Timing of AVR and MVR in AR and MR has always elicited huge discussion in cardiology literature. Mind you, if the patient is symptomatic and there is LV dysfunction, it is absolutely easy to make a decision.Here, the question of timing doesn’t arise at all. (Of course, the symptoms and LV dysfunction should be confirmed to arise because of valve disease, not because of any other systemic disease, or LV dysfunction might be due to associated CAD. *I know a women who got her leakinging mitral valve replaced because she developed symptoms of dyspnea due to anemia .
Timing becomes a big issue only in patients with no symptoms at all. Some cardiologists put them on a treadmill. It is controversial, as anyone will develop symptoms. But , somehow, we should make it sure, patients are truly asymptomatic.
For long, we relying on some gospel echo parameters. I don’t how good they are. But , no one really knows,how and when the onset of LV dysfunction would be , and how it will progress. But, we are bound by the guidelines , as on today. There is some critical difference between the echo parameters , based on we intervene.
For mitral valve the threshold is lower. It needs early MVR for same degree of regurgitation as AR. It is proposed by the author for the benefit of fellows to easily remember the cut offs. It may be called as the 40:60 rule for MVR and 50:50 rule for AVR. The former denoting LVESD and later referring to LV EF %. The difference in echocardiographic thresholds arises because the two lesions cause fundamentally different hemodynamic loads on the left atrium and ventricle .(Read the legend in Image)
Final message
With mortality and morbidity for valve replacement steadily falling, it is likely more and more patients will be taken for surgery early. Of course, intervention guys are raring to go with percutaneous TAVR and TMVR, so the thresholds are expected to fall.
Human myocardium does not read hospital sign boards . It simply doesn’t bother whether thrombolysis is done in a moving van or a stationary room . When confronted with a life threatening emergency , all that it demands is quickness with which it is administered. Yet, in modern interventional cardiology, a same thrombolytic drug transforms from a life-saver into a forbidden clinical error, depending on whether it was injected in an moving ambulance or in the emergency Department.
This is the comical, yet tragic, irony of modern STEMI care.
Pre-hospital lysis is celebrated as a great strategy , while ultra fast in hospital lysis even within the “golden hour” is frowned upon as low-quality treatment.
At the heart of this paradox lies , the cult like status of primary PCI .It is true, pPCI has been etched as the gold standard of ACS care. However, most of the experienced cardiologist* know its perceived supremacy is not absolute ,largely attributed to the seductive power cath lab . (* Few have the courage to admit it )
Respect the myocardium not the cath lab
The efficacy thrombolysis is strictly a function of time, not geography. Landmark data from the CAPTIM trial explicitly demonstrated that when thrombolysis is administered within this early window, mortality rates are equivalent, and in some subsets superior, to immediate pPCI.
The current system of care willingly accepts this when a paramedic administers the drug but reprimands a physical if he does the same in his CCU .Why ? We seem to suffer from a misplaced academic arrogance that demands , fate of every coronary event must be decided only in cath lab. Any thing else is considered as deviation from the standard of care
Final message
It is time to change how we use the terms “pre-hospital” and “in-hospital” thrombolysis and replace them with a simple terminology . Symptom to Reperfusion Time. If a patient presents to a pPCI-capable center within the first hour standalone, ultra-fast ER lysis should be made an established, protocol equivalent to pre-hospital care, which is at equipoise with (un)disputed gold standard of pPCI as per the landmark study of CAPTIM.
Postamble
It is heartening to note In-hospital thrombolysis continues to be dominate mode of reperfusion at any point of time, inspite of the negativity surrounding it. Can we take this as a proof of real mettle of pPCI ?
The famous & popular 3-24 hr time window for pharmaco-invasive strategy (PIPCI) was adopted, blindly from STREAM (prehospital Tenecteplase + PCI <6-24h in <3h presenters) and FAST-MI trials assuming uniform IRA patency. It fails to stress the importance Initial time window to lysis, and its response . This makes the distinction between true rescue vs routine pharmaco invasive PCI a hazy excercise . Thus, both inappropriately delayed or a hastily-routine PCI has become all too common.
The 24-hour upper cutoff in pharmacoinvasive strategy serves to prevent reocclusion, or to address any residual mechanical stenosis . It is not meant for myocardial salvage, which is irrelevant if lysis was successful.
Mind you, IRA optimisation is not a time bound emergency in a well recannalised vesseel. In fact, PCI is not an absolute neccesity for long term IRA patency especially if it an coronary erosion. If there is TIMI 3 flow ,and there is little ischemic substrate , there is no need to chase the , supposedly sacred 24 hr time window. If the lysis achieves complete( or almost complete) IRA patency, PCI can safely be extended to 48-72 hours, or even permanent deferral (No-PCI , stand alone thrombolysis) in stable patients with optimal medical therapy.
An interesting study is published , from my institute in the current issue of AJC with a title ” Extended Pharmacoinvasive PCI Compared to Primary PCI: Insights From Madras Medical College STEMI Registry” . This study argues for extending the time window for pharmacoinvasive strategy to 48 hrs. (It could still be higher.) It suggests , this flexibility suits the LMIC, due to logistical realities. ( Glad to be listed as a co-athour)
I am sure, this study, demands to reset the 24 hr upper limit of cut off for pharmaco invasive strategy.Looking beyond this study, there is an urgent need to clarify the specifc purpose of the generalised time window of “3 to 24” hr time window in pharmaco invasive strategy.
A call for new sub defintions in the time windows in PIPCI
1.Successful Lysis* (TIMI 2-3, in about 70%): Routine angiography/PCI 3-24h (prevent reocclusion/residual stenosis) .Extendable to 48-72h + is possibel. Permanent deferral if the pateint and myocardiumare , with a patent IRA . (Implying no need for further salvage at all , we should allow a green corridor for patients with successful standalone thromolysis to exit the hospital without a PCI ) Doing a PCI onlu t0 prevent fear of reocclusion in the first 30 days is not backed with good data.
2.Failed Lysis* (TIMI 0-1, 30%): Rescue PCI immediately (<3-6h post-lysi, like PPCI) Here the time window should be hastened and can never afford to extend it, at any stretch of imagination.
* Ironically, the 24hr cut of has no place in both the above subsets. (May be in failed lysis , 24 hr cut off might apply , again it is 12 hr longer than primary PCI )
Final message
“Time is no longer muscle , if the Intial lysis is successful“
What is the purpose of “24-hour” upper limit cut of time in pharmaco invasive strategy ? The 24 hr is not universally valid. Pharmaco Invasive strategy time windows need to be based on timing and efficacy of the Initial lysis.
Postamble
Commenting this paper as a third person :
One limitation in this study is to be admitted. I think, the generalised comparative efficacy of extended PIPCI with primary PCI can not be made, for the simple reason, the extension of time window is possible only in patients who had successful lysis. This study may ideally be concluded as “3-24h pharmacoinvasive PCI can be extended to 48h if the initial lysis successful” . Further, If initial lysis fails (30% TIMI 0-1), any extension is contraindicated and requires immediate rescue PCI akin to PPCI. Also, data regarding non-IRA intervention might help understand the importance of the extension of the time window better.
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.
Covered stents are exclusively reserved for coronary artery perforations. Yes, that’s what we think. There has been limited exploration regarding the value of covering the complex lesions, which could prevent future coronary events .
It is possible, covered stents might play a extended role , other than perforations as in complex .friable thin capped lesions . As of June 2025 , haven’t found any such study in cardiology literature.
The recently released PREVENT study argued for PCI for patients with vulnerable high risk plaque. Ironically , it is found plaques with very thin cap ie <50microns are at risk of rupture by the radial stress of struts in the immediate or late follow up.
The thought of this study came when we witnessed high recurrent events, due to plaque prolapse, TCFA injury, new plaque ruptures, micro emboli. no reflow etc in patients with complex lesions.
Any past studies done on this aspect ?
There have been some attempts to use covered stents in degenerated venous grafts. Also, the M-Guard stent system was used in the past to seal thrombus during primary PCI. Both showed mixed results. (Gracida 2015)
Are we ready for a trial with a far fetched Imagination ?
What about jacketing and sandwiching the coronary lumen internally with a synthetic layer of tissue? That can potentially prevent recurring events indefinitely. (It is like making a native coronary artery into a Teflon-coated tube.) The proposal may look crazy until we find a inert layer of synthetic tissue to false roof the coronary lumen. But someone can make a start.
Final message
Covered stents are not just meant to arrest blood leaking outwards, in case of perforation , it can also be used seal high risk plaques, that ruptures and leaks its content into the lumen.
*In the following document, a brief outline and proposal is written about such a study. Whoever wants to do such a study, may use it. I wish I could be an external adviser, as I am no longer attached to a teaching hospital or research center.
Before , we begin such a study, one may look at the long term outcome of patients who had already received covered stents for perforations. This is important because, PTFE’s pro-thrombotic potential and need for additional vigilance is yet to be defined.
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.
This quote is being sent for the annual meet of “Right care movement” I know ,this can sound outrageous, permissble limits of abuse ? Up to 2% or 5% ? Let it be anything . Meanwhile try to enlighten yourself , the key differences between misuse & abuse.
The contents of the this blog is being published as Kindle E book , as per the request of many of the readers. Every article will continue to be open source in this site. Again I shall reiterate the book format is not aimed at any commercial intent. It is only to facilitate learning in a single book format Here is the link to book https://amzn.in/d/euhL5vu
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Please Note
The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
Dr.S.Venkatesan MD 