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Posts Tagged ‘cath lab’

                                                          Left main coronary  lesions are  fairly common  during routine coronary angiogram.These may be a critical or a innocuous lesion.The  word “left main” triggers a sort of alarm reaction to many cath lab staff as well as the cardiologists and surgeon.Many times, these left main lesions are detected in patients   with chronic stable angina who have stable symptoms. Left main disese has not been graded  clearly in literature . Often it is perceived , any lesion in LM is serious.

There is an unwritten rule,  rather a medical compulsion  to take a patient  with left main disease  for emergency CABG ( Now some centres ,emergency PCI) .Some institutions make it  a rule these patients  are posted  in the  next available slot in the theatre.

 The basic question we raise here is   “Should we consider all  left main  disease  as  an  emergency”?

Not really , especially when it occurs in a stable angina .One can wait , buy some time to fully evaluate and prepare  the patient  and may be the patient can be posted  as an elective case. It is a well recognised fact that, CABG carries adverse outcome when done as an emergency procedure. This is primarily due to inadequate pre op work up and resultant complications. It is also well known ,  surgical  back up team may not be available in full strength in odd hours .

This post is  to convey the message , that left main is  a serious disease but that doesn’t  mean it should elicit  a panic reaction and be taken as an ultra emergency . There has been many morbid and fatal outcomes in many hospitals due to this apparent  pseudo emergency !

 

Note* 1.Left main  disease during acute coronary syndrome is to be seen in different perspective.2.Some of the proximal LAD lesions are so tight and  could be more significant than left main lesions.

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Interventional cardiology as a speciality is in cross roads.

The number of coronary interventions (PCI) has increased exponentially world over. With increasing  Cath labs and growing  expertise ,  access to PCI has enormously increased  even in underdeveloped countries.  Meanwhile ,  public lack  specific technical information about the appropriateness  of these costly procedures. It is our duty to do self audit on this issue.  .

                           In this context,  the evaluation  following a PCI  should look beyond  lumen oriented  endpoints.  Many  land mark trials on DES report 3 months are 6 months angiographic outcome and better luminal appearance . Many   tend to worry  more about the status of the stent rather than the patient !  This is primarily because the device companies have repeatedly stressed the technical end points rather than clinical end points .

It is a  well recognised fact  that ,stented coronary artery never guarantees against future  coronary events (ACS) either within the stent or away from it .It is an explict fact that , a patient  after getting a coronary stent , especially a drug eluting stent carries a life long risk of acute stent obstruction and possibly SCD .This information is rarely passed on to the patient in  and hence they are not able to take “learned consent”

It is true ,  one gets  a gratifying feeling  when  opening up a obstructed artery , but we also need  to answer this simple question   What is it’s impact on  patient’s  life  ?

COURAGE & OAT trials have put a break on the  prevailing precondtioned behaviour in the labs, namely any obstruction must be relieved if  technically feasible .

One should recall  the Gruentzig’s legacy  . Whaterver,  we do inside  a  patient’s coronary artery must have some useful purpose . We should not use patient’s  coronary artery to show our expertise and skills !

Dr.S.Venkatesan, Madras Medical College, Chennai, India

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Thousands of dissections happen in cath labs  all over the world every day  very rarely it is painful . The answer is not clear. Both have rich vasa nervorum. Aortic dissection  involves media and smooth muscle . Coronary dissection may also be a  equally painful  , probably we are not recognising it ! or we attribute   all  chest pain in ACS  to ischemia .

Deep dissections into the smooth muscle should be painful.  Type c nerve fibers carry pain signals from heart

Answers welcome.

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