Dr.S.Venkatesan MD

Posts Tagged ‘lancet’

Science can wait … not the suffering patients!

Posted in Uncategorized, tagged best medical quotes, bmj, hippocrates, jama dr s venkatesan sangareddi, lancet, medical ethics, nejm, osler willam, pateint care vs science, practical bio ethcis, primum non nocere, science and ethics on January 14, 2026|

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How do mitral valve balance its Tethering and Closing Forces ?

Posted in Uncategorized, tagged coapt study, eccentric cs concentric mr, jacc, lancet, lub dub, macr, Mechanism of mitral regurgitation, mitra clip, mitral annulus, nejm, role of stethoscope in current era, scai, TAVR, teer, tethering cs closing forces in mitral valve on January 3, 2026|

Preamble : The Lubs & Dubs

The lubs and dubs, along with some added sounds are the only language, the heart can speak in health and distress. It’s a worrying story altogether, gradually many of us are becoming “cardiac illiterates” as we struggle to read , its gentle communication. it is not our fault. Stethoscopes are reduced to become a social marker of being a doctor. We may excuse ourselves, even if we can’t differentiate a systolic from diastolic murmur, after all, hand held echo machines, instantly tell the diagnosis.

( After reading this article, fellows are expected to understand why the first heart sound in MR (ie the lubs,) are mostly soft,  some times normal or even loud in certain conditions)

Now, let us go to the mitral valve dynamics

How many of us are aware, there is a big science of physics and biology operating when the mitral valve perfectly closes at the level of the annulus, with each systole , balancing different sets of known and unknown forces.

In this article, we will see how these two sets of forces mitral valve tethering and closing forces balance out each other to seal the mitral valve and what happens when the forces begin to fight each other.

Balance of Tethering and Closing Forces in Mitral Valve Coaptation

The mitral valve (MV) coaptation refers to the edge-to-edge apposition of the anterior and posterior leaflets during systole, ensuring a competent seal to prevent regurgitation. This process is governed by a delicate balance between tethering forces (which restrain leaflet motion to prevent prolapse into the left atrium) and closing forces (which approximate the leaflets for sealing).

• Tethering forces: These are primarily transmitted through the chordae tendineae from the papillary muscles (PMs) to the leaflet free edges and bellies, pulling the leaflets apically and laterally toward the left ventricular (LV) apex. They arise from:
• Closing forces: These are driven by the transmitral pressure gradient during systole, where rising LV pressure (generated by LV contraction) exceeds left atrial (LA) pressure, pushing the leaflets together. The force is proportional to the LV dP/dt (rate of pressure rise) and peaks in midsystole.
• Balancing mechanism: Coaptation occurs when closing forces overcome tethering, enabling leaflets to meet with sufficient overlap (coaptation length >8 mm typically). Imbalance favors regurgitation: excessive tethering (e.g., from PM displacement) causes apical tenting and incomplete closure; insufficient closing (e.g., low LV contractility) fails to seal the orifice. In health, the forces are synchronized with systole, with closing forces dominating midsystole to minimize the effective regurgitant orifice area (EROA).

Paradoxes in the Balancing Mechanism

MV mechanics exhibit several counterintuitive paradoxes, where adaptive or dysfunctional responses lead to outcomes opposite to expectations. These highlight the interplay of geometry, contractility, and force transmission:

1. Paradoxical systolic PM elongation: Normally, PMs shorten during systole (1 cm) to offset annular descent and maintain annulopapillary balance. Post-myocardial infarction (MI), scarred or ischemic PMs paradoxically elongate driven by transmitral pressure tension. This decreases annulopapillary distance, attenuates tethering, and reduces MR severity—contrary to the intuition that PM weakness worsens regurgitation. However, extreme elongation risks leaflet prolapse, flipping the paradox to increased MR.
2. PM dysfunction attenuating ischemic MR: In isolated dysfunction, reduced PM contraction intuitively increases slack chordae and prolapse risk. Yet, in localized basal inferior LV remodeling, PM dysfunction (measured as reduced longitudinal systolic strain) inversely correlates with MR fraction attenuating MR by limiting excessive tethering. This holds only with certain level of remodeling . Gross and asymmetrical remodeling can exaggerate tethering and increase the MR.
3. Dynamic EROA reduction despite peak driving pressure: MR often peaks early systole (when closing forces are low and tethering dominates) but paradoxically decreases midsystole, even as LV pressure (driving force) maximizes. This occurs because rising closing forces (transmitral gradient) overcome tethering, shrinking the orifice mimicking reduced regurgitation when it should worsen.Thgis mechansim can some times seen when MR jet is bi-fid in doppler tracing.
4. Imbalanced chordal forces causing focal prolapse: In acute ischemic MR (e.g., posterior wall ischemia), tethering redistributes unevenly: tension drops in ischemic-side chordae but rises on the nonischemic side causing focal tenting and relative prolapse on the ischemic commissure. This creates an eccentric jet despite global LV contraction.

This article clearly tells us that the forces acting on the mitral valve apparatus are so complex. The conceptual model of tethering and closing forces may be oversimplified. There are variable interactions between them. More importantly, the atrial forces also influence and intrude into these forces. Realize that MV competence is not just about force magnitude but their vectorial distribution and timing, often amplified by LV geometry changes.

Final message

As cardiologists and surgeons, we must realize the fact, how important it is to analyze both anatomy and the physiological impact when we rush to clip, cut, or repair it with annuloplasty and subvalvular interventions.

*Sometimes, it might even be tempting to do mitral valve replacement, even when it is not indicated, because we need not bother about all these dizzy mechanics and physics of MR jet forces.

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AI clinical consults : Beware of machine hallucinations, that could become a permanent medical record of your patients.

Posted in Uncategorized, tagged AI assitted consultation in hospitals, AI consultations, AI in medical profession, ai in medicine, annals of internal medicine, Artificial Intelligence in cardiology, bmj, jama network, journal of AI in medicine, lancet, nejm on December 6, 2025|

It is predicted, (or already happening ) atleast 30 % of clinical consults happen with AI assistsnce or with completely with machines.

The Initial work up is suggested by the AI bots, even in ER rooms. They may be right in 80% of times. But, who is it to filter and grab those remaining 20%. No one , except a astutely learnt clinician. Unfortunately, there is no super AI to do this job.

Final message

This is the beginning of, a new exciting & dangerous era, for the medical profession. If we are not vigilant or loose our common sense, these bots will soon reach their next destination, ie patient’s bed side.

Reference

BMJ in its current Issue address these  aspects of increasing AI usage in the clinical consults

1. Clinical competencies for using generative AI in patient care BMJ 2025; 391 doi: https://doi.org/10.1136/bmj-2025-085324 

https://doi.org/10.1136/bmj-2025-085324

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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|

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Trying to become a truly Professional Physician !

Posted in Uncategorized, tagged bmj, ethics in cardiology, ethics in medicine, Hippocratic oath, jama network, lancet, medical ethics quotes, nejm, who is a professional cardiologist on August 10, 2025|

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Post-amble

Are you a professional physician doctor ?

Honestly I am struggling to become one , it is still a long way to go.

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Trust deficit in medical research and Journals : Need for an unprecedented transparency in declaring conflicts of Interest. 

Posted in Uncategorized, tagged bmj, conflict of interest, jacc, jama network, lancet, medical ethics, nejm on July 25, 2025|

An Awakening Call to the Guardians of Medical Science

Dr. Venkatesan Sangareddi MD, Former professor of cardiology, Madras medical college,Chennai .India

Medical science remains a cornerstone of human progress, and what we have achieved in the last 100 years is unprecedented. Every one of us is aware that the trust placed in medical research is sacred. Also, the medical profession is expected to remain noble as long as human beings exist. However, as in all walks of life, there must be trade-offs to any positives. Yes, this trust has increasingly become vulnerable, threatened by the pervasive and often subtle influence of conflicts of interest (COI). This is especially explicit in the current medical research landscape.

While the scientific community has made strides in acknowledging and requiring disclosure of COIs, particularly from authors , the measures are proving insufficient. There is a big irony sitting right across us. It is made to look, as if conflicts of Interest (COI) exist only with the authors.

The following article written by the author (Ref 1) calls for an  awakening to every medical journal publishers, regardless of their prestige or impact factor, to recognize their vulnerability . We are expected to adopt a new paradigm of transparency in declaring COI, that extends to every participant in the publication process, including the scientific or ethical committies that approve the study ,the peer reviewers, the publishers and finally to the industries that fund the research.

Reference

1,Click here to download the full paper: A caution: It is a fairly lengthy article. (15 minutes read) Hope the suggestions made in the article are not labeled as unrealistic and possibly crazy as well.

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Evidence based common sense, is rare entity in medical literature

Posted in Uncategorized, tagged bmj, common sense in medicine, ebm, ethics in medicine, evidence based medicine, experince based medicine, false evidence, jacc, jama network, lancet, medical education, nejm, pitflls of ebm on July 10, 2025|

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Early TAVR trial : Too early to call

Posted in Uncategorized, tagged acc, accurate neo tavi, aortic valve repalcement, bmj, early tavr nejm, esc, ethics, how end points of a study defined?, lancet, medical statistics, primary endpoints, sapiens core valve, stsscore, tavi, tavr for asymptomatic, tavr vs surgery on January 18, 2025|

We know TAVI is in the striking distance , to literally take over most aortic valve interventions. From a humble beginning from very high surgical risk with prohibitive comorbidity, now it has almost touched the totally asymptomatic, relatively morbid-free patients. Thanks to the hardware, expertise, and motivation from multiple forces.

While the numbers increase, still the debate between SAVR and TAVR is riddled with speculation, skepticism, and absolute confidence. (Reason: TAVI is a passively fixed valve in a blind procedure at a self-selected annular plane, with no option to remove the crushed native leaflet debris and the resultant complications. Lastly, TAVI’s lifespan* is currently less than half of a mechanical valve. *Expected to improve with polymer valves)

The latest trial to join the litereture is EARLY TAVR in October 2024

Here is a brief, personal comment about the paper for non-academic consumption. Look carefully at the 15th second of the video. Pause it, look at the number over there on the bar of unplanned hospitalisation.

It is a staggering 41.7% in clinical surveillance group, twice more than TAVI group, pathologically tilting the conclusion of the study.

Video source and courtesy https://youtu.be/3wwQEEG4aWg

By the way, what is that unplanned hospital admission? Who is planning that admission in the asymptomatic control group? If 41% of people in the clinical surveillance group needed hospital admission, what does it mean? Does that mean clinical surveillance was so poor that they were rushed to the hospital despite being asymptomatic and stable in the surveillance period?

Why should totally asymptomatic patients get admitted in the control arm, in such huge numbers? You can presume what could be the reason. My guess is too sinister.

Another issue plaguing the RCTs for decades, is continuing even in 2025. That is putting together death, stroke, and unplanned hospital admission as a combined endpoint in the same basket. This is the familiar old cheat story i.e., used to intentionally torture the truth.

Final message

Any student with basic sense of statisitcs can interpret the result of this landmark trial from NEJM correctly. The question we need to ask is, what are the triggers for those unplanned hospital admissions?

Further, it is good for NEJM (and the medical community) not to accept any papers, if the studys’ endpoints are not appropriate or defined with the intention to manipulate, which happens in many sponsored trials.

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Will meta-analysis really come under an original scientific research ?

Posted in Uncategorized, tagged evidence based medicine, fisher, jama network, journalof statistics, kaplan meir, lancet, levels of evidence, medical ethics, medical statistics, MEDICALEDUCATION, meta-analyses, meta-analysis, nejm, pearson, pvalue, randomised control trial, rct vs metaanalyses, why two meta analysis difer ? on October 10, 2024|

“In one sense, meta-analysis would come closer to a milder form of ethical plagiarism”

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Can meta-analysis really be called as original scientific research ?

No it is not, but some may say yes. It is very difficult to dispute either. But, the fact of the matter is, meta-analyses are not a true science of innovation. It is using some others’ work( sort of intellectual steal ?) done by a group of scientists interested in the same research topic, trying to squeeze more info from these studies. It is a glorified group journal club activity.

Image source & Courtesy http://www.inquasar.com

At best, meta-analysis can be referred to as knowledge and evidence aggregation. Surprisingly, mostof the academia seems to give more weight to meta-analysis, disproportionately more than the original researchers. This is because meta-analytic scientists backed by big journals claim, they can bring out more info out of the original. The assumed scientific superiority of meta-analysis is expected to be downgraded soon, as these sort of evidence aggregation can be done easily by any AI-powered engines. Network meta analysis, by dedicated medical scholastic AI networks can do this in a fraction of a second.

Meta analyses as of now is sitting proudly as crowning glory at the top of evidence pyramid. This is one of the reasons for the false glory surrounding anyone (or anything ) associated with meta-analyses. I doubt whether it really deserve the top slot. (An excellent debate between RCT vs metanalysis) Wish, the meta-analysis taste its own medicine at least once. We need to have a meta-analysis to show it is really superior to other forms of evidence. I cant find one as yet.

What about systematic review ? This looks better, as it has less statistical content , and the researcher is at least compelled to go deep and get enlightened on the topic as they spend months together on the topic.

How is meta analysis different from original research?

There is no new data collection ,no primary hypothesis testing . It primarily focus on summarizing existing evidence. To do it properly, there are certain standards.

1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
2. Cochrane Handbook for Systematic Reviews of Interventions
3. MOOSE (Meta-analysis of Observational Studies in Epidemiology)

Ref :Finckh A, Tramèr MR. Primer: strengths and weaknesses of meta-analysis. Nat Clin Pract Rheumatol. 2008 Mar;4(3):146-52.

Positive side of metanalysis

While meta-analyses aren’t original research, it’s a crucial tool for evidence synthesis, research translation informed decision-making.

Flaws of metanalysis

It is a academic business with done studies. So it is 100% retrospective. It might come with irreversible errors. Unless every error in the past studies is accounted for and curated the result of meta-analysis, it can never be foolproof.

Should we get permission from all the authors who did their original studies before doing a meta-analysis?

As long as fair use criteria applies there is no need , but a moral obligation is definitely there . Other wise metanalyses will come closer to a milder form of academic plagiarism of others’ work. (Of course legally and scientifically approved)

Final message

In the world of true scientific research, meta-analyses can not be considered as great scientific work. It is just evidence aggregation, which of course could be meaningful if and only if the studies taken were done properly.

However, meta-analysis has undisputed value in aggregating rare cases, scenarios, diseases, and problems where there are very few published studies. Collecting them together in an organized fashion serves a real good purpose.

Reference

1.Pearson K. Report on certain enteric fever inoculation statistics. Br Med J. 1904;3:1243–6.

2 Smith, Mary L.; Glass, Gene V. (1977). “Meta-analysis of psychotherapy outcome studies”. American Psychologist. 32 (9): 752–760. doi:10.1037/0003-066X.32.9.752.

3. Eysenck, H. J. (1978). “An exercise in mega-silliness”. American Psychologist. 33 (5): 517. doi:10.1037/0003-066X.33.5.517.a.

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