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Why the future looks bleak for our patients . . . unless some drastic things happen !

February 1, 2011 by dr s venkatesan

It is often said optimism is key to success . From the patient’s and physician’s  perspective   it is the willpower that has saved many lives. Positive minded patients  do not die without fighting. We  know self belief can do wonders in medical  care  !

If  self  belief is  the ultimate healer ,   trusting the   doctor  and  the hospital  are  equally important  . Patients believe in  doctors and doctors believe in science . Science is not sacred .It is man-made   .Those men  who create  science  need not be  holy  either !

Can  we  trust modern medicine in the current form  ?

I am afraid the answer is  too tilted towards  . . . “No”   I am not a pessimist  in the strict sense  . However ,   the future   looks bleak  in most places  ! unless some strong remedial measures are under taken.

Statistics   suggest , patients  are  rapidly losing   the belief   in their physicians   ,  considering the track record of our  health care management in recent  times . Global trends in the last 5 decades indicate the health care delivery system has gradually  been  hijacked from the Govt to the private hands.

It is  quiet a shocking  revelation ,   the private  sector  health care  has done  more damage  than  the state   driven health care . How  foolish   our expectation  can  be !   For fulfilling the millennium  goal ( Health for all )  most  countries  have  handed  over the  baton  to the  greedy corporates .

How on earth , one can expect  the   private / corporate  sector  to provide  equitable health   for all  . It  would be wealth for all  those involved in  this flawed medical care  system  at the cost of  poor !

Read this book  . . .To understand the nuances of how our health care industry is bulldozing  , like an army tank into the population  and  most of us  is a victim or a partner to this .

Click here  for  the  Book review

From The Hindu January 2011

Final message

Entry of capitalism into health sector is probably the worst  infliction   man kind  has suffered , than all those deadly viruses and bacteria   over a last few centuries !

Medical science is a phenomenal  gift  created , nurtured and grown by the sixth sense of our ancestors .Their only aim was to provide relief to the sufferings.  Now their dreams,  vision and goals lie  shattered .

No hospital  has a  specialty called  “humane care”  , while  many  have  a separate  department   to  do a  neuro  metabolic imaging    for a  depressed  man with Alzheimer  disease   in his nineties   and  a  Bio – Robot  driven    fuzzy logic  lab   to  predict cardiac  events  in a soon to die rich man . Absolute waste of resources !

There is  no doubt , we have become a  sort of  salves to  science  . . . (Irrational science to be precise ! ) It is a man-made monster.  Even a most conservative person  (including the author )  could    be causing  some damage as we  are forced to follow  the unruly scientific publications .  Probably  . . .yes . . . we can’t eliminate  it   but   identify  futility of modern science try to get  rid of it . !

A related article

Those were the days   . . .  When doctors practiced medicine  . . .and much more  . . .

A  wonderful  piece of writing   by Dr Susikaran  Thangasamy from the open pages of  India’s national newspaper

‘The Hindu” http://www.thehindu.com/opinion/open-page/article1137935.ece

What is the remedy ?

First of all , every one should answer this question to their conscience

What ails  our health care  system  today ?

Do not be part of it . . .  solutions  will come automatically !

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Simplified “Life cycle” of PTCA

January 28, 2011 by dr s venkatesan

Life cycle of PTCA : Let us hope it do not become extinct !

Does PTCA  , a great Innovation for mankind,  is facing a threat of  extinction ?

It seems so . . . the stents  are losing its shine  in most situations. A simple evidence  . . . for that . . . can  be found in answering the following question

What drives the extensive research in biodegradable stents now ?

The simple answer is , we are fed up with the metals inside the coronary  artery. We want to get rid of it !

Too much of knowledge , often blunts our senses . Our track record clearly  reveals this fact. We needed a major study INTERHEART to tell the world   that  ,exercise is good and tobacco is bad for heart  !  Now ,we forgot a  simplest solution for  getting rid of  metal inside the coronary artery ,  which  is  “not to implant  the stent”  at all ! (Instead we do billion dollar research for making  bio – absorbable stents ,  which in the first place may not be required in the majority !

Read the related article . Does POBA has a role now ? in my site

The only situation  , where PCI   may  withstand the test of time could be in ACS (Both in STEMI and high risk NSTEMI !) PCI is cosmetic in most of the chronic coronary syndromes .

Final message

Our fight against human atherosclerosis will have to be , by medical means .PCI at best will  provide  a supportive role in selected patient group. It requires lots of common sense  and   scientific ignorance to achieve this.   Risk reduction ,  prevention , optimal   medical therapy  will have to play a dominant role in the next few decades .  This is something similar to the environmental issues we face in protecting our planet .No amount of green industry  will protect  the earth . It requires better social and  behavioral  ethics  from  mankind   and their  rulers !

Posted in bio ethics, Cardiology -Interventional -PCI, cardiology -Therapeutics | Tagged , , , | Leave a Comment »

A simple solution from Canada , for all those complex Echocardiography formulas !

January 27, 2011 by dr s venkatesan

Few web sites provide   free  cardiology  service.  This one from cardiomath beats  all  ! It makes the job easier for all those cardiologists who spend  lots of time in echo lab . It provides  simple  online tool  for all common calculations in clinical echocardiography

Here is  the link to the website of cardiomath

With  due  Courtesy   to

Author: Dr. Chi-Ming Chow  Developer: Edward Brawer  Illustrator: Ellen Ho
Sponsored by  Canadian society of echocardiography

Posted in echocardiography | Tagged , , , , , , , | Leave a Comment »

What is “Partially successful” or “Partially failed” thrombolysis ?

January 26, 2011 by dr s venkatesan

Nothing in this world is black and white. In fact,  most events are in between . The irony is , our brain  always wants to view  things in two distinct entities !

  • Success or failure
  • Beautiful or ugly
  • Good or bad
  • Win or lose,
  • Rich and poor etc . . . etc

So it is no  surprise !  cardiologists  also travel in the same boat !

They classified  the events after thrombolysis   into two dogmatic categories . Successful  thrombolysis or failed thrombolysis   . . .  as if no other event  can occur in between .

Traditionally 50% regression of ST segment is called successful .   What  about 30%  and 40 % ST regression ?

Further , there is an important caveat  in the timing,  as we  traditionally assess ,  90 minutes of thrombolysis .

Consider the following  situation  :

  1. Thrombolysis  is failed at 90 minutes, but  succeeds  at 120/180  minutes ?
  2. Is 50 % ST regression at 180 minutes is as bad  or as good as 25 % regression at 90 minutes ?
  3. How to label a patient who  is extremely comfortable in spite of ECG criteria of failed thrombolysis ?(Surprisingly this situation is fairly common !)

So, without finding answers to some critical questions , we have defined the success  of thrombolysis with  half baked data .

This is exactly , is the reason we  are unable to do a  valid  study on failed thrombolysis, rescue PCI etc .  We know the results of rescue PCI  ,  always  been  contradictory to the general logic !

It is estimated a substantial number of  STEMI patients following   thrombolysis   fall into a category of partially successful thrombolysis implying partial restoration of blood flow and salvage. The correct definition for  successful thrombolysis and reperfusion should be at the myocardial mass level , and  not at the level of coronary artery.The ECG  is the best available indicator.

Implication for having a  poor definition  of  failed thrombolysis

It is not a rare sight to wheel  in , a patient to a cath lab  with label of failed thrombolysis dangling in his neck  who is clinically  stable  (Has a less than required 50%  ST regression , but a definite, favorable trend with a 30 % ST regression  at 90 minutes  )

How many cardiologists will be willing to abort a CAG/PCI  , as a repeat ECG just  before puncturing  in the  cath lab reveals    successful  thrombolysis ? (little  delayed though !)

If only we have better methods to risk stratify patients following thrombolysis , we can avoid

  • Huge costs incurred
  • Expected and unexpected hazards of doing an emergency  intervention in an adequately salvaged STEMI
  • Hundreds of cardiology man hours can be saved  for better purposes .

Final message

Classifying thrombolyis into  success  or  failure  is a  skewed  way of looking  at this important  issue .

It is an irony ,  cardiologists often  triage LV dysfunction , valve disease , cardiac failure  etc  into 4  grades (  minimal  , mild , moderate or severe  ) . It is  still a mystery ,  why thrombolysis  is never graded  like that ,  and it is always considered as  all or none phenomenon !

There is a substantial number of patients  with partially successful ( or shall we call partially failed !) thrombolyis  .This group must be given adequate attention or inattention  . There  is a urgent need for a through review of how we look at  the post thrombolysis status  . It is better to use the newer imaging modalities like PET/MRI more  liberally to identify  exact sub group  of failed thrombolysis who will benefit form revascularisation .

Posted in Cardiology - Clinical, cardiology -ECG, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology-ethics | Tagged , | 1 Comment »

For all those proud heart patients . . . here is a heart repair manual !

January 20, 2011 by dr s venkatesan

Manuals are not only for doctors . There are few heart  maintenance manuals for patients as well.

This one from Philadelphia ,  is worth reading and of-course  following  thereafter  !

 

Some books can be as effective as CABG or PCI .

This  one is definitely in that league  . . .

Posted in Best books in cardiology, Cardiology - Clinical | Tagged , , , , , , | 1 Comment »

Who killed Starr -Edwards valve ?

January 15, 2011 by dr s venkatesan

Prosthetic valve implantation has revolutionized the management of  valvular heart disease . The original concept valve  was a ball in a cage valve  , still considered as a  fascinating discovery.  It was conceived by the young Dr Starr and made by Engineer Edwards  .This was followed   by long hours of arguments,  debates and  experiments that ran into many months . The  silent corridors of  Oregon hospital Portland USA remain the only witness  to their hard work and motivation.  At last,  it happened , the first human valve was implanted in the year 1960. Since then . . . for nearly  50 years these valves  have done a seminal  job for the mankind.

With the advent of  disc valve and bi-leaflet valve in the  later decades of 20th century , we had to say a reluctant good-bye to this valve.

There is a  lingering question among many of the current generation cardiologists and surgeons why this valve became extinct ?

Starr and Edwards with their child !

We in India , are witnessing these old warrior inside the heart functioning for more than 30 years.From my institute of Madras medical college  which probably has inserted more Starr Edwards valve than any other  during the 1970s and 80s by Prof . Sadasivan , Solomon victor , and Vasudevan and others .

It is still a mystery why this valve lost its popularity and ultimately died a premature death.The modern hemodynamic  men  working from a theoretical labs thought  this valve was  hemodynamically  inferior. These Inferior valves worked  like a  power horse  inside the hearts  the poor Indian laborers  for over 30 years.

A Starr Edwards valve rocking inside the heart in mitral position

The cage which gives  a radial support* mimic  sub valvular apparatus, which none of the other valves can provide.

* Mitral  apparatus has 5 major  components. Annulus, leaflets, chordae, pap muscle, LV free wall.None of the artificial valves has all these components.  Though , we would love to have all of them technically it is simply not possible.  The metal cage of Starr Edwards  valve partially satisfies this  , as  it acts as a virtual sub valvular apparatus.Even though the cage has no contact with LV free wall, the mechano hydrolic  transduction of  LV forces to the annulus  is possible .

Further , the good hemodyanmics of this valve indicate , the cage ensures co axial blood  flow  across the mitral inflow throughout diastole. .Unlike the bi-leaflet valve ,  where the direction of  blood flow is determined by the quantum of leaflet excursion  in every beat . In bileaflet valves  each leaflet has independent determinants of valve  motion . In Starr Edwards valve the ball is the leaflet . In contrast to bi-leaflet valve , the contact area  of the  ball and the blood in Starr Edwards  is a smooth affair  and  ball makes sure  the LV forces are equally transmitted to it’s surface .

The superiority of bi-leaflet valves and disc valves  (Over ball and cage ) were  never proven convincingly in a randomized fashion . The other factor which pulled down this valve’s popularity was the supposedly high profile nature of this valve. LVOT tend to get narrowed in few undersized hearts.  This  can not be an  excuse , as no consistent  efforts were made to miniaturize this valve which is  distinctly possible.

Sudden deaths from  Starr Edwards valve  .

  • Almost unheard in our population.
  • The major reason  for the long durability of this valve is due to the  lack of  any metallic moving points .
  • Absence of hinge  in this  valve  confers  a huge mechanical  advantage with  no stress points.
  • A globe / or a ball  has  the universal hemodynamic advantage. This shape makes it difficult for thrombotic focus to stick and grow.

Final message

Science is considered as sacred as our religion .  Patients believe in us. We believe in science. A  good  durable valve  was  dumped from this world  for no good reason. If commerce is the  the main issue ( as many still believe it to be ! )  history will never  forgive those people who were  behind the murder of this innocent device.

Cardiologists and Cardio thoracic surgeons are equally culpable  for the pre- mature exit of this valve from human domain.  Why didn’t they protest ?  We  can get some solace  ,  if  only we can impress upon  the current valve manufacturers  to  give a fresh lease of life to this valve .

http://www.heartlungcirc.org/article/S1443-9506%2810%2900076-4/abstract

Posted in cardiac surgery, Cardiology - Clinical, cardiology -Therapeutics | Tagged , , , , , , , , , , , , | 5 Comments »

Heart is like your Car : Do you need to service it periodically ?

January 15, 2011 by dr s venkatesan

It is   surprising  to find  many   similarities between  our heart and the car .Both essentially carry out  mechanical function.  One carries the  life , while the  other beats ,  breaths life !

  • The car is the status symbol  of modern life  , while the heart is a life by itself .
  • The car has a 4 stroke engine  , while the heart has only two strokes – systole and diastole !
  • The car pumps petrol  , the heart does it with blood.
  • The car can afford to take rest at night in your garage   but  , your heart doesn’t.
  • Car  can be replaced  by a fresh one every 5 -10 years your heart can’t be.
  • In India  , it is  mandatory   for  the cars  to be  insured for  about  10 Lakh  rupees , while  the   poor hearts of our country men  are not even insured for a  single pie  !
  • A dent in your  new  Toyota  can give us   sleep less nights for many days .  A bruised and battered heart with tobacco and cholesterol is rarely  bothered about .

When the silent  screams of the heart  are not respected and heard ,   there is no other option left  for  it ,  to register its protest  , except with  a  heart attack   .This  can either be a  SOS call  or  a  call from  Heaven !

Final  message

Remember ,  the   heart breathes  your life ,  your car  doesn’t .Heart is   million times glorious than your car.

It is foolish to compare  the heart with a car . But let us  at least  learn to respect it  . . . like  our car.

Heart service station

  • Authorized heart service centers are few . Insist on genuine spare parts. Good  service engineers are becoming a rare breed.
  • Remember  both defective spare parts   and  dysfunctional service  engineers  can ruin your heart.
  • Do not allow your heart to  be explored and dismantled for flimsy reasons.
  • Never hand over your heart to strangers.
  • Do not-self indulge in 64 slices  of  fancy   shooting  of  your heart . Resist the temptation.
  • Finally do not ever go for unscheduled  free heart  service camps . That is the beginning of  trouble for your heart.

Some hearts  may  servicing alright , but realise , you are the master of the  service station .

If only you respect it , it  rarely requires to be sent to a  garage (cath lab )


Simple life style, adequate activity,   nutritious diet,  peaceful   sleep,  good work ethics ,respect to  fellow citizens  ,good-bye to  anger , helping the poor, a joyous family life , and finally  . . . less  visits to your physician  !  These  make  a  perfect , sure shot  recipe  for  living   100  glorious years !

Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology innovation | Tagged , , , , , , | Leave a Comment »

Sure shot recipe for living 100 years !

January 15, 2011 by dr s venkatesan

Why is it .  .  .  so difficult ,  to  acquire  healthy   habits  and   good  behavior  in life ?

How to over come it ?

Answer :

No body can answer this question . . .Except yourself  !


Posted in bio ethics, Cardiology - Clinical, medical quotes | Tagged , , , , , , , , , | Leave a Comment »

5 minutes crash course on Ventricular septal rupture !

January 14, 2011 by dr s venkatesan

We know,  electrical deaths constitute the bulk of sudden cardiac deaths in MI.  Mechanical deaths due to pump failure, muscle rupture , valve leak , also cause significant deaths   .(Surprisingly many of the mechanical deaths   may also   fulfill  the sudden death criteria !)

Free wall rupture is  invariably a fatal event. Papillary  muscle trunk  rupture  leads to severe LVF and unless intervened sure to result in fatality.

The ones who tear their interventricular septum  are some what blessed ! Here ,  the rupture does not result in instant death as there is  no loss of blood ,   instead , there is an  volume over load of right ventricle  followed by the  left ventricle  after a  few beats. Hypotension is the  rule. Even though this is a major complication there is something about  VSR which makes it unique.

Sudden giving way of IVS has  a decompressing effect on the ailing left ventricle.This many times  bring a  temporary relief to LV and if the patient survives the first few hour he is likely to stabilise  further . In fact , sudden deaths within 24hours after the onset of VSR is an exception.This defect always gives the cardiologists and surgeon some time to plan the management. We need to use this time judiciously.

The natural history is delicate . Five themes are possible

  1. Very unstable – Instant death( Fortunately a  rare theme )
  2. Unstable – Deteriorating further
  3. Unstable to Stable * fit for discharge even without surgery
  4. Stable from the onset and  continue to be stable* .
  5. Stable to Unstable (Probably the most common theme )

* Pleasant themes occasionally witnessed !)

Here is 55 year old women came with extensive anterior MI with lower septal rupture.(She belonged to type 3 of the above scheme)

)

Note the septal rupture is visible even in 2D Echo

 

Color flow showing significant shunting from LV to RV.This shunt depends upon the LV contractile function, LVEDP and ofcourse the RV pressure

 

If there is severe RV dysfunction or bi ventricular dysfunction flow across the defect is inconspicuous.Brisk left to right shunting may be an indirect marker for good LV systolic function and absence of significant pulmonary hypertension.Both imply a better outcome.

The main determinant  of survival is the  underlying LV dysfunction and associated co morbidity(Renal function ) and complications .

Infero -posterior ruptures tend to be complex and  may have multiple irregular tracks  that makes it difficult to repair.

Investigations

Echo cardiogram is the mainstay .Serial echos should be done to assess the mechanical function and the progress of VSR.Hemodynamic monitoring may be done without injuring the patient .

Medical management

  • Often supportive , but  effective . Dobutamine infusion can maintain a life for few days.
  • Paradoxically , LV dysfunction and elevated LVEDP restricts volume overloading of VSD.
  • Associated MR, Arrhythmias  need to be taken care of .

Surgeons role

  • Very Vital.
  • Experience counts.(Individual as well as  Institutional )

Timing of surgery

Continues to be a controversy . Surgeons love to operate in a stable patient. But they need to realise , surgery is often needed to stabilise  many  patients. . The issue of tissue friability  is blown out of proportion in the literature .When a  life is  is at danger we can not worry about  friable tissues !

The rule of thumb could be

  • Operate as early as possible in unstable patient.
  • Post pone surgery in stable patient as late as possible ( Late here means . . .elective non emergent surgery )

Surgical options

  • Simple VSR closure without  knowing coronary anatomy
  • Simple VSR closure after knowing coronary anatomy
  • VSR closure with CABG ( total revascularization)
  • VSR closure with partial revascularization

In our experience  each of the above , has a role in a given patient depending upon the logistic , financial , social and even  the available expertise. (A good surgeon in bad Institution !)

Is coronary angiogram mandatory  before attempting to close VSR ?

Logically yes. If it is not available  just do not bother .  But, many times , when issue is saving lives , we can not afford to be too scientific , many lives have been saved by not following  such strict  protocols .A simple emergency  thoracotomy and closure of rupture site (Without even touching the LAD ) can be a distinct  and viable option in  a selected few .

Role of cardiologists

Contrary to the popular belief the role of cardiologists is minimal , except  to prepare  the patient and hand over to the surgeon.

Interventional approach to close  a VSR  is currently  be termed as an  adventurous option ! The VSRs  can assume unpredictable shapes  and the  tears can be multiple  in  different planes. The devices , catheters and  other hard ware are not specifically made to tackle these  issues  .An acquired VSR  should never be compared with congenital VSD.

Posted in cardiac surgery, Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, Echo library and gallery, echocardiography, myocardial disease | Tagged , , , , , , , , , , , , , , , , , , | 2 Comments »

Newer observations about tall T waves in STEMI

January 9, 2011 by dr s venkatesan

T waves attract less  attention in STEMI ,except for the  fact   tall T waves  implies   hyper acute phase of  STEMI.

What is the duration of hyper acute phase ?

  1. Few seconds
  2. Few minutes
  3. An hour
  4. Few hours
  5. Any of the above

Answer

No one exactly knows  .It can  be highly variable .  So , 5  could be  the correct answer .  

 * Most importantly  hyper acute phase  need not occur in all patients with STEMI as suggested in experimental models.

Some  observations in T wave behavior in STEMI

Mechanism of hyper acute  T waves

It is the pottsium channel dynamics.Transient intracellular hyperkalemia  is thought to be responsible.

T wave as marker of  reperfusion

Inverted T wave in precordial leads are a good marker of IRA patency  especially in LAD

Slowly evolving STEMI

This is relatively  new concept . STEMI with a prolonged hyper acute phase  ,  ie ,  T waves ” dilly dallying”  for hours or even few days have been recognised. (This was  refered  to pre-infarction angina in the past )

This sort of T wave behavior makes it difficult to diagnose STEMI.Enzymes will help , still  thrombolytic guidelines  demand us to wait till ST elevation to occur. This is  unfortunate .But as physicians we are  justified to thrombolyse tall T waves with a clinical ACS .The other simple solution is to shift the patient to cath lab to find what exactly is happening in the LAD ! 

Now , what is new about  T waves in STEMI ?

It is  the localizing value  in LAD infarct

A tall persistent  hyper acute T wave  helps us to localise a LAD lesion .This paper from Netherlands ,  clearly  confirms this observation. The study was done from a primary PCI cohort,   a perfect setting to assess the  T wave behavior  in the early minutes /hours of  STEMI .

Other mysteries about T waves in STEMI

Does hyperacute T waves  occur in infero-posterior STEMI ?

I would believe it is very rare .Our CCU has not seen any tall T waves in inferior lead. Further analysis of the  data from the  above study could answer this question .

How often a  hyperacute T waves transform into NSTEMI ?

This again is not clear.Most of the hyper acute T will evolve as STEMI .But  , nothing prevents it to evolve as NSTEMI a well . After all , a hyper acute T   MI can  spontaneously lyse in a lucky few , ( Who has that critical  mass of natural  circulating TPA )  .If  these natural lytic forces are only partially successful , it may evolve into de nova NSTEMI.

Bi-phasic T waves in ACS.

A benign looking T waves with terminal negativity in precordial leads  can some times be a deadly marker of critical LAD disease.This has been notorious to cause deaths in young men which often correlates with the widow maker lesion in LAD.

What is a slowly evolving STEMI ?

Prolonged tall T wave phase  possibly   indicate , the myocardium is relatively resistant to hypoxic damage .

The most bizarre aspect in our understanding about ACS pathophysiology  is the concept of  time window , based on which , all our  ACS therapeutics revolve !

Does all myocardial   cells  have a same ischemic shelf  life ?  Can some patients  be  blessed with  resistant myocardial cells   when confronted with hypoxia or ischemia ?

                                 It is well-known  , in some hearts ,  the  muscles go for necrosis within  30 minutes of  ischemia,  while some hearts can not be infarcted even after 24 hours of occlusion .So , slowly evolving STEMI is a feature of  myocardial ischemic resistance .This is not  a new phenomenon as we have extensively studied about the concept   ischemic preconditioning .

We wonder there is something more to it . . .  the quantum of preconditioning  can be inherited .Further  , we are grossly ignorant about  the molecular secrets of  non ischemic metabolic  preconditioning  .

Final message

                         T waves attract less  attention in STEMI . Cardiologists are often tuned to look only the ST segment , after all ,  ACS  itself is classified based on  the behavior of this segment.(STEMI/NSTEMI) . We need to recognise ,there is a significant subset of ACS   affecting exclusively T waves.  Shall we call T elevation  MI ? ( TEMI )

Do not ignore T waves in STEMI. It has more hidden electrophysiological  treasures that  is waiting to be explored .

Posted in Cardiology - Clinical, cardiology -ECG, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions | Tagged , , , , , , , , , , , , , | Leave a Comment »

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