregnancy  (2) cardiology -Preventive  (8) cardiology -Sexual health  (2) Cardiology -Technology  (5) Cardiology -Therapeutic dilemma  (34) cardiology -Therapeutics  (308) Cardiology -unresolved questions  (277) Cardiology classics  (5) cardiology congenital heart disese  (23) Cardiology hypertension  (15) Cardiology Illistrations  (1) Cardiology Illustrations  (2) cardiology innovation  (15) Cardiology Innovations  (4) cardiology journal club  (13) Cardiology journal links  (2) cardiology journals  (21) Cardiology lipids /dyslipidemia  (4) Cardiology Outcome analysis  (1) Cardiology Patho physiology  (2) cardiology physiology  (2) Cardiology quotes  (18) Cardiology research topics  (6) cardiology research topics for fellows  (2) Cardiology Risk assesment  (9) Cardiology teaching websites  (4) Cardiology therapeutics  (1) cardiology thesis topics  (1) cardiology wisdom  (6) cardiology women  (3) cardiology- coronary care  (127) cardiology-Anatomy  (32) Cardiology-Arrhythmias  (66) Cardiology-Coronary artery disese  (93) Cardiology-Echocardiography  (4) Cardiology-Electrolytes  (1) cardiology-ethics  (58) Cardiology-Land mark studies  (41) Cardiology-Statistics  (5) cardiomyopathy  (5) carotid interventions  (3) Cath lab Hardware  (3) cath lab tips and tricks  (28) Centre for cardiology unlearninng  (1) cerebral circualtion stroke  (3) cerebral circulation stroke  (3) Chest pain  (1) Chronic total occlusion  (1) chronic total occlusion (CTO)  (1) Clinical cardiology  (58) Clinical cardiology  (7) Clinical cardiology -Cyanosis  (2) Clinical cardiology -JVP  (2) clinical cardiology -Murmurs  (1) clinical lipidology  (1) coarctation of aorta  (1) Comparative efficacy  (1) Complete heart block  (1) congenital heart disease  (3) constrictive pericarditis  (1) constritctive pericarditis  (1) contrast induced nephropathy  (1) Coronary angiogram  (1) Coronary collateral circulation  (1) coronary sinus anatomy and physiology  (1) coronary sinus filling and emptying time drsvenkatesan  (1) coronary veno occlusive disorder  (1) coronary venous circulation  (1) cost effectiveness in cardiology  (2) Criteria and Nomenclature  (1) critical care ccu  (8) cto chronic total occlusion  (5) Diabetes and Heart  (5) Diastolic dysfunction  (3) Dilated cardiomyopathy  (5) Dissection coronary  (1) dr s venkatesan -Personal  (6) dynamic auscultation  (1) dyslipidemia  (3) early repolarisation syndrome  (3) ECG -Basics  (1) Echo library and gallery  (15) echocardiography  (64) Echocardiography – LV dysfunction  (4) Echocardiography -Normal measurement  (2) Echocardiography-hemodynamics  (4) Echocardiography-Limitations of LV EF %  (1) Electro physiology  (4) Electrocardiography-ECG  (1) Electrocardiology -Basics  (1) Electrolyte and Heart  (1) Electrolytes and heart  (1) Embryology : Heart valve development  (2) embryology of heart  (2) emotion and cad  (1) ESC ACC Guidelines  (1) Ethics in Medicine  (16) evidence based cardiology  (4) excercise stress test .EST  (3) fame study ffr  (2) Fracional flow reserve  (2) Future cardiology gadgets  (2) future of cardiology  (1) Futuristic cardiology  (1) Gender issues in medicine  (1) general medicine  (11) great cardiologists  (1) great illustrations in cardiology  (4) Great Men in cardiology  (2) Great men in Medicine  (1) Great websites in cardiology  (13) Hadwares in cardiology  (2) Hardware techniques tips  (9) health economics  (1) Heart failure with preserved LV EF  (1) Heart transplantation  (2) Heart valves  (1) Hemodynamics  (15) Hemodynamics  (1) hemodynamics during Labor  (1) Heparin  (1) HFpEF  (1) HFrEF vs HFpEF  (1) Hippocratic oath  (3) history of cardiology  (23) Histroy of medicine  (6) hocm hcm  (2) hyperlipidemia  (2) Hypertension  (5) hypertrophic cardiomyopathy  (3) ICD  (1) ICD -Tips and Tricks  (2) ICD and Pacemakers  (3) infective endocarditis  (2) Infective endocarditis : Pathology  (1) Infrequently asked questions in cardiology (iFAQs)  (182) innovations in cardiology  (3) Interesting case study  (1) Interventions -Structural heart disease  (1) ischemic cardiomyopathy  (2) ivus  (1) IVUS /OCT/NIR  (1) Jugular venous pulse  (2) JVP -Jugualr venous pulse  (1) Land mark articles in cardiology  (4) Left atrial enlargement  (2) Left main disease  (4) Left main stenting -Tips and tricks  (4) lipid metabolism  (1) lipids lipid metabolism  (3) Long and Short QT syndromes  (1) LSCS for heart disease  (1) LV dilatation is diastolic dysfunction  (1) LV function  (1) Medcal research  (5) Medical education  (12) Medical ethics  (14) medical quotes  (43) medical satistics  (4) metabolic support of heart failure  (1) Mitral annulus -Functional mitral regurgitation  (2) Mitral balloon valvotomy  (1) Mitral prosthetic valve-Surgical tips and techniques  (1) Mitral regurgitation  (3) Mitral stenosis  (2) Morality in medicine  (1) Multimodality Imaging  (1) MVPS  (3) My favorite quote  (1) My presentations  (13) myocardial disease  (25) Neuro cardiology  (1) New hardware  (1) Newer cardiac Imaging  (1) Newer hardwares in cardiology  (2) Newer technology  (1) NSTEMI  (2) obesity  (1) open artery hypothesis  (2) opening snap  (1) oral anticoagulants warfarin acitrom  (1) Pace maker Tips and tricks  (5) Palpation  (1) Pathology-Vulnerable plaque  (1) patient education  (1) PCI PTCA Hardware  (6) pericardial disease  (14) pericardial effusion  (1) Pericardium  (3) perioperative risk assessment: Non cardiac surgery  (1) Permanent pacemaker  (2) platelet function  (1) post dilatation  (1) prasugrel  (1) Pregnancy and heart  (5) pregnancy and heart disease  (7) Preoperative evaluation  (1) Preventive cardiology  (3) Primary -PCI  (10) Primary PCI  (12) Primary prevention of CAD  (3) Primary prevention studies  (1) prosthetic valve dysfunction  (2) prosthetic valves  (2) prosthetic valves -Technical issues  (1) PTMC  (2) PTMC -Tips and tricks  (3) Public Health  (4) Public health issues  (4) Pulmonary arterial hypertension  (4) Pulmonary circulation  (3) pulmonary embolism  (1) pulmonary hypertension  (7) Pulmonary vascular resistance  (1) pulmonary vein ablation  (1) quantitative coronary angiogram  (1) Quotes  (15) radial coronary angiogram PCI  (1) Radial Interventions  (1) RBBB vs RVH  (1) RBBB/LBBB  (1) Reperfusion  (2) rf ablation  (1) rheumatic heart disease  (9) Right atrial appendage  (1) Right ventricle  (3) RIsk factors  (1) Science and Religion  (3) side branch jailing  (1) Social medicine  (7) stains and ldl  (1) STEMI  (9) STEMI -Managment  (8) STEMI-Primary PCI  (20) stress doubtamine echo  (1) stroke  (3) Syncope  (6) systemic hypertension  (1) Systolic decapitation in aortic stenosis  (1) TAVR  (2) TAVR /TAVI  (2) tavr tavi  (2) TAVR VS SAVR  (1) Teaching points  (1) Technology  (3) Technology Emerging  (2) TEE-Transesophageal echocardiography  (1) Tetrology of Fallot  (2) Thesis/Research topics for cardiology fellows  (1) Thrombolysis  (9) Thrombolysis -Tips  (3) Tips and tricks in cath lab  (5) Top ten in cardiology  (7) Tutorial in clinical cardiology  (18) Two line sermons in cardiology  (17) Uncategorized  (798) valvular heart disease  (21) Venkat quotes  (15) Venkatesan -Presentations  (1) Viability assessment  (1) vulnerable plaque  (1) Wintage cardiology  (8) wisdom in cardiology  (6) WPW syndrome  (2) X ray  (3)

• 

• The contents of the this blog is being published as Kindle E book , as per the request of many of the readers. Every article will continue to be open source in this site. Again I shall reiterate the book format is not aimed at any commercial intent. It is only to facilitate learning in a single book format Here is the link to book
  https://amzn.in/d/euhL5vu

  • 

• Archives

  • January 2026 (6)
  • December 2025 (11)
  • November 2025 (7)
  • October 2025 (8)
  • September 2025 (7)
  • August 2025 (9)
  • July 2025 (10)
  • June 2025 (8)
  • May 2025 (9)
  • April 2025 (7)
  • March 2025 (10)
  • February 2025 (4)
  • January 2025 (9)
  • December 2024 (11)
  • November 2024 (8)
  • October 2024 (10)
  • September 2024 (5)
  • August 2024 (5)
  • July 2024 (6)
  • June 2024 (5)
  • May 2024 (4)
  • April 2024 (7)
  • March 2024 (4)
  • February 2024 (8)
  • January 2024 (6)
  • December 2023 (8)
  • November 2023 (13)
  • October 2023 (14)
  • September 2023 (5)
  • August 2023 (6)
  • July 2023 (10)
  • June 2023 (5)
  • May 2023 (5)
  • April 2023 (4)
  • March 2023 (5)
  • February 2023 (2)
  • January 2023 (7)
  • December 2022 (3)
  • November 2022 (5)
  • October 2022 (5)
  • September 2022 (4)
  • August 2022 (3)
  • July 2022 (9)
  • June 2022 (2)
  • May 2022 (1)
  • April 2022 (2)
  • March 2022 (1)
  • February 2022 (3)
  • January 2022 (7)
  • December 2021 (3)
  • November 2021 (5)
  • October 2021 (8)
  • September 2021 (4)
  • August 2021 (6)
  • July 2021 (6)
  • June 2021 (7)
  • May 2021 (5)
  • April 2021 (4)
  • March 2021 (3)
  • February 2021 (6)
  • January 2021 (8)
  • December 2020 (4)
  • November 2020 (5)
  • October 2020 (7)
  • September 2020 (7)
  • August 2020 (10)
  • July 2020 (6)
  • June 2020 (9)
  • May 2020 (9)
  • April 2020 (5)
  • March 2020 (7)
  • February 2020 (3)
  • January 2020 (4)
  • December 2019 (4)
  • November 2019 (6)
  • October 2019 (3)
  • September 2019 (6)
  • August 2019 (3)
  • July 2019 (1)
  • June 2019 (3)
  • May 2019 (2)
  • April 2019 (2)
  • March 2019 (2)
  • February 2019 (4)
  • January 2019 (2)
  • December 2018 (2)
  • November 2018 (2)
  • October 2018 (2)
  • September 2018 (1)
  • August 2018 (2)
  • July 2018 (3)
  • June 2018 (1)
  • May 2018 (3)
  • April 2018 (1)
  • March 2018 (3)
  • February 2018 (3)
  • January 2018 (1)
  • December 2017 (3)
  • November 2017 (3)
  • October 2017 (3)
  • September 2017 (2)
  • August 2017 (2)
  • July 2017 (2)
  • June 2017 (2)
  • May 2017 (4)
  • April 2017 (3)
  • March 2017 (3)
  • February 2017 (5)
  • January 2017 (3)
  • December 2016 (2)
  • November 2016 (5)
  • October 2016 (4)
  • September 2016 (3)
  • August 2016 (5)
  • July 2016 (3)
  • June 2016 (4)
  • May 2016 (3)
  • April 2016 (6)
  • March 2016 (4)
  • February 2016 (3)
  • January 2016 (5)
  • December 2015 (6)
  • November 2015 (5)
  • October 2015 (8)
  • September 2015 (2)
  • August 2015 (5)
  • July 2015 (7)
  • June 2015 (4)
  • May 2015 (6)
  • April 2015 (5)
  • March 2015 (7)
  • February 2015 (15)
  • January 2015 (8)
  • December 2014 (5)
  • November 2014 (9)
  • October 2014 (7)
  • September 2014 (9)
  • August 2014 (5)
  • July 2014 (11)
  • June 2014 (5)
  • May 2014 (4)
  • April 2014 (5)
  • March 2014 (8)
  • February 2014 (8)
  • January 2014 (5)
  • December 2013 (7)
  • November 2013 (7)
  • October 2013 (14)
  • September 2013 (12)
  • August 2013 (15)
  • July 2013 (15)
  • June 2013 (15)
  • May 2013 (15)
  • April 2013 (15)
  • March 2013 (15)
  • February 2013 (15)
  • January 2013 (15)
  • December 2012 (15)
  • November 2012 (15)
  • October 2012 (15)
  • September 2012 (15)
  • August 2012 (15)
  • July 2012 (15)
  • June 2012 (15)
  • May 2012 (15)
  • April 2012 (15)
  • March 2012 (15)
  • February 2012 (15)
  • January 2012 (15)
  • December 2011 (15)
  • November 2011 (17)
  • October 2011 (17)
  • September 2011 (17)
  • August 2011 (21)
  • July 2011 (20)
  • June 2011 (17)
  • May 2011 (15)
  • April 2011 (17)
  • March 2011 (25)
  • February 2011 (20)
  • January 2011 (20)
  • December 2010 (18)
  • November 2010 (21)
  • October 2010 (21)
  • September 2010 (25)
  • August 2010 (20)
  • July 2010 (10)
  • June 2010 (11)
  • May 2010 (19)
  • April 2010 (16)
  • March 2010 (14)
  • February 2010 (22)
  • January 2010 (18)
  • December 2009 (20)
  • November 2009 (20)
  • October 2009 (3)
  • September 2009 (21)
  • August 2009 (19)
  • July 2009 (12)
  • June 2009 (12)
  • May 2009 (11)
  • April 2009 (15)
  • March 2009 (21)
  • February 2009 (4)
  • January 2009 (12)
  • December 2008 (13)
  • November 2008 (9)
  • October 2008 (22)
  • September 2008 (20)
  • August 2008 (16)
  • July 2008 (14)
  • June 2008 (7)

• Blog Stats

  • 6,603,481 hits

• Please give your feed back .

• Click below to see who is watching this website live !

  
• This site will never aim for profit. Still ,this donation link is added at the request of few visitors who wanted to contribute and of-course that will help make it sustainable .

• Please Note

  The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.