It is believed coronary artery branching pattern is as unique as our finger prints.Left main coronary artery usually bifurcates .Uncommonly it may trifurcate or rarely quadrificates.
When it gives a cluster of branches like in this patient , the left ventricle is richly supplied with multiple pathways .
These are the patients who are protected well during a coronary event as any one of these branches can back up.However, if leftmain is involved one can guess the consequences !
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With TAVR (Transcutaneous aortic valve replacement ) threatening to take away the Aortic valve surgery atleast in high risk subsets from surgical domain ,a new development is taking place in aortic valve surgery. Minimally Invasive aortic valve replacement and implantation of low profile , bio prosthetic valve placed in aortic root without active suturing .This type of AVR can be done without traditional sternotomy with minimal bypass time , less surgical morbidity and mortality.
It has some specific advantages over TAVR, as the native valve is removed , calcium is debrided and hence less stroke and para-valvular leak .In TAVR cardiologists are blinded ,do lot of guess work to place the valve in right position , struggle to handle the deformed and distorted native valve tissue .My belief is,surgery does a more precision job , since the valve is placed in optimal position .One more issue is, complication of complete heart block and subsequent requirement of pacemaker , its prohibitively high for TAVR as on 2016.(up to 25% )
These new generation valve are expected to narrow the gap between AVR and TAVR. Still. avoiding a surgery is the biggest advantage which drags most patients to TAVR. However, one should ensure quality shouldn’t be compromised for simplicity.
There are two valves available for suture less AVR , both from Bovine pericardium.
1.Perceval (Psorin)
2.Intuity (Edwards)
Evidence
CAVALIER and TRITON (PERSIST -AVR forthcoming)
Message for the patients
TAVR is a revolutionary treatment modality, agreed .However , one need not blindly accept the TAVR if offered especially in low and medium risk* situations just because it avoids a surgery.(*Of-course technology may evolve further ) Discuss with surgeons .Be well informed about all the intricacies.Currently surgical risks seem to overstated and TAVR risks are underplayed in spite of huge cost advantage in favor of surgical AVR.
A note of caution , for suture less AVR must be made .Basically , surgeons tried to imitate the cardiologists, .Ironically , it has the same issues of TAVR for possible migration of valve.Conventional AVR with active permanent fixation sutures will remain the 24 carrot gold standard for AVR and all others may just glitter !
Please realise, medical decision making and consent forms are increasingly looking similar to signing a house mortgage loan which comes with lots of known and unknown “conditions apply”!
Reference
Posted in Aortic valve replacement, cardiac surgery | Tagged Aortic valve replacement, percutaneous aortic valve vs surgical valve replacement, should i go for avr or tavi ?, tavr vs avr | Leave a Comment »
Hypertrophic cardiomyopathy (HCM) is the most common primary cardiac muscle disorder.It is one of the extensively studied medical entity in terms of pathology, genetics, electrophysiology and treatment.Though it has dramatic myocardial phenotypic expression , longevity can be near normal except in a minority who are prone for LV dysfunction and SCD due to the indirect electrical instability.These arrhythmia arise due to myocardial disarray , micro vascular disease or fibrosis.
NSVT by definition is runs of VT at a rate of > 100 /mt occurring less than 30 seconds.
How common is NSVT in HCM ?
On Holter study with 178 patients with HOCM (Adabag JACC 2005 ) 90 % showed VPDs
For sudden death, NSVT on Holter ECG had negative and positive predictive values of 95% and 9%, and sensitivity and specificity of 45% and 69%, respectively.
In this series from StGeorge hospital London from 630 patient incidence of NSVT was 19% and 4 episodes were observed in 48 hr in most .Monserrat L, JACC 2003
What is the duration , How fast and how frequent is the NSVT ?
It is expected the total burden of NSVT would have a definite impact on outcome. Curiously the duration, fastness and frequency of NSVT was not related to prognosis in atleast one study (Monserrat L, JACC 2003)
Relationship between age and burden of NSVT ?
Aging has a sobering effect on these ventricular ectopic activity by probable conditioning and fibrotic interruption of electrical activity.
How often a episode of NSVT convert to VT ?
Considering the day to day even it should be termed extremely rare . Even among person who survived an SCD the next episode of VT can be very rare.
What is the current Indication for ICD in HOCM ?
Secondary prevention (Consensus > Controversy )
Primary prevention (Controversy > Consensus – Still evolving )
Questions galore . . . answers struggle !
Does NSVT arising from single focus or multiple focus ?
What is the relationship between NSVT and degree of obstruction ?
What is the relationship between NSVT and MRI detected myocardial scars ?
How effective is beta blocker suppress NSVT ?
Can we implant ICD for only NSVT ?
Is it true ICDs add more anxiety , distress and harm than the index disease ?
How to program ICD to ignore NSVT and fire only for VT ?
For further information , refer this most authentic knowledge base. 
Final message
Predicting which NSVT will go for SCD in HOCM can be as difficult as predicting the next major earth quake that would strike the pacific rim that experiences unrecognized tremors on everyday basis .We have learned to live with that right ? So it appears NSVT is more of a nuisance arrhythmia for both the patient and physician .
Still , science demands identification individuals with highest risk for arrhythmia . How to do it ? Is it the morphological features , degree of obstruction or genetic finger prints. It is still not resolved . One thing is clear we can’t advice ICD for all those with runs of NSVT for perceived fear or pressure from peers or industry !
Posted in hocm hcm | Tagged hocm hcm, how to manage non sustained vt in hcm hoc, hypertrophic cardiomyopathy, icd for nsvt, managment issues in hocm, nsvt in hocm, sustained vs nonsustained vt in hocm | Leave a Comment »
One of my fellows gave a discharge summary for a 62 year old patient with stable diabetic CAD who had Triple vessel disease with a final advice reading as CABG / PCI/or OMT .
There was a near fury over his angiogram report in the cath meet. How can be eligible for all the three Intervention at the same time ?.(PCI -Percutaneous coroanry Inervention ,CABG-Coroanry artery by-pass graft, OMT-Optimal medical therapy )
The lesion in question was , Triple vessel disease(Non critical LAD) and significant LCX and again a non critical RCA .Syntax was less than 22 for sure , however the patient had class 2 angina (now reducing ) .When asked to explain , the fellow argued since the patient is symptomatic , has DM with TVD he is eligible for CABG , since LCX lesion was discrete and PCI was distinctly possible , of course as all three lesions would be eligible for OMT on any given day ! he inferred .
How can a cardiologist be so casual and non-commital in an important medical decision where a life of a heart is at stake.There was a unanimous condemnation about the report. As a consultant he has to be specific , one can’t leave the decision to your patient’s whims . . . rather it’s our scientific whims that should prevail !
The curiosity continued and looked amusing for many. I was the only one supporting his argument ! After all , he is being frank and understood the futility of applying evolving knowledge base in critical decision making. But, I asked him to grade the choices .In my opinion OMT should be the first choice if it can be administered , but reality tells me true OMT is rare as a modality at-least in this part of world . However every one should insist for it.
Apart from poor compliance for OMT , pressure mounts for a procedure from peers and non peers . I am sure many patients will end up with an invasive modality sooner or later backed by a second or third opinion driven by that elusive googled intellect !
Final message
When clinical decision making is debatable with available knowledge (Especially with futile and evolving knowledge base !) , please include your patient into the debate and you may even consider giving him the veto power.If Hippocrates is alive today , I am sure he will argue for medical knowledge and ignorance should be equally shared with their patients.
Counter thoughts
Don’t give the choice to your patient . . . that would mean you lack clarity, wisdom and confidence !
No, I don’t agree , I know there are some patients who are well informed , rational , more focused than even a professional !
Posted in cardiology -Therapeutics, Cardiology -unresolved questions, Infrequently asked questions in cardiology (iFAQs) | Tagged cabg vs omt, oci vs cabg vs omt, pci vs omt, ptca vs medical vs cabg, what is optimal medical management omt |
Junctional tachycardia(JT) is often a misunderstood arrhythmia. Technically, any tachycardia arising from the AV junction could be termed as JT.Even AVNRT was considered as a form of Junctional tachycardia till recently.The crux of the issue is , true anatomical extent and borders of so called AV junction is yet to be clearly demarcated .The common perception that AV node is a discrete structure is an anatomical illusion , rather its collection of condensed fibers with proximal nodal approach and distal fanning .
Now , we have a proper definition by the apex scientific bodies ACC/AHA/HRS 2015)
Source :2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: Executive summary A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society April 2016Volume 13, Issue 4, Pages e92–e135
Please note :The key point is , JT by definition should be a focal /automatic tachycardia either due to triggered activity or after depolarisation and the boundaries of junctional tissue is liberally extended up to His bundle.
Read related post :What does the term junctional tachycardia mean in current era?
Reference
http://www.heartrhythmjournal.com/article/S1547-5271%2815%2901188-1/pdf
Posted in Cardiology -Definitions, Cardiology-Arrhythmias, Electro physiology, Infrequently asked questions in cardiology (iFAQs) | Tagged acc aha hrs svt guidelines, define junctional tachycardia jt, definition of junctional tachycardia, junctional tachycardia | Leave a Comment »
I don’t know the answer, rather I am afraid to answer that question.
Read this article , that may help find answer to this forbidden question.
Posted in Uncategorized | Tagged ethics in modern medicine | Leave a Comment »
100% occlusion of a coronary artery result in STEMI.This includes both thrombus and mechanical component .We are very much blinded till we touch , feel and see the lesion with a wire or IVUS to quantify the mechanical component’s contribution in the genesis of STEMI.It is generally believed (True as well ) thrombus is the chief culprit .It can even be 100 % thrombotic STEMI with just a residual endothelial erosion and hence
zero mechanical component .However , the point of contention that non flow limiting lesion is more likely to cause a thrombotic STEMI than a flow liming
lesion seems to be biased and misunderstood scientific fact .
What happens once 100 % occlusion take place ?
Sudden occlusion , is expected to evoke a strong fire fighting response within the coronary artery.The immediate reaction is the activation of tissue plasminogen system. In this aftermath few succumb . ( Re-perfusion arrhythmia generated as VF ) .The TPA system activates and tries to lyse the clot.The volume , morphology, attachment, content of thrombus , and the elasticity of fibrin mesh , location of platelet core would determine the life and dissolvablity of thrombus. Even a trickle flow can keep the distal vessel patent .(Please note a timely TIMI 2 flow can be a greater achievement than a delayed TIMI 3 flow !)
What happens to the natural history of thrombus in STEMI ?
Thrombus formed over the culprit lesion can follow any of the following course
Factors determining thrombus migration
The interaction between the hemodynamic forces that push a thrombus distally and hemo-rheological factors that promote fresh proximal thrombus formation are poorly understood. The altered intra-coronary milieu with a fissured plaque covered by platelet vs RBC / fibrin core, totally of obstruction, reperfusing forces , re-exposure of raw areas and the distal vessel integrity all matters.
While, logic would tell us, thrombus more often migrates distally assisted by the direction of blood flow, an opposite concept also seeks attention , ie since the blood flow is sluggish in the proximal (to obstruction site )more thrombus forms in segments proximal to obstruction.
(In fact, its presumed in any acute massive proximal LAD STEMI , it takes hardly few minutes for the thrombus to queue up proximaly and clog the bifurcation and spill over to LCX or even reach left main and result in instant mechanical death.)
What is the significance of length and longitudinal resistance of the thrombotic segment in STEMI ?
If thrombus is the culprit let us get rid of it , this concept looks nice on paper , but still we don’t know why thrombus aspiration in STEMI is not consistently useful. We also know little about the length of the thrombotic segment .When a guide wire is passed over a STEMI ATO it may cross smoothly like “cutting a slice of butter” in some , while in few we struggle and end up with severe no-reflow inspite of great efforts .Why ?
What is the Impact of distal collateral flow in flushing fresh thrombus ?
The efficacy of collateral flow in salvaging myocardium is underestimated. Distal vessel flow if perfused partially by acute collaterals the thrombus load is not only less it’s soft and fail to get organised early that would help cross the lesion easily.
Posted in acute coroanry syndrome, STEMI, STEMI -Managment | Tagged device migration, distal vs proxial migration of thrombus, FAILED THROMOLYSIS, primary pci total study, thrombus stemi | Leave a Comment »
Answer : I guess all mechanisms contribute.Though E appears unlikely, its backed by evidence (Ref 5)
Balloon pericardiotomy is done as a drainage procedure in recurrent pericardial effusion. It is actually a replication of surgical pericardial window by Interventional cardiologist.The window not only drains the effusion , it also act as a continuous drain. Though the benefits are real (Pericardial fluid is shunted away from the pericardial space) the exact mechanism of its benefit is not clear .
By concept , the catheter and balloon should not cross the pleural space , (As pneumothorax may ensue) but still pleural effusion is a common consequence of this procedure .How is this possible ? One probable explanation is, the pleural space has some hidden communication with pericardial space .The other possibility is that, balloon creates virtual tissue channels in the para-cardiac spaces of mediastinum .The extra-cardiac lymphatics does the drainage job without true shunting pericardial space into the pleural space..
There is an article from Annals of thoracic surgery which specifically looked into the mechanism of benefit of surgical pericardial window and came to a surprise conclusion, ie, it is not the continuous drainage that keeps the space dry , rather it is likely the window somehow obliterates the pericardial space permanently.(Sugimoto 1990,Annals of thoracic surgery )
Future Innovation : A technical add-on to balloon pericarditomy could be , delivering a covered stent across the pericardial space into peritoneal space like a VP shunt done by Neurosurgeons.(If no body has done this , Can I claim the patency for this !)
The procedure
Image used from Daniel A. Jones & Ajay K. Jain, Journal of thoracic Oncology , 2011
Risk of procedure
The procedure carries a definite risk especially if done in an emergency fashion. The aim of procedure is two fold one to drain pericardial effusion second to prevent recurrence of effusion .Since procedure carries considerable risk its to be performed only in malignant effusion that are documented to be recurrent.
Surgical vs Balloon window and other alternatives
Surgical window creation is well known procedure , ever since Palacios (Ref 1) in 1991 described this per cutaneous approach as an alternative to surgery has become less popular. The risk of anesthesia and co-morbidity makes balloon pericardiotomy attractive. But surgical window creation still may have a role. A video assisted pericardiotomy by thoracoscopy is also possible .Another option is injecting sclerosing agents into pericardial space .This time tested simple modality probably requires more attention.
Need for subsequent pleural tapping
It should be realised this procedure may just shift the fluid from pericardium to pleural space. Some of them become significant effusion that requires pleural space drainage.
Concern of risk of dissemination of malignancy
Its a real issue , there has been instances of accelerated death after the procedure. Hence this procedure is a trade-of between patient comfort and quality of life with a potential risk of dissemination impacting the longevity of life .
Posted in cardiac tamponade, Cardiology -Therapeutic dilemma, Pericardium | Tagged balloon pericardiotomy, percutaneous baloon pericardiocentesis |
The field of cardiology has seen great men over the centuries. Few women have permanently stamped their presence in that history .Jane Somerville can be termed mother of pediatric cardiology along with Maude Abbott She has a fascinating life history , having worked in Royal Brompton , Imperial and Guys London.She was mentored by pioneers like Paul wood , Blalock and others .She is primarily interested in the pediatric cardiology especially congenital heart surgeries .The classification of pulmonary atresia with VSD goes with her name.
Dr. Jane Somerville : British cardiologist , (b-1933 )
She carries the credit of starting the Pediatric cardiology world congress in 1990 ,is the founder of GUCH (Grown up children with congenital heart disease.) .
Here is a rare interview from he to Dr Robert Califf for Heart.org. For those,who like to have a glimpse of cardiology in its vintage times , don’t miss it.Dr Jane addresses the past treasures , explores specific issues of facing pediatric cardiology and frank expression about the issues of women being a cardiologist in a man’s world.
She has a foundation in her name that helps the children and adults with congenital heart disease.
Reference
The landmark paper in BHJ 1970
Posted in congenital heart disease, history of cardiology | Tagged history of cardiology, Jane somerville, pulmonary atresia jane somerville | Leave a Comment »
“Men are from Mars , and Women are from Venus ” . . . Do you agree ?
Many probably witness the much talked differential behavior among the gender every day. Its argued , men take more risk in life ( often senseless !) , some go to the extreme to suggest Men are Idiots and decorate them with a provocative title MIT (Men Idiot Theory ) (Mcpherson 2011).Risk taking is important in life, but at what cost ? Does women (Who are caring by nature ) help themselves and the society by less risk taking behavior ?
I stumbled upon this rare piece of writing from BMJ which would demand in depth analysis into this gender phenomenon based on evolutionary biology and genetics.
This article concludes, Yes, men . . . indeed tend to take some foolish risks in various life situations that result in potential harm.
What is the influence of MIT on medical profession and patient outcome ?
Now , Iam compelled to ask a hypothetical question .Does women medical professionals take less aggressive stance and low risk taking behavior ?
If it’s true, It may have some striking advantage too.
Reference
1.Harris CR, Jenkins M, Glaser D. Gender differences in risk assessment: why do women take fewer risks than men? Judgm Decis Mak2006;1(1): p. 48-63.
2.Eckel CC, Grossman PJ. Men, women and risk aversion: experimental evidence. In: Plott CR, Smith VL, eds. Handbook of experimental economics results. Vol 1. North-Holland, 2008:1061-73.
3.McPherson J. Women are from Venus, men are idiots. Andrews McMeel, 2011
4.Northcutt W. The Darwin Awards: The official Darwin Awards: 180 bizarre true stories of how dumb humans have met their maker. Orion, 2004.
Posted in bio ethics, Gender issues in medicine, Hippocratic oath, history of cardiology, Histroy of medicine, medical quotes, Wintage cardiology | Tagged medical ethics gender issues | 1 Comment »
Dr.S.Venkatesan MD 