dr s venkatesan | Dr.S.Venkatesan MD

Posts Tagged ‘dr s venkatesan’

Forbidden quotes in medicine : Healing shall prevail over harming

Posted in Uncategorized, tagged bmj, british journal of medical ethics, dr s venkatesan, ethics in medicine, famous quotes on medical ethics, Hippocratic oath, indian journal of medical ethics, lancet, madras medical college, medical education, modern medicine, nejm, venkatesan sangareddi, world health organisation on April 9, 2026|

Read Full Post »

Many second opinions might be wrong too … consume it with caution !

Posted in Uncategorized, tagged appropriate procedure, bio ethics, bmj, british journalmof medcial ethcis, clinical decision making, dr s venkatesan, esc, inappropriate interventions, lancet, madras medical college, medcial decsion making, medcial errors, medcial ethics, medical education, medical incompetence, nejm, pateint empowerment, principles of practice of medicine, private vs public health, second opinion, third opionion, venkatesan sangareddi, what ails modern medicine on March 8, 2026|

Getting a second opinion from another expert is a valuable option for our patients when they face a complex decision-making process, especially when a cardiac intervention is advised. No doubt, it is their fundamental rights too.But this could be hard, if the second opinion is sought regarding indication for coronary or interventional procedure.

It is much, much comfortable to concur with the original decision if it is pro -Intervention. (even if it is against your conscience). Vetoing a procedure which was advised by some big hospitals is almost impossible for cardiologists sitting at their office, however experienced they may be. This is because it is sort of going against, the mainstream and defying science as well. Both doctors and physicians are stuck.

I confront such situations often from patients following elite cardiology consults. I had been forthright and genuine and said a firm no or yes to many such procedures . I understood much later, that only a minority of the patients followed my No advice , while invariably they accepted my yes.

After much confabulations , recently, I have made some recalibarations on my values, (decent term for compromise ) despite all the ethical stuff I write in these columns. But, three things I ensure , before giving my opinion which goes against my assessment.

“This procedure is not indicated in the true scientific and moral sense, but 1.If you lack full trust, or 2. If you are not ready to accept the risks of not doing it, or 3. If the fear (of not doing it ), would nag you constantly, then get it done as per the advice of the big guys”.

Final message

Until we acquire the courage to express our true opinion , we certainly fall under the tag of medically incompetent.

Very soon, getting a second* or even third opinion may not really matter. Doctors are silently persuaded to follow the guidelines thursted by big scientific syndicates along with compulsion to go with patient wish & preference.

*Caution and clarification

Second clinical opinion for helping to arrive at a medical diagnosis is of immense value and a great thing to do. In fact, doctors themselves ask for it when they are in doubt. This article is about second opinion regarding the appropriateness of various interventional procedures that is defining modern medicine.

Read Full Post »

What is the realistic definition for “fact vs fake” news

Posted in Uncategorized, tagged bmj, dr s venkatesan, expressions in cardiology, fake vs fact in medical science, jama network, lancet, madras medical college, medical education, medical ethics, nejm, quotes in medical ethics, venkatesan sangareddi on November 18, 2025|

Read Full Post »

Defining optimism is not an easy task in science.

Posted in cardiology -Therapeutics, Ethics in Medicine, tagged dr s venkatesan, dr venkatesan sangareddi, ethics, optimism, optimism vs pessimism, optimist, positive vs negative thinking, venkat quotes, venkatesan sangareddi, widom quotes on April 9, 2025|

Read Full Post »

Why prosthetic mitral valve DVI increase with obstruction, while Aortic valve DVI, decreases?

Posted in Uncategorized, tagged aortic and mitral dvi, dopper velocity index, dr s venkatesan, dvi, echocardiography doppler bernouli equation, esc acc jase, madras medcial college, prosthetic valve assessment, vti, why mitral valve dvi increase with obstruction ? on December 23, 2024|

Final message

Prosthetic valve assessment is complex, thought process intensive examination. Not every echocardiographer can do it efficiently. It needs a good knowledge of anatomy, physiology of inter & Intra valvular hemodynamics .It demands thorough understanding of principles of Doppler echocardiography and also the hidden truths( ie, How we take liberty with the mighty Bernoulli equation for granted )

In spite of the number of imaging and doppler parameters we are able to gather ,still, we need to analyze them with reference to the clinical presentation. Mind you, even an innocuous episode of fever, associated dyspnea, and tachycardia can elevate the mitral gradient and sound a false alarm.

Depending solely on prosthetic valve gradients to diagnose obstruction is the biggest error we commit. We have seen this, even from elite hospitals. Echocardiography is not the final say, one may require cine fluoroscopy, CT scan or even PET (Infected peri prosthetic abscess) in appropriate situations.

Reference

1.Zoghbi WA, Jone PN, Chamsi-Pasha MA, Chen T, Collins KA, Desai MY, Grayburn P, Groves DW, Hahn RT, Little SH, Kruse E, Sanborn D, Shah SB, Sugeng L, Swaminathan M, Thaden J, Thavendiranathan P, Tsang W, Weir-McCall JR, Gill E. Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr. 2024 Jan;37(1):2-63. doi: 10.1016/j.echo.2023.10.004. PMID: 38182282.

2.H, Freeman WK. Echocardiographic Assessment of Prosthetic Valves. Rev Cardiovasc Med. 2022 Oct 11;23(10):343. doi: 10.31083/j.rcm2310343. PMID: 39077122; PMCID: PMC11267339.

Read Full Post »

AI in Cardiology: Was the past perfect …is the future tense?

Posted in Uncategorized, tagged AI in cardiology, artificial intelligence, dr s venkatesan, drsvenkatesan, madras medical college on June 11, 2024|

This is a condensed video version of PPT slides of my recent presentation.Please pardon, there is no audio as of now. Will make a voice-over and post soon.

Topic : AI in cardiology

Occasion: Prof Rathnavelu Subramanian memory oration. Cardiological Society of India Chennai.

Date : 8-06-2024

Acknowledgment & Courtesy: Images and videos from open source

Read Full Post »

Loyalty in the medical profession: Something seems to be wrong!

Posted in Quotes, Uncategorized, wisdom in cardiology, tagged best quotes in medical ethics, dr s venkatesan, dr venkat quotes, madars medical college, medical education, medical ethics, venkatesan sanagreddi on November 10, 2022|

Read Full Post »

Time to tweak the definition of “Professional incompetence” in medical practice.

Posted in Uncategorized, tagged artificial intelligence, dr s venkatesan, dr venkatesan sangareddi, future of medical ethics, gene therapy, hippocrates, journal of medical ethics, lown foundation, madras medical college, medical ethics, medical quotes, nano medicine, nejm bmj lancet, noble profession, principles of practice of medicine, quotes medical ethics best, sir william osler on January 28, 2020|

Read Full Post »

“Non academic” Tips and tricks in CTO – PCI : Open sesame ! , Show me your treasures !

Posted in cardiology -Therapeutics, Cath lab Hardware, cath lab tips and tricks, cto chronic total occlusion, tagged absolute refractory period, Best guideline on cto pci, cart reverse cart, chronic total occlsuion, cross boss sting ray, cto club, CTO club euro, cto euro club, cto japan club, cto mmc chennai madras medical college, decision cto trial drsvenkatesan, dr s venkatesan, ethical guidelines in cardiology, ethical issues in cto, management strategies in chronic total occlusion, see saw technique, tips and tricks for cto opening on November 27, 2017| Leave a Comment »

We know, The Mysterious Alibaba cave opens with a voice password . . . legend tell us it had unlimited hidden treasures. It would appear , CTOs mimic the cave in several ways. What is inside ? Should we open it ? Can we come out safely ? Do we have any magical password in cath lab to get across the complex tissue boulders ?, every cardiologist would love to have one !

chronic total occlusion alibaba cave corsair fileder xt pronova guideliner micro catheter asahi cart reverese cart cross boss sting ray

Dear CTO,Open Sesame . . . I have come with all the wires you love ! Please let me in !

Indication

“CTOs are never an emergency . . .but please realise we can very easily create one while resuscitating a dead snake !

Don’t think hard on evidence , then , you may not do a single case of CTO in your life .Forget all those pessimistic trials like OAT,COAT, etc and the recent ones DECISION-CTO. Ignore all guidelines. Ask your patient, and his insurance company , if they are willing , reserve the cath lab and get ready.

Pre-procedure planning

Spend at least a hour to analyse the CTO Imagery one day prior and create n action plan.

Keep knowledgeable staff for assisting , but never ask for fellow colleagues help because it hurts our ego ! Cardiac surgeon’s back up is a welcome addition even if it’s on paper.

If possible , try to ask the patient genuinely ,what is his symptom at least once ! before starting the procedure.

Timing of the procedure.

Don’t post a CTO patient either on a busy Monday morning or lazy Friday afternoon.

Hardware Inventory

The wires ,catheters, the balloons form the essential tool box .There is more than a handful of coronary automobile companies manufacture this .It is all about metallurgy , knowledge of wires, catheters , and tip thickness, (Bullet shaped as in Asahi ) , slipping , hydrophophic or philic, polymer coating , trackability, pushability , memory etc etc.

Guide wire tip morphology is as Important as the Lesion characteristics !

Analysis of the lesion (Probably most important)

Unlike conventional PCI we have no initial target.We need to poke first and find the target next ! Distal vessel status is most important ( Careful review of retrograde filling through collaterals could give more information than CT angiograms .Calcification, diffuse disease can be a real hurdle)

Lesion morphology

Softness of lesion has to be felt (Requires good wire which has sensor (Paccinian corpuscles and Merckle disc ideal ?) I guess the cortical tactile feel is as vital as the intervention expertise .I know at least one diabetic colleague of mine who finds it difficult to cross a CTO and admits he never found it easy to feel the lesion through the wires . Autonomic dysfunction ?)

Operator expertise

(Note: These are like reading swimming guidelines , you can’t learn in the shores reading books ! you have to plunge !)

Many techniques are proposed .Sequential approach (Ironically experts are licensed to use specialized wired wires directly .Beginners are advised to go with non specialized hardware and escalate step by step) Some centers are blessed with new age weapons like cross Boss and sting ray that confront the lesions in multiple frontiers. (Carpet bombing?)

CTO playground. : Its essentially a coronary contact sport with expert septal surfing , tunnelling, knuckling , kneeling , bending . Of course , It can end up in a gratifying win in few , still most of us tend to play this game without a goal (post !) Source of the Image : Unknown Due credits to the creator.

They are basically about poking the head of the lesion and trying to cross an occluded vessel millimeter by mm towards the presumed distal vessel in an Imaginary trajectory. Proximal cap, central core ,the blind tunnel , distal capsule and exit points each must be successfully conquered.

CTO crossing is the ultimate capacity of the operator to realise and feel the position of the wires in true lumen and their confidence levels in their conviction!

Multiple wires up to three are used some times to poke the lesion two of them are used to shut the false tracks and the other one is expected to enter the true lumen (Looks too good on theory !) . These are referred to in as many terms like parallel wire see-saw , CART ,Reverse CART etc .Retrograde techniques do help us but has no magic solutions.The lumen contrast , guide wire tip movement and its side branch entry would help.

Tacking complication :Always anticipate , it’s not negative mind set to look for it !

Keep pericardiocentesis kit , covered stents , micro snares and other retrieval devices ready in cart. Your support staff should be well versed with what is happening around them. Some of the dye leaks and stains are safe .They imply minor perforations that form sealed hematomas (The plane of perforations also matters. myocardial (ab-pericardial ) leaks are well tolerated .Distal perforations are also safe as long as CTO is not opened ) Online echocardiography should be readily available to monitor pericardial space leak.

When bleed into pericardial space is life threatening , A comical, but life saving option is to close the artery and restore the CTO its original state and come out of the lab quietly !

Newer Imaging guidance : Can be useful , still may not matter much when considering the interventional acumen .

CTO PCI : Time as therapeutic end point.

CTO is not an endless game with out time frame .In my opinion it shouldn’t cross 45 minutes each as in a soccer game with a brief strategic time out and of course with liberal use of ,yellow and red cards

Future directions

Japanese are the ones who pioneered CTO Interventions . We expect more Innovations ! Is it the forward looking IVUS ? It is akin to tunneling for underground metro train with GPS guiding .If you can mark the proximal and distal points , rest will be be taken care by mortised self tunneling catheters from Robotic arms steered by sophisticated algorithms.

Final message

CTO PCI remains a real Interventional challenge. We are often double blinded in both directions (antegrade as well as retrograde ). Needs much effort ,time, hardware and most importantly a non fatigued mind and body. The benefits we get may vary between gratifying to outright mediocre .Of course , it surely satisfies operator ego and express pride and courage !

Is crossing and stenting a CTO synonymous with true success ?

Yes it is , for the cardiologist and the hospital . . . I’m not sure about it for the patient !

In this sense , CTOs mimic the mysterious Alibaba cave that tempts us with Imaginary treasures but can trap us with a wrong password !

Post-Ample

* Who should CTO PCI ?

I have seen young , enthusiastic cardiologists with Immature support staff attempting CTO in remote sub- urban settings ! Though patience and expertise are essential ingredients, some amount of organised training and hardwares make CTO PCI safe and effective. Enthusiasm and affordability alone can’t be an Indication for this complex set of coronary lesions.

Reference