Left main ostial lesion remains a challenging task .A new stent design is proposed here.
The lesion
The hardware
The technique
Final message
This thought came when I recently encountered a patient with a left main ostial stent which was projecting well into aortic root .It is an open access patency ,whoever is capable of converting this idea to a clinically applicable technique is welcome to proceed !
Posted in Cardiology - Animations, Cardiology -Emerging technology, Cardiology -Interventional -PCI, cath lab tips and tricks, Left main stenting -Tips and tricks, Uncategorized | Tagged aorto ostial left amin stenting, aorto ostial lesions, buttoned stent for left main ostium, how to do left main stenting, left main ostial stenting, left main stenting, new techniques for left main stenting, ostial left main lesion, ostial lesion, stent design for ostial lesions, tips and tricks in coronary stenting, tips for left main stenting | Leave a Comment »
* Currently it is better to use only two terms .Epicardial fat and thoracic fat .Other terminology should be avoided.
Which part of cardiac cycle it is measured ?
Since epicardial fat is a compressible structure , in diastole the myocardial mass encroaches the epicardium any imaging modality the distinction between epicardial and para-cardiac fat tends to attenuated.
Even MRI images obtained with diastolic gating , may not be reliable .End systolic frames are now considered ideal.
(J Am Coll Cardiol. 2011 Oct 4;58(15):1640;Distinction of “fat around the heart”.Kaushik M, Reddy YM.)
What is the normal epi-cardial fat volume ?
There is no standard normal.In one large study from Boston in people with a BMI between 25-30 the mean epi-cardial fat volume was 125 cubic cms
(*Intrathoraic fat same as para-cardiac fat located outside parietal pericardium )
How to differentiate fat from pericardial fluid ?
It can be a very difficult issue especially when you expect both as in hypothyroidism .It needs proper gain settings and interpretation.
Here is case report of how epicardial fat was mistken for PE even in TEE
Can we measure the net mass of cardiac fat , does it compress the heart ?
When we say average heart weighs 300 grams it includes fat embedded in it. I don’t think it is possible to measure the fat mass ,but clinically it may be important.Read this .Can-epicardial-fat-constrict-the-heart-an-authentic-yes-from-ulsan-korea ?
Final message
Estimation of epicardial fat volume is largely a research tool.In grossly obese patients it may have some clinical utility.Increased anterior fat pad in routine 2D echo is an useful screening test. However, it requires MRI/CT imaging for accurate quantification.
References
Posted in Cardiac MRI, cardiac radiology | Tagged end systolic epicardial fat, Epicardial fat thickness, how to measure epicardial fat ?, para cardiac fat, paracardiac fat, pericardial fat, pericardial fat vs pleural effusion | Leave a Comment »
CHB with CAD is a common combination especially in the elderly.
Which will you Intervene first ? Is the AV block related to CAD ?
How to differentiate Ischemic from degenerative AV block ?
Differentiating is often difficult.Even coronary angiogram may not answer the query unless it is totally normal . For AV block to occur usually LCX / RCA lesion is required. LAD lesion in isolation are rare to cause CHB .
How often re-vascularisation reverses ischemic CHB ?
Logically you expect more reversals.In real world it rarely happens.
Therapeutic options in combined CAD and CHB
Can worsening of ischemia occur after pacemaker ?
Very much possible . Since the patient has been benefited by low heart rate in terms of MVO2 consumption .(Inserting a pacemaker is like sudden withdrawal of beta blocker !)
Rate adoptive pacing can confer chronotropic competence which may bring back the angina.So,what was a insignificant lesion can become hemodynamicaly relevant and may require angioplasty later.
*The above clinical issue is applicable for sinus node dysfunction and CAD as well.
Final message
There is no fixed rule in the management strategy in combined CHB and CAD .
Generally , electrical therapy should be given preference .Symptom guided approach may be practical.
In this scientific era , one may argue to deal both issues together by simultaneous PCI and pacemaker , still option 3 and 6 remain clear favorites !
If angina occurs even in baseline bradycardia it is obvious the obstructive CAD is significant and needs immediate fixing .
Finally , though it looks an attractive concept , It is very rare for CHB to get reverted by PCI or CABG.
Posted in cardiology -ECG, Cardiology -guidelines, Infrequently asked questions in cardiology (iFAQs) | Tagged chb and double vessel disease, complete heart block and triple vessel disease, how to manage sinus node dysfunction and cad ?, sick sinus syndrome and cad, sss and cad, SSS AND CHB | 6 Comments »
All left to right shunts are acyanotic heart disease to begin with. Cyanosis appears if there is progressive PHT and reversal of shunt .We know this happens late in ASD.(third decade)
It is important to remember some of the patients with large ASD can show significant desaturation without severe pulmonary HT. This should not be mistaken for Eisenmenger reaction.
How ?
In any large ASD ,
Finally ,two conditions should always be considered
* It is useful to recall ,even PFOs can shunt right to left at times of extreme RA pressures like during PEEP ventilation and orthostatic deoxia in sick ICU patients are reported (If PFO can shunt R-L , why not huge ASD ?)
Final message
Cyanosis in ASD is not always an ominous sign .There are few important causes other than Eisenmenger. Though it occurs intermittently , persistent mild desaturation is also possible.
Posted in cardaic physiology, cardiology -congenital heart disease, Cardiology -unresolved questions, Clinical cardiology -Cyanosis | Tagged common atrium vs large ASD, IVC streaming and cyanosis in asd, mechanism of cyanosis in ASD, unroofed coronary sinus, valsalva manuver and cyanosis in ASD | Leave a Comment »
Any new ST depression occurring during EST is sine qua non for inducible ischemia.But,this rule does not uni-formally apply in all 12 leads .ST depression occurring is certain leads is more important. While severe global ischemia can depress ST segment in most leads ,factually only the leads V 5 and V6 predict true Ischemia.This because , bulk of LV muscle mass faces these two leads.
Isolated ST depression in inferior leads during exercise
Probable mechanism
How to report such EST ?
You can report it as such, what you have observed.
If you are statistically inclined you can also mention the likely hood of CAD by positive predictive value (PPV) of the test (Low with isolated Inferior ST depression )
If you are really confused , and do not want to scratch your brain we have the most convenient terminology invented by cardiac physicians ie Borderline EST, or Mildly positive EST “
Should we do Angiogram for such patients ?
In this era of catching normal people who attend master health check ups for a day care CAG . . . it is not all a crime to do angiogram in a patient who shows suspicious ST depression in three of his leads (2,3,AVF) especially if he also complains of vague chest pain.
Alternate investigation
Of course , we always have the luxury of using MDCT that can stunningly photograph the coronary arteries.
It is a mystery investigation, if it comes entirely normal every one is happy.Even slightest defects in the photography has a potential to confuse both physician and the patient .
What I do ?
I hesitate to do routine CAG if ST depression occur exclusively at peak exercise beyond 10-12 METS , which disappear fast.(Many times we can apply this rule to classical ischemic ST depression of lead V4 as well !)
ST depression in any leads (with any degree) following an episode of ACS seems to be important.
Related topic
Posted in Cardiology - Clinical, cardiology -ECG, Cardiology -Therapeutic dilemma, Cardiology -unresolved questions, excercise stress test .EST | Tagged 3, excercise stress test, Isolated ST depression in Inferior leads during EST ., poor r in 2 3 avf, st depression in inferior leads in 2, What is positve stress test | Leave a Comment »
The WordPress.com prepared a official 2013 annual report for this blog.
Here’s an excerpt:
The Louvre Museum has 8.5 million visitors per year. This blog was viewed about 540,000 times in 2013. If it were an exhibit at the Louvre Museum, it would take about 23 days for that many people to see it.
Click here to see the complete report.
Posted in Uncategorized | Tagged dr s venkatesan wordpress blog | Leave a Comment »
Dear friends,
It all started in 2008. This is 6th year of my attempt to share knowledge in cardiology.The followers of my blog is the only strength that sustain my writing .
Wishing you all a Happy , wonderful and a prosperous , New year 2014
But . . . please be reminded we don’t require a New year to bring a bout of happiness , it is sitting right in our minds every day !
On this day let me quote my most revered quote of Hemmingway.
Ernest Hemmingway the Nobel laureate who was born in USA, Lived in Paris , fought in world war 2 , lived in the deep forests of Africa with wild animals during the fag end of his life .He had a Intimate relationship with Cuba, made a passionate appeal to end the man made disaster called wars in this planet , before his life ended in 1961.
To connect with this noble (Nobel ) soul reach through Wikipedia Link
Posted in bio ethics, Cardiology classics, Cardiology quotes, My favorite quote | Tagged cardiology ethics, cardiology quotes, clinical cardiology, happy new year 2014, my favorites quotes | 3 Comments »
Posted in Cardiology - Clinical | Tagged a2 os interval, a2-os interval after atrial fibrillation, atria fibrillation and pressytolic mumur cresendo accentuation criley concept, criley concept, cycle length and mdm, s3 in mitral stenosis, what happens to mdm after atrial fibrillation | 1 Comment »
Following are revered facts . . . among the “Guardians of Cardiology” !
When false truths are synthesized to conceal a true myth . . . where will the poor myth complain ?Following are revered facts . . . among the “Guardians of Cardiology” !
Posted in bio ethics, Cardiology - Clinical, Cardiology -Pacemakers and ICD, cardiology -Therapeutics, Cardiology -unresolved questions, medical quotes | Tagged ethics in cardiology, thromolysis vs priamry pci, vvi vs ddd pacemaker | Leave a Comment »
It costs just one Dollor !
Harvard school of Public health has recently published some hard data about the adverse effects of bad diet habits especially the impact of soft drinks on long term cardio vascular health.
Another prestigious journal confirms it . . .
The ultimate journal for the cardiologists Circulation reaffirms it .
We have overwhelming evidence , prolonged use of soft drinks
increase CAD (Like tobacco ). Still , we haven’t added the customary caution on the bottles of these soft drinks ?
Why ?
My guess would be, there are powerful forces in modern society that would love to keep the threat of diseases high in the human domain so that all stake holders make a profit .
The poor , World health instigation(WHO) and various public health forums simply watch it .If they protest , they are at risk of sucked into the loop of deceit !
Failure to reverse public health hazards may be a lesser crime in modern days . . . But , here comes a series of advertisements in Indian media , that is a strong indicator that human intellect and the sixth sense is going nuts !
It suggests , Do you want ever lasting happiness . . . Drink it . . . earnestly believe in it . . . and drink again !
I was also told a shocking fact that , The beverage war in India has started and the soft drink giants have heavily Invested to take it into the rural markets .Their aim is to provide “health for all Indians” by 2020 !
Concluding question
Posted in bio ethics, cardiology -Preventive, Cardiology quotes, Cardiology Risk assesment, cardiology-ethics, Medical education, Preventive cardiology, Public Health, Quotes, Social medicine, Venkat quotes | Tagged art of buying happiness, coroanry artery disease prevention, degenerating sixt sense, effect of soft drinks on cardio vascular health, good vs bad, happiness image, harvard school of public health soft drinks, human intellect and sixth sense, preventive cardiology, public health hazard and cardiology, sixth sense, soft drinks and cad, soft drinks and incidence of new diabetes, world health organisation | Leave a Comment »
Dr.S.Venkatesan MD 