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Cullotte technique for bifurcation stenting . . . a best technique . . . under utilised

June 28, 2013 by dr s venkatesan

culotte technique for bifurcation senting
Original article
Chevalier B, Glatt B, Royer T, Guyon P. Placement of coronary stents in bifur-

cation lesions by the ‘culotte’ technique.Am J Cardiol 1998;82:943 – 949

Posted in cath lab tips and tricks | Tagged , | Leave a Comment »

Do you know the exact definition of ECG ?

June 28, 2013 by dr s venkatesan

The humble looking strip of ECG  recorded  in millions ,  every day across the globe  has a complex definition.

And this definition  is  the most apt I have found.

An electrocardiogram (ECG) is a curve showing the potential variations against time in the whole body stemming from the heart, which is an electrochemical generator suspended in a conductive medium.

Einthoven(Dutch)  is the the man who invented the ECG  ,  got a Nobel price for not only inventing the string galvanmeter to record ECG,  but also  making us understand   the rules  of the  electrical wave front  that emanates from the heart.( Not to forget the  original concept  of who demonstrated electrical activity from heart by by capillary electrometer.  by Waller.(British). In my opinion waller should have shared the Nobel prize. I am  sure ,even Einthoven would agree to it.

Of course , do not ask  which  comes first  ” Ionic  flow” or  “the current”  that  comes with it !

Credit goes to  the creators of this  wonderful book  on medical physiology and put that free on the net . Three cheers to  them .

The book is from  University of Copenhagen  , Pannum Institute of Medical Physiology.

physiology text book paulev Zubieta sweden

Reference
British physiologist Augustus D. Waller of St Mary’s Medical School, London publishes the first human electrocardiogram. It is recorded with a capilliary electrometer from Thomas Goswell, a technician in the laboratory. Waller AD. A demonstration on man of  electromotive changes accompanying the heart’s beat. J Physiol (London) 1887;8:229-234
Willem Einthoven introduces the term ‘electrocardiogram’ at a meeting of the Dutch Medical Association. (Later he claims that Waller was first to use the term). Einthoven W: Nieuwe methoden voor clinisch onderzoek [New methods for clinical investigation]. Ned T Geneesk 29 II: 263-286, 1893

Posted in cardiology -ECG, Cardiology journal links, Cardiology teaching websites, Infrequently asked questions in cardiology (iFAQs) | Tagged , , , | Leave a Comment »

How does beta blocker acts as an anti anginal agent ?

June 28, 2013 by dr s venkatesan

Even though multiple mechanisms operate  the major mechanism is due to augmentation and  diversion of blood flow towards sub endocardial region* which is  main area of ischemia in most patients with Angina .
subendocardial-blood-flow
*Beta blockers  does this by smoothing   the  myocardial contractility there by  reducing  trans-myocardial gradient. The coronary arterial perforators which traverse from epicardium to endocardium gets less squeezed and promotes sub endocardial perfusion. 
Link to  a related article from this site

Posted in cardiology -Therapeutics, Cardiology-Coronary artery disese, Uncategorized | Tagged , , , | Leave a Comment »

Coronary angiogram in Corrected Transposition (C TGV, L TGV)

June 28, 2013 by dr s venkatesan

In L TGV  ventricles are Inverted . Since , coronary  arteries go with  the respective ventricle  , LAD originates from Right sinus , and RCA arises from Left sinus . (Complex anomalies  in origin, course still possible )  LAD supplies   venous ventricle . RCA  supplies systemic ventricle .

The most surprising Irony is that major epicardial  branches run in their respective grooves in the bulk of the patients with L TGV .The LAD runs  in anterior interventricular  groove and LCX in left AV groove etc. (That’s real  power of nature , these epicardial branches home in to their grooves even in the midst of bizarre AV and VA connection !)

Here is the the ultimate reference  article ;  A  study from 255 hearts with C TGV . I wonder ,  we will  never  get a study like this ! 

coronary anatomy in corrected transpostion og great arteries ltga c tgv Ltgv annals of thoracic surgery 1994

Questions to ponder

  1. Is RCA  blood flow adequate to support systemic ventricle ?
  2. If this RCA is a non dominant  one what happens to this ventricular function ?

Implication in surgery

Progressive RV dysfunction is a major determiant of long term outcome . Unless we do an arterial switch  diverting respective ventricular flow  it  is not going to help much in the long term

coronary anatomy in corrected transpostion og great arteries ltga c tgv Ltgv 2
Link to full text article

Posted in cardiology -congenital heart disease, Cardiology-Land mark studies | Tagged , , | Leave a Comment »

P wave twisting : An extreme form of wandering pacemaker .

June 28, 2013 by dr s venkatesan

Wandering pacemaker is benign  cardiac arrhythmia . The only danger  is , it can create false alarm .This patient was referred   as  AV dissociation

wandering pacemaker

Read a related article  from this site .  ( A restless pacemaker goes for a walk down the  lane )

wandering pacemaker

wandering pacemaker

Posted in Cardiology-Arrhythmias | Tagged , , , | Leave a Comment »

Look AHEAD . . . and feel depressed about this Insensitive study !

June 28, 2013 by dr s venkatesan

In the  2013 American diabetic association(ADA)  annual meet  a paper was presented   which raised  many eye brows ! . The  results were flashed across mainstream media. Published in New England journal of medicine online.

Look Ahead ADA lifes style NEJM

It may be a  well conducted  trial  but  poorly interpreted  one . It reports one of  the dubious   observations  as a major conclusion  and  confuse the public.

Life style modification is the key to prevent  major diabetic  and cardiac events  . This is well  proved beyond doubt.

Epidemiological evidence  from various  global health  statistics  accumulated over a century will vouch for primary prevention of  diabetic and cardio vascular disease .

Link to Editorial on Look Ahead  : http://www.nejm.org

Why this study wants to make  a mockery of this fact ?  .Fortunately the accompanying  editorial  has  realistically  reported the implications of this study.

Final message

I argue the medical fraternity and patients to ignore this  study . It can be convincingly concluded something is seriously wrong with the outcome analysis  ,  however  modern may be the statistics. Some  groups are obviously worried about the natural and effective control of diabetic by good life style alone . It is a clear case of confusing the public .

There is huge collective evidence  and  common sense  for the  increased physical activity to reduce  cardio vascular risk  (INTERHEART)

Final Message

If life style modification is not going to help  . . . what is the alternative  to our patients ?

Drugs . . . yes  . . . one has to depend on it   . . . this study  seems to suggest .

To me, this is  a dangerous study   . It  plays a spoil sport on a great fact and  belief . This paper  should never have been published in a journal  like  NEJM . Atleast the conclusion  should  have  been re-written !

I guess this study would  promote the  Homo-sapiens  to  be inactive  and  make them diabetic and  consume drugs  perennially !

Reference

http://www.nejm.org/doi/full/10.1056/NEJMoa1212914?query=OF 

Posted in Diabetes and Heart, Social medicine | Tagged , , | Leave a Comment »

Medical Education in India : The future looks bleak and tense !

June 28, 2013 by dr s venkatesan

This is a wonderful   and  realistic article on the Issue by none other than  former Health secretary of the Government of India  Ms Sujatha Rao

medical education In India

http://www.thehindu.com/opinion/lead/doctors-by-merit-not-privileg

Posted in bio ethics, Medical education | Tagged , , , | Leave a Comment »

INTECH : Open Mind . . . Open science . . . what a lovely concept !

June 28, 2013 by dr s venkatesan

I stumbled upon this  web   site . I think this  can be  glorified as the  standing  example  for     “Democracy  of science”

INTECH open science open mind

http://www.intechopen.com/subjects/cardiology-and-cardiovascular-medicine

Posted in cardiology innovation, cardiology journal club, Cardiology journal links, cardiology journals, Cardiology teaching websites, Cardiology-Land mark studies, Great websites in cardiology | Tagged , , , | Leave a Comment »

Gastritis + Cervical spondylosis = Classical Angina

June 27, 2013 by dr s venkatesan

Spinal cord is a busy  neurological  highway to brain .It  runs  24/7  non stop  with unlimited  horizontal and vertical lanes .It is such a compact  structure , it can  easily  get confounded   when multiple signals converge,  diverge, summate , deduct , reflect back,   or cancel out .
A 64 year old women came to me for  second opinion  regarding   chest pain . A  cardiologist  had  just adviced her  an  emergency   coronary  angiogram and also suggested she may require an  urgent  PCI  as well .
I listened to her history in my office  . . .  In  her own words .
Doctor , I am  getting  sudden   compressing  type of  pain which  starts in the centre of the chest and soon transmits to the left shoulder and  gradually reach the inner aspect of the hand up to the little finger . And occasionally it is very severe and some times i feel like sweating as well ! I am unable to predict when it comes doctor !
It was  so convincing  but one  feature was  not fitting In . She said , she used to walk  daily   and do all house hold work with no pain . She also  recalled about the  acid peptic disease , and neck pain periodically due to cervical spine problem.
Her resting ECG was normal .She was  afraid to do a stress test . After thinking  for a minute , I had no  other option  but  to endorse  my colleague’s view and asked her  to go for coronary angiogram .
One  thing I  suggested differently was , I told her it was not an  emergency , I also  conveyed my gut feeling  that it is unlikely to cardiac  pain . One week  later  CAG through radial route  was done . Both of  us were  happy  to find a  normal  coronary  angiogram !

Final message

Pain is a  feeling . It can be  perceived  at  multiple levels  . The site of origin , spill over on transit and at the level of brain .  A patient with multiple  potential source for pain can either summate , deduct , reflect  or cancel out .This can confuse the clinician in a dramatic fashion as it did to us ! . To complicate the matters  further , gastric pain can trigger a cervical  pain and vice versa . (Spill over effect)

Posted in cardaic physiology, cardiac physiology, Cardiology - Clinical, Clinical cardiology | Tagged , , , , | Leave a Comment »

Only fools will manage unstable angina medically !

June 27, 2013 by dr s venkatesan

Only fools will   manage unstable angina  medically !
 
That was exactly the statement ,  one popular Interventional  cardiologist   told a small gathering  in one of the weekly meet .
 
Do you agree ? 
 
 
 
 
 
Answer
 
We can’t  make a blanket  statement like that . We have clear  guidelines (Of course as licensed and certified cardiology  practitioner  you have  every right to violate it !)  .
 
UA is risk stratified in Low , Intermediate and High risk  categories .Only high risk group  require emergency Intervention .Even in high risk group there are some reservation.(ICTUS  study )
 
There are some very mild forms of  UA (High grade stable angina precipitated by an emotional stress will exactly mimic UA. Similarly most  secondary UA due to tachyardia , Anemia  etc should not  cause an alarm .)
 
 
*Please note  , currently coronary angiogram is included in medical  investigation  in most  patients with UA . The  confusion in interpreting  such statements  is partly because many physicians/ cardiologists consider  doing a coronary angiogram by itself an  Interventional  management
 
 
Reference

Posted in Cardiology -Interventional -PCI, cardiology- coronary care | Tagged , , , | Leave a Comment »

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