Dr.S.Venkatesan MD

History of cardiology : Robert F Rushmer, a cardiac scientist par excellence .

February 1, 2021 by dr s venkatesan

Few individual’s works mattered more than others in the field of cardiology. Here was a man born 1914 in Utah, studied at Rush university trained in Mayo, settled in Seattle as a pediatrician. But his passion drove him to become a specialist cardiac physiologist with an urge to find the answers to all those lingering queries that arise as a practicing clinical cardiologist.  He built an exclusive animal lab to study the mechanics and physics of circulation and cardiac pumps in the 1950s 

 

                          1914-2001

He can be called the new age, Harvey of the 20th century. He seemed to always bother, how is it that the 6 liters of blood traverse from heart to the periphery and comes back going through vast lengthy circulation with variable pressure and little energy loss.? He also made the very pertinent discovery in neural control, the effect of gravity on circulation. His interest in how venous return would have to match cardiac output was phenomenal. 

His grasp of cardiovascular physiologic concepts was so powerful and his book on cardiovascular dynamics was so popular. probably the first scientific textbook on circulation. I am sure he had shaped the thought process of so many physicians (I will vouch for myself) and helped create hundreds of cardiologists all over the globe. Dr.Rushmer also did pioneering work on diagnostic ultrasound and doppler. I can recall a video on cardiac embryology edited by him in the 1960s in pre-computer era that probably can not be beaten even today in terms of clarity of content and production value.

Through his thoughts like an engineer and mathematician still, he was able to blend the knowledge together and pass it on to the generation next clinician. No wonder, he was the founder and headed the department of biomedical engineering in the UW. The University of Washington holds an annual Rushmer lecture. 

If one person deserves an award for excellence in cardiovascular science for the 20th century, Dr.Rushmer’s name should definitely, come on top. Though he won several accolades, I feel scientific societies have missed an opportunity to felicitate him with the more worthy award. If the Noble prize in medicine is given for a lifetime contribution to cardiovascular physiology wonder why he can’t be considered for it posthumously.  

It is heartening to note, at the fag end of his career he moved from core science to philosophical and ethical truths of science and technology. He once said, “We’re confronted with the ethical, political, and technological consequences of our medical triumphs. We have to learn quickly how to deal with these profound problems by looking ahead to recognize and avoid complications of our technical breakthroughs’ How true his observation has turned out to be!

 

Reference

https://www.washington.edu/news/2001/07/16/dr-robert-rushmer-diagnostic-ultrasound-pioneer-dies-at-age-86/

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Posted in Basic sciecne, Basic science -Physiology, Best books in cardiology, bio ethics, great cardiologists | Tagged best books in cardiac physiology, best cardiology books, cardiovascular physiology, famous Seattle doctors, Great Men in cardiology, history of cardiology, Robert F rushmer, Seattle cardiologist, university of washington biomedical department |

Wrong-way catheter during radial angiogram : An Illustration

January 19, 2021 by dr s venkatesan

The commonest cause* for repeated entry of right radial catheter to descending aorta is not due to any anomaly. Most times,it is just a skewed angle between right brachio-cephalic artery with Aortic arch, that deflects the catheter to the descending aorta . Just make sure, aortic root is entered with a deeply held inspiration.

*Anomalies of the aortic arch, aberrant right subclavian, Kommerell’s diverticulum, vascular ring must be kept in mind.

 

Postamble: A true abnormal course

Though, It might appear prudent to avoid the radial route when encountering anomalous subclavian arteries, the reality is different and adventurous. We have acquired great expertise and successful PTCAs have been done through these tortuous vascular highways.

This is a case report from Dr H.S. Isser, Gunjan Garg, from Safdarjung hospital New Delhi. 

 

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Posted in Anatomy of heart | Tagged aberrant right sub clavian artery, aortic arch anomalies, arteria lusoria ptca, brachio cephalic artery aortic arch angle, radial angiogram tips, radial pci |

Principles of practice of medicine: 2020 version

January 14, 2021 by dr s venkatesan

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Posted in Medical education, Medical ethics, medical quotes, Venkat quotes | Tagged best medical quote, drsvenkatesan, drsvenkatesan.com, ethical quote in medicine, ethics of medical practice, Hippocratic oath, hippocratic quotes, madras medical colllege, primum non nocere, principles of practice of medicine |

How important is CAD in HFpEF ?

January 7, 2021 by dr s venkatesan

One of the topics rarely discussed in heart failure is  CAD as a contributory factor in HFpEF.

This is a copy of the presentation done at the ECHO India Annual scientific meet  2019 at Kolkatta. India.

 

Will try to find out the recorded version with audio. Here is a GIF run through.

PDF version Download here

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Posted in CAD in HFpEF, Heart failure with preserved LV EF, HFpEF, HFrEF vs HFpEF | Tagged diastolic dysfunction, dr venkatesan ppt prsentation, presentation on HFpEF and cad |

Mitra clip for Rheumatic mitral regurgitation: A break through Indication

January 5, 2021 by dr s venkatesan

Mitra clip is a small metal device that is delivered percutaneously, to clip the incompletely coapting (closing) mitral valve. It was first introduced to treat degenerative mitral regurgitation. It is an interventional imitation of the famous edge to edge Alfieri stitch repair.This procedure in fact converts the single mitral valve orifice into two. In the process, curtails the regurgitation jet orifice significantly. Though the technique looks nice and simple to hear, lots of per and post-procedure issues need refinement. Conceptually it is ideal in primary disorders of the mitral valve. (Read EVEREST 2 criteria for optimal patient selection)  There have been more than 60000 Mitra clips implanted worldwide wide. Thanks to Abbot.

In secondary MR (due to LV dysfunction) Mitra clip has shown mixed results( MITRA-FR not much benefit, COAPT -Did show benefits)

Now, what about Mitra clip as a remedy for rheumatic mitral regurgitation?

This is the question everyone likes to ask. Now we have some interesting breakthroughs. Dr. Ningyan Wong from the National University of Singapore reports probably the first case (Ref 1) . The videos are reproduced with the creative commons license.

 

Note the classical thickened AML in rheumatic mitral regurgitation.

 

 

TEE showing severe MR

 

Post Mitra clip : A real surprise to note near-total abolition of regurgitation. (This really is good news for the rheumatic mitral valves )

Technical issues

• Should be isolated MR
• P2/A2 scallop clipping is the key to success. 
• The thickness of the leaflet limits the success (Grasping the leaflet will be difficult)
• Clip Induced mitral stenosis is a distinct risk.

Potential role and future

RHD forms 90 % of valvular heart disease in a country like India. The incidence of Isolated MR in both acute rheumatic fever and chronic  RHD are substantial. If only we refine the hardware and technique to suit these thickened rheumatic valves, Mitra clip is expected to make an impact in this unique group of patients where surgery can be avoided or at least postponed. 

Though we would very much like to do such a trial in our place, logistics has effectively precluded it. I wish some large centers like AIIMS New Delhi or PGIMER Chandigarh and others can take this concept to the next level.  

 

Reference

1.Ningyan Wong, Peilin Cheryl Marise Tan, Zee Pin Ding, Khung Keong Yeo, Successful MitraClip for severe rheumatic mitral regurgitation: a case report, European Heart Journal – Case Reports, Volume 3, Issue 3, September 2019, 

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Posted in MVPS, valvular heart disease | Tagged alfieri repair mitral valve, coapt mitra-fr everest trials, mitra clip, mitra clip for rheumatic mitral regurgitation |

Year end quiz : What is the name of this Investigation ?

December 29, 2020 by dr s venkatesan

Just roll over the virtual marker along the coronary lesion to get the underlying flow ratio. Blue is an absolute normal segment. Green is ok, orange and red slow-moving coronary traffic jam zones. it’s just like drawing a google map showing life traffic. No wire, no adenosine FFR comes inbuilt in every angio shot. Looks great Isn’t it? This is called QFR. Quantitative flow ratio derived from routine coronary angiograms. It can also guide us to find the optimal sites of both proximal and distal stent landing zone in the best physiological manner.

Which company makes this ?

Any studies done with QFR ?

FAVOR 2 study was reported in TCT. This modality is expected to evolve.

Final message

Whenever possible every anatomical lesion in the coronary should be substantiated by physiological parameter and possibly coronary Imaging to know plaque morphology and vulnerability. Though it is wishful thinking, still for all logistic reasons, most of the real world stenting will be based only on the blind anatomical luminogram.

At this point, please let me utter a non-academic hyperbole. Even a casual query to your beloved patients about their true symptoms and exercise capacity shall make these ultra-modern coronary physiology studies redundant in many. A well-performed and well-interpreted stress test is a good, objective, non-invasive indicator of coronary flow across lesions. It is wise to keep this as a basic clinical foundation in the evaluation of CAD, even as we continue to learn and forget half evolved modalities with rapid expiry dates like FFR, IFR, CT-FFR. QFR shows some promise though. Please watch for next in line coronary physiology – OFR, Optical flow ratio from OCT run through.

Reference

Jelmer Westra Shengxian Tu Overview Of Quantitative Flow Ratio And Optical Flow Ratio In The Assessment Of Intermediate Coronary Lesions US cardiology review volume 14 2020

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Posted in acute coroanry syndrome, Tips and tricks in cath lab | Tagged coronary doppler, coronary flow physiology, ffr vs ifr vs ct ffr vs qfr, ISCHEMIA trial, non invasive ffr, oct ivus, when to intervene a stable cad |

LA myxoma surgery : Preventing recurrence should be an important goal.

December 13, 2020 by dr s venkatesan

Cardiac myxoma is the most common primary tumor of the heart that presents as mitral inflow obstruction/ regurgitation often with a systemic presentation. It can be either familial, syndromic, or sporadic. Excellent imaging is possible and diagnosis has become straightforward. Surgery is the specific treatment,

What information do the Surgeons need? 

Size, attachment to surrounding structures is the key. The myxoma origins most often in IAS and defining its attachment is crucial. Mitral leaflet distortion, Injury ( and even attachment) is possible. It is helpful for the surgeons if we let them know the mechanism of mitral regurgitation prior to surgery. Echocardiogram including  TEE is sufficient in most. MRI may add some more info. The aim of surgery is to remove the tumor mass completely.

Is myxoma a completely benign tumor?

Another issue is our poor understanding of the recurrence of myxoma. Why should a benign tumor be recurrent? If recurrence is a feature to be counted as a sign of malignancy, myxoma can be definitely a suspect. There seems to be a catch. It is invasive, locally recurrent,  still not malignant. (Whether sarcomatoid degeneration happens is not known. Most pathologists deny this) The problem is, still we are not clear about the cell of origin of this tumor. All that we know is its origin mesenchymal stem cell.

 

Note 50 % tumor mass enters the left ventricle with diastole. No wonder, as the tumor plops with diastolic cardiac cycle a high-pitched sound simulating opening snap followed by an MDM perfectly mimics rheumatic mitral stenosis. An MR murmur is equally common.

Common sites of recurrence

• Interatrial septum
• The atrial surface of anterior mitral leaflet 
• From contra-lateral atrium rarely

The mechanism of recurrence is either due to incomplete resection or due to its multifocal origin.

4 chamber view showing what appears to be a small narrow pedicle attaching to IAS. Please note echo imaging can be deceiving. Surgeons must inspect the mass in toto before taking the decision to excise IAS or not

What the surgeon needs to do?

The aim of surgery is to remove the tumor completely. It’s painful to diagnose recurrence and subject the patient to another surgery. (We encountered a sorry situation recently) So, when we remove the tumor we should ensure sufficient clearance with normal tissue.Biatrial approach is preferred by some surgeons.( Ahmet Yüksel  Braz. J. Cardiovasc. Surg. vol.31 no.4  July/Sept. 2016)

If the tumor is not well delineated, it is better to remove a significant area of IAS along with tumor mass and subsequent patch closure. Recurrences in AML and contralateral atria is unfortunate and can’t be predicted.

Further, the mitral valve is to be inspected and functionally tested. Minimal repair work or even rarely replacement might be necessary.

 

TEE imaging of LA myxoma. Note how fragile the edges of the tumor looks. It explains the high incidence of tumor embolus in this condition. Also, to be noted is the forceful impact of the tumor mass on AML that predisposes chronic mitral valve damage.

Final message

Referring a patient to a cardiac surgeon is not a bland ritual. (Have seen many single line referrals such as triple vessel disease referred for CABG) A well-informed interaction by the cardiologist with the surgical team and a possible per-operative echo consult, especially in rare surgeries will bring the best for the patient.   

Reference

1.Reber D, Birnbaum DE. Recurrent cardiac myxoma: why it occurs. A case report with literature review. J Cardiovasc Surg (Torino). 2001 Jun;42(3):345-8. PMID: 11398030

2.Alkhulaifi AM, Horner S, Pugsley WB, Sturridge MF. Recurrent Left Atrial Myxoma. Cardiovascular Surgery. 1994;2(2):232-236. 

 

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Posted in Cardiac myxoma | Tagged IAS patch closure for myxoma, LA myxoma surgery, mesenchymal cell tumor myxoma, myxoma benign or malignant |

Arrhythmia basics: How often we need to know the mechanism of arrhythmia ?

November 2, 2020 by dr s venkatesan

How many times you have treated cardiac arrhythmia in both emergency & non-emergency situations?

Infinite times.

How many times did you really bother to know the mechanism of a given arrhythmia before ordering medication or shocking?

Hmm,.. let me think. (Except for AVNRT/ AVRT, and few VTs, very rarely I have worried about the mechanism  !)

Why is it so? because treatment takes priority and we are able to tame the arrhythmia even without knowing the real mechanism.

The following slide is a gross summary of the cardiac arrhythmia mechanism

Understanding cardiac arrhythmia is vitally important for a few reasons in a few settings.

• In acute settings, we need to know automatic tachycardias will not respond to shocks. Reentry tachycardias will respond more promptly. (Of course, we may not know it till we shock ) Calcium blockers like verapamil might block triggered activity in MAT. Overdrive pacing is the answer for many automatic tachycardias and some refractory reentrant tachycardias (ATP protocols in ICD has taught us this ) 
• In the chronic setting when you contemplate mapping, locating, and ablating arrhythmias, mechanisms are important. The task here is locating slow conduction paths and decoding the diastolic circuit around the scar  (If you plan ICD, knowledge about mechanism  becomes redundant again)

• Finally, knowing the mechanism of arrhythmia is a fascination by itself to help understand the great subject called cardiac electrophysiology, where 100s of ion channels work nonstop drawing the action potential on a moment to moment basis sustaining our life.

A challenge

Can you localize a VT and find the mechanism in a patient who is Ischemic /hypoxic and acidotic? You can never do it. Please note, most polymorphic VTs can’t be localized. The mechanism is either automaticity, trigger activity, or even micro-reentry. You need to shock and look for the causes.(Link to How does the treatment of monomorphic VT differ from Polymorphic VT? )

Final message

Should we need to know about the mechanism of arrhythmia we treat?  Definitely yes, if you have that passion to know the truth, or else just order Amiodarone or shock and check out of CCU. (Of course, we have a very good option of calling EP consult the next day.)

 A review article on mechannism of cardiac arrhymias

Rev Esp Cardiol. 2012;65(2):174–185

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Posted in Basic science -Physiology, Brugada syndrome, cardiac electrophysiology, cardiology -Therapeutics, Cardiology-Arrhythmias | Tagged brady dependent vt, brugada syndrome, eads dads, early and late after depolarisation, enhanced automaticity vs triggerred activity vs reentry, mechanism of cardiac arrhythmais, phase 2 reentry, phase dependent vt |

Acute Aortic syndrome : Please mind the length of “Ascending Aorta” as well.

November 1, 2020 by dr s venkatesan

 Aorta probably is the most critical structure in the entire circulatory system. (apart from the heart of course !) It is a 1.5 to 2.5 mm thick tube, with a diameter of 2.5 cm/length of 30 -35 cm from the aortic valve to the iliac bifurcation.(Eric Borsero 2011) It handles about 7500 liters of blood every day. Understanding the Aortic pathology has vastly improved at the molecular level with deep gene sequencing that defines fibrillin phenotypes.  Meanwhile, CT ,  4D MRI and 3D prototyping have landed us in a new era where we can feel the exact models of a patient’s virtual aAorta for monitoring and treatment purposes.

Image source https://doi.org/10.1002/jmrs.212

 

While acute Aortic syndromes is the one that bothers us most, even chronic aortic enlargements are equally risky as at any time it can become acute. Though the risk of aneurysm and rupture is related to the histology and molecular disruption at the level of aortic media, we can only rely easily on is its dimension. Traditionally we bother about the diameter since it is the aortic radius that Influences the stress through to Laplace law.(Wall stress equals twice the radius /Thickness of wall)

Click over the Image for ESC Aortic disease guidelines

The annulus is the narrowest part, it gains about 50% width (10mm) at the level of the sinus of Valsalva to reach about a maximum of 35 mm and again narrows at ST to a junction (almost to the same diameter of the annulus) It continues further as ascending, arch and descending aortas with gradual tapering. 

Risk of rupture

Katherine H.Chau et all https://doi.org/10.1016/j.pcad.2013.05.007

Are you aware aorta keeps growing with age?

Unlike many other organs, growth of which gets arrested by adulthood, aorta appears to grow well into middle and elderly age.The aorta grows by 6cm in total length between age 20 to 80 (Ref 1)   The average growth of the ascending aorta is .18mm /year

This fact was reported 70 years ago Dotters famous study Circulation 1950  https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.2.6.915

I used to wonder in many elderly why chest x-ray shows wide superior mediastinum still echocardiogram didn’t show any dilatation.This we call it as aortic unfolding. The term unfolding of aorta may represent the elongation of both ascending and descending aorta. The mechanism is due to multiple factors, like lax ligamentous of aortic attachment, dilatation, and longitudinal elongation.

Unfolding of the aorta . (How to measure unfolding Lee JW, (2014) Aortic Unfolding Determined Using Non-Contrast Cardiac Computed Tomography: Correlations with Age and Coronary Artery Calcium Score. PLoS ONE 9(4): e95887. )

How Important is the length of the aorta?

Risk of Aortic aneurysm is usually attributable to the diameter (Accepted normal 2.1cm/m2) . However, in IRAD registry, 50 % of aortic dissection happened in aortas less than 5 cm. So there is something more than the diameter that confers the risk of an aortic event. Is it the length and elongation?  After years of observation, we now realize it is indeed true. It is a surprise we didn’t realize  elongation of aorta also confers the same aortic wall weakness like that of Increased diameter (Longitudinal deformation/Stretch )

How to measure the length of Aorta?

It is best measured by CT scan or MRI. There is a new parameter called  Wu Index, which is based on both length and width of the aorta , which predicts the risk of aortic event. 

 

 

Jinlin Wu, Mohammad  Zafar, Yupeng Li,  J Am Coll Cardiol. 2019 Oct, 74 (15) 1883-1894.

Final message 

Aneurysm of the aorta is traditionally defined based on the degree of dilatation. It’s time, Aortic length should also be included in defining aortic aneurysm. We need to monitor it periodically as well in the population at risk. 

Reference 

1.Adriaans BP, Heuts S, Gerretsen S, et al. Aortic elongation part I: the normal aortic aging process. Heart 2018;104:1772–7.

2.Ascending Aortic Length and Risk of Aortic Adverse Events  Jinlin Wu, Mohammad  Zafar, Yupeng Li, 

J Am Coll Cardiol. 2019 Oct, 74 (15) 1883-1894.

3.Pape LA, Tsai TT, Isselbacher EM,  Aortic diameter > or = 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2007;116:1120-1127

 

The comprehensive reference 

4.Hiratzka LF, Bakris GL, Beckman JA,  2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart  J Am Coll Cardiol 2010;55:e27-e129.

 

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Posted in aortic aneurysm | Tagged marfan aortic dissection aorta size, new coconcepts in aortic dimension, normal aorta size, normal aortic root size, what is normal length of ascending aorta |

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• 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

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