If only . . . we get an image like this , echo can help rule out most left main disease with conviction .
Have a close look at it ! One can get a good image of coronary ostia in short axis view . But , here it is well visualized in long axis .
I tried to put color flow within left main .
What about pulsed Doppler across left main ?
After all it needs 2mm sample volume and this left main was near 4.5mm . So keep trying !
Posted in Cardiology -Interventional -PCI, cardiology- coronary care, cardiology-Anatomy, Cardiology-Coronary artery disese, Echo library and gallery, echocardiography, great illustrations in cardiology | Tagged left main by echo tte, left main coroanry artery, left main ostium, rare echocardiogram images | Leave a Comment »
In this complex world , simple innovations fail . . . just because they are simple !
Here is a new* PTCA catheter which has a two balloons , the distal one dilates the lesion and the proximal one has a stent over it . The stent is just deployed after the dilatation by the proximal balloon . The proximal balloon not only help us prepare the lesion before stenting it also helps in crossing difficult lesions . Further , it can be even used to post dilate the lesion . It can be a non compliant balloon as well . It appears a good concept .
*Not really new I believe , Accuramed owns the patent for this twin balloon catheter over a decade now .(First twin balloon Gemini PTCA was used in 1988 )
I do not know why we haven’t adopted it yet , while many dubious innovations are making merry around the world !
The only downside could be , combinations of stent and balloon sizes are limited . But , it is not a major issue .The ability to fine tune the stent apposition moments after the procedure , by h a simple pull back is just amazing !
This catheter is made by
A C C U R A
Medizintechnik GmbH
Max-Planck-Str. 33 61184 Karben Germany
Tel +49-6039-9201-0 Fax +49-6039-9201-22
E-Mail info@accura.info
http://www.accuramed.de
Final message
Two balloons over a single catheter is a new development .I wonder it can be the standard of care in all PCIs . Hope somebody takes this concept to the next level for the benefit of our patients.
Link to the manufacture
http://www.accuramed.de/fileadmin/daten/en/Gemini_System.pdf
Posted in Cardiology -Interventional -PCI, cardiology innovation | Tagged balloon support and coronary stenting, crossing a lesion with balloon, doubel balloon catheter, gemini stent balloon accuramed, gurentzig innovations in ptca, innovatons in ptca, non compliant balloon in ptca | Leave a Comment »
* Obfuscation: hiding of intended meaning in communication, making communication confusing, wilfully ambiguous, and harder to interpret
This world can not be a perfect place and it is foolish to expect the same ! What is published in medical literature is at best , an abstract thinking of an unfinished agenda . Still public think science is . . . what doctors say ! They feel doctors can not simply watch a person dying. They want us act like God. This is how medical men became Demi-Gods by default.
Here was a big opportunity . Who exploited it ? Obviously the greedy corporates who embarked on a dirty journey to en- cash this trust and fill their coffers .This is the foundation on which the basics of medical market economy rides !
It is an un-pardonable on-going deceit among modern human civilization . It has spoiled the trust between the patient and doctor and probably irreversibly contaminated in recent decades !
There are very few positives though, with occasional noble medical souls (Like BMJ,Lancet ) trying to keep the sinking ship afloat !
This sounding board article (Now we rarely get to see ) from NEJM way back in 1975 exposes a shocking revelation politely . Now, 40 years after , the importance of such article has grown many fold . We are witnessing every day , medical scientist break stories ( Yes . . . it is story ) in general media with absolute academic cowardice !
We expect more such face bashing articles from NEJM . It would definitely make immense good for our profession which needs it desperately !
Reference
I’m linking the original NEJM article ; Hope it does not violate copy right !
Posted in cardiology journals, cardiology-ethics, Cardiology-Land mark studies | Tagged academic cowardice, data manipulation', data torturin, fraud in medical research, intentional mis communication, medcial ethics, medical cowardice, medical obsfuscation, medical research | Leave a Comment »
6 minute walk test is the simplest of all functional testing in cardiac evaluation . Though walking is a routine day to day motion , it is essentially a hemo-dynamic stress for the heart , especially so for an ailing heart . Even though it appears simplest of all investigation there are strict guidelines available for performing this .
It is surprising American thoracic society has come out with a specific guideline for this .Many of us are not aware of existence of such guideline , hence this post , with courtesy of ATS I am giving a link.
Guyatt G. H.,Sullivan M. J.,Thompson P. J.,(1985) The six-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can. Med. Assoc. J. 132:919–923.
Butland R. J. A.,Pang J.,Gross E. R.,(1982) Two, six, and 12 minute walking tests in respiratory disease. B.M.J. 284:1607–1608.
History and genesis of the concept
It was originally used in COPD in 1976 with a 12 minute walk .Cardiologists abbreviated it to 6 mts for their convenience.
McGavin CR, Gupta SP, McHardy GJR. Twelve minute walking test for assessing disability in chronic bronchitis. Br Med J 1976;i:822-3.
In modern times we have an Android application for 6 minute walk test
Posted in Cardiology Risk assesment, Clinical cardiology | Tagged 6 minute walk test, american thoracic society guidelines 6 six minute walk, ats guidleines for 6 minute walk test, cardiac functional capacity, nyha vs 6 minutes walk test, six minute walk test | Leave a Comment »
This article provides you every thing you want to learn about ASD device clsoure .The anatomy , the art of doing TEE in cath lab etc.Do not ever shy away from lesser known journals .It is simply amazing to find hidden treasures .Thanks to Mr Tim Berners–Lee invenor of the Internet !
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Great websites in cardiology | Tagged asd device closure best articles, asd rims, lesser known cardiology journals, mexican cardiology journals | Leave a Comment »
Even though cardiologists consider themselves master of ischemic heart disease , their collective clinical acumen is put into acute stress test when they confront a patient with dilated LV and severe LV dysfunction.This is not a rare situation in clinical cardiology we stumble upon such instances often .Most of them are conferred a tag of DCM .
The differentiation from ischemic vs idiopathic or primary muscular is not a wasted academic exercise , since ischemic DCM may get reversed with revascularisation .We have various tests to differentiate ischemic from idiopathic like CAG,MRI, 3D RTE, etc . Still common sense would tell us 95 % of times we can differentiate ischemic DCM from non ischemic by asking two critical questions in the bed side echocardiogram
Idiopathic DCM is primary disease of muscle hence the cardiac muscle as a whole fails ( We know they are a single folded muscle sheet )
Since Ischemic DCM primarily affect left ventricle and left atrium RV,RA enlargement are terminal events.
* Please note the traditional dependence on CAG to diagnose ischemic DCM is fraught with a risk of missing small vessels induced DCM,
*** If atrial fibrillation is present longstanding it can dilate both atrium but still RV will be normal in sized in ischemic DCM until very late stages
Here is a 20 second flow chart to differentiate ischemic DCM from idiopathic
Posted in cardiology -Therapeutics, Cardiology -unresolved questions, cardiomyopathy | Tagged differentiating ischemic and non ischemic dcm, ischemic cardiomyopathy, ischemic dcm, non ischemic dcm | Leave a Comment »
If you are a doctor and whatever be your specialty . . . if you do not read this article and understand the nuances probably you will not become a complete medical professional !
While BMJ struggles to propagate a vital truth , this banner on a Indian high way tempted the public to go for 64 slice CT scan . . .just like that !
Final message
Accruing medical knowledge and skills is only one aspect of medical profession. Applying it properly in our patient population is entirely different ball game . Let us be disease curers and not disease hunters . This is important because disease hunting is a dangerous game , where victims can be innocent bystanders. This is exactly same thing Hippocrates refered to as Primum non nocere 1000 years ago. It has required a huge statistical study to RE-INVENT this universal fact !
Posted in bio ethics, cardiology journal club | Tagged britsh medical journal, cochrane nordic data base master medical check up, hippocrates, land mark article, master medical checkups, medical ethics, primum non nocere | 1 Comment »
The major issue of contention is fear of conversion of pure ischemic stroke into hemorrhagic stroke .
But here is a catch if you worry about that . . . who will worry about recurrent emboli from heart ?
References
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678170/pdf/nihms104070.pdf
Recommendation for heparin
Recommendation for anti-platelet drugs
I think the 2007 stroke guidelines are the latest .Even after going through the guidelines I am not really clear about the answer for the question posed in this article.
One more thing I (mis) understood was , In acute stroke thrombolysis seems to be safe . . . Heparin seems to be dangerous ? Is that true ? It defies logic for me !
One possible explanation is thromolysis is a emergency single shot salvaging process . While prolonged heparin will ooze blood into Infarct ! This is exactly is the reason in tPA should not be followed up with heparin in acute strokes.(unlike STEMI where a follow up heparin is a must )
Regarding prevention of recurrent emboli , we need to bother about whether it is predominately platelet rich or RBC rich
Readers may contribute to find the exact answer !
Posted in cardiology -Therapeutics, Cardiology -unresolved questions, cerebral circualtion stroke, cerebral circulation stroke, general medicine | Tagged acute stroke mangement, aha 2007 stroke guidelines, anti platlet drug in stroke, aspirin clopidogrel in stroke, cardio-embolic stroke, heparin for ischemic stroke, role of heparin in embolic stroke | Leave a Comment »
A 60 year old man with chest discomfort and severe breathlessness and blood pressure of 160/110 was wheeled into CCU. A diagnosis of acute anterior STEMI was made and he was about to be thrombolysed . Since his blood pressure was high they were waiting for it to come down with IV Nitrglycerin
I was called to see this patient .Here is his ECG .
Though ECG suggested anterior STEMI , I was fairly convinced it was in fact LVH and incomplete LBBB.
I confirmed with the patient about the onset of symptoms . It was primarily breathlessness and only a vague discomfort .Meanwhile , the troponin came as positive and CPK MB was normal. The combined troponin positivity and ST elevation almost confirmed the STEMI , and the urgency for thrombolysis was intensified . One resident suggested an emergency PCI.
My self , in spite of being a cardiologist was isolated among the physician team . I had to urgently prove to them it is indeed not STEMI ! I did a bed side echo and showed the physician colleagues a vigorously contracting hypertrophied left ventricle with a EF of 68 % . There was negligible wall motion defect . . . if at all any !
They were still far from convinced ? They were sort of amused .There is ST elevation , there is troponin positivity. . . what else you want . . . they seemed to ask ?
I asked them . . . How can an acute extensive anterior MI contract so well , without a trace of wall motion defect ?
It took me considerable time and effort to convince them that the whole thing was not a STEMI. Finally they agreed .It was a simple LVH with secondary ST elevation due to incomplete LBBB . Troponin elevation simply represent minor myocardial injury associated with hypertensive LVF . This patient was discharged within 24 hours in perfectly stable condition . Since he had mild elevation of creatinine and was sent for nephrology work up.
Final message
LVH with secondary ST elevation in V1-V4 is a common situation that mimics acute STEMI . Cardiac failure can result in non ischemic troponin release . Acute medicine is an unique art . Some times it demands all your senses to be on alert mode . Realise , in the above case , in spite of the the classical triad of chest pain , ST elevation , troponin positivity it almost led to a wrong diagnosis of acute myocardial Infarction .
After thought : What if they had thrombolysed this patient or taken for a PCI ?
When the clinical suspicion is high and circumstantial evidence point to an ACS , this error can be justified . After all , 5 % of famous ISIS study population were not suffering from STEMI but got thrombolysis !
* One real possibility in this ECG is old AWMI with re-infarction or a dyskinetic septum lifting the ST segment .But both were excluded by the rapid bed side echo.
Posted in cardiology -ECG, critical care ccu | Tagged acute coronary syndrome, coronary care secrets, diagnostic issues in ccu, differential diagnosis of stemi, incomplete lbbb, lvh incomplete lbbb | Leave a Comment »
The popular clinical entity Idiopathic dilated cardiomyopathy is often a “dust-bin diagnosis” . The fact is the word idiopathic simply reflects our ignorance.
For God nothing is idiopathic . . . he knows how each and every cell would behave .
so , when a patient presents with progressive dilatation and heart failure refractory to all medical therapy he is termed as idiopathic and posted for heart transplantation. And only later , we realize the whole thing is due a terrible form of reversible DCM . That is pheochromocytoma induced DCM , which recurred again in the transplanted heart. What a costly Ignorance ?
Image courtesy and source http://www.dreamstime.com.
Is sub- clinical pheo like situations rampant ?
We know that high levels of both epi and nor- epinephrine circulate in cardiac failure . We presume it to be a secondary effect .
How can we so sure about it ? There is a distinct possibility of adrenal gland hyperfunction and hyperplasia in all DCMs (Idiopathic or ischemic ! ) The dramatic beneficial effects of beta blockers in cardiac failure will vouch for it .
So , It remains a fertile filed for the youngsters to explore . . . the hyper adrenergic mediated reversible component of any cardiomyopathy and cardiac failure .
Final message
The default approach in any patient with progressive / refractory cardiac failure should be , to consider whether they fit into any form of reversible myocardial disease . What is idiopathic in remote clinic of your distant country side may be well recognized secondary cardiomyopathy . The irony is , even sophisticated university hospitals many times miss the true etiology as in the above case report .
So, the term Idiopathic dilated cardiomyopathy (iDCM ) may aptly be named as Ignorant forms of DCM , with an attractive abbreviation . . . iDCM
Reference
2.Kelley SR, Goel TK, Smith JM.Prog Cardiovasc Nurs. 2005 Summer;20(3):117-9. Pheochromocytoma presenting as heart failure.
4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1894695/pdf/20070600s00025p244.pdf
5. http://downloads.hindawi.com/crim/medicine/2011/596354.pdf
Posted in cardiology -Therapeutics, myocardial disease | Tagged ignorant dilated cardiomyopathy, irreversible dilated cardiomyopathy, pheochromocytoma and dilated cardiomyopathy, reversible cardiomyopathy | Leave a Comment »
Dr.S.Venkatesan MD 