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IPL 2013 : A cricket carnival derailed by manic media !

 

April-May  is  carnival time in India . . . cricket carnival.  In IPL  . . . Indian premier league , eight teams  will fight for the cup . IPL 2013  became a  smashing  hit  , until  last week  when  three players were arrested for  spot fixing in  an  over . And for the past 10 days the entire Indian  media has gone into  manic reaction over it !

Still ,  the  sport was wonderful , the skills shown were extraordinary , and what happened  was an aberration just like in  any other aspect of life  .  IPL is perfect mix of  sports , business , commerce and some sleaze .  Actually in a successful  business model  , one should actually be surprised  if  corrupt  practices  does not occur !

The game of cricket can never be killed by money !  The way  the issue was handled by  the media and the  reactions and public debates   for me  looks irrelevant . Is it justified ? 

We the people and media has  much much important things to do in India !

Fixing a Fix  . . .

Politicians fix voters by giving money !

CBI is fixed by Government  for money  !

Media  fixes  news  for money !

Students of the noble profession are desperate  to  fix examiners with  money !

Finance ministry’s  annual budget  is fixed by business tycoons !

Private medical colleges fix entrance exams after getting money !

Super powers fix  terrorists selectively  for money for self benefits !

Drug companies  fix doctors with  money !

Doctors  fix  labs  by  getting money !

Anxious parents try to  fix  marks of their children  for  money !

Government  fixes  tender  for money !

Some Judges fix  verdicts after getting money !

Live kidney donors are fixed  by criminal cartels for money !

Advocates  fix  false evidence   with  money !

Police fix innocents as criminals after getting money !

Thousands of marriages are fixed  with  money after  hiding  illicit  relations !

Huge  bank loans are fixed  based on  false affidavits and  promises !

TV reality shows are fixed with mad money !

Even pilgrims fix  Darshan  time by  paying huge money !

And finally  . . . One cricketer bowled   one of  the  balls . . .wide . . . .  in one of  the  over after getting money  !

The whole world erupted !

Postamble

Can  there be  any justification for  justifying wrong  things in life ?

  If life is a fight between  good and evil  , I thought  it is absolutely absurd to justify  it  until recently  . . . but a  great epic of  India , Bhagawad Gita  which is considered as the  ultimate guideline for living ,differs (Or is it my perception !)

The summary of the epic goes something like this

• Whatever happened has been good.
• Whatever happens is good
• Whatever will happen is also good.

Bhagavad Gita  has one more sermon  to  confuse  us ( me )  completely !

“Do your duty , do not expect any  returns and do not watch injustice silently  , protest  and fight  it with your full  potential” !

I welcome  the experts  of the Bhagawatham  to clarify me on this issue !

Basic instincts in cath lab : It is too tempting to poke the non IRA . . . What shall I do ?

Doing multivessel PCI during acute STEMI is forbidden except in cardiogenic  shock . (or in some very unstable patients without cardiogenic shock)

The reason

• During acute MI   hemodynamics  are precariously balanced.We do not know yet how  emergency multivessel plasty alters this .
• Our  initial aim should be   confined to myocardial salvage in the IRA . Total myocardial revascularization is niether  the  priority nor its desirable.
• The more  time  you spend  within the inflamed coronary artery , more its  hazardous.
• Multiple stenting  is prone for thrombus   and  migration  into side branch .
• Stent opposition is sub optimal in many thrombus infested lesions.

 

Still  . . .  in real world it is extremely difficult to curtail the urge to stent  all eligible lesion during primary PCI !

 

 

How to avoid it ? 

If the patient is poor or the insurance limit is low , the issue  of multi vessel stenting does not arise at all  !

Always  ignore  complex  non IRA lesions  during primary  PCI. Be happy if a non IRA has a bifurcation lesion !

Still , some lovely looking lesions in non IRA  would be  tempting  and inviting .  Indulge at your own risk !

* Please remember if  the proximal  LAD  has a non IRA lesion , it may be sensible to attempt  simultaneous revascularisation even if the patient is stable !

Other unrealistic advice

• Keep the professional fee and other benefits   fixed whether  we do a single or multiple   vessel stenting (Realise  . . .  surgeons do not charge more for a  4  vessel by-pass graft  than a single  ! )
• Keep the current AHA/ACC/ESC guidelines pasted right next to the fluroscopy monitor .
• Ask your subordinates to repeatedly caution   you  about the possible  excesses and ask them to wave a red flag !
• You may  empower the   senior staff nurse   with a veto power  to shut off the cath lab once IRA plasty is  completed and the patient  is stable.
• In extreme  situations , keep a cath  marshal ready to manually evacuate  the primary operator  from cath lab !

Reference

Does radial coronary Interventions increase stroke risk ?

The link between brain and the  hand  starts right from fetus .  It is a well known fact  vertebral artery   competes with hand blood flow  . In the right side , there  is one more  vascular issue !  .Bracho cephalic  artery  arises  directly  from aorta and supplies the  right  hand and  right half of brain.

It remains a mystery  why left brain  is   blessed with a  separate  origin ,  while right has to share it with blood meant for hand  .It is beyond science  . . . isn’t

It is possible the left hemisphere  of brain   has more   purpose   to be alive  ,  with bulk of the cognition work to do . Hence   God created a  separate  supply to it !  Of course , he  would   have never  thought ,  the  possibility of  his ” mean” creations   adventuring  within the   arterial tree  !

Click over the Image for animation

Please remember  whenever  we   play with   catheters and wires  through   radial route , we  are  hugging  and scraping   the artery meant  for cerebral circulation !

Final message

Femoral Interventions  enjoys a proven  track record. Currently ,  radial route has virtually taken over with  few  advantages . However , the  overall stroke risk in the two approaches  remain  low but genuine (.4 %) .It may be true , arch manipulation is more  with  femoral but  the threat to  vertebral and brachiocephalic circulation  is more with radial .  When the available evidence are  not conclusive  and  new ones are not forth coming  . . . it is wiser to rely on common sense !

Reference

I think  this 2011  study  from the  prestigious stroke journal  has convincingly answered the issue

It concludes , the right radial approach  is indeed risky  to develop cerebral  micro embolism   when compared to right femoral

A Review article in  Circulation

Other references

1.http://stroke.ahajournals.org/content/38/7/2176.full.pdf+html

2.Transient Cortical Blindness after Coronary Angiography Journal of International Medical Research. 2009;37:1246-1251,

3. Stroke and Cardiac Catheterization Circulation. 2008;118:678-683,

Why the left atrium does not enlarge in ASD even though the shunt traverses this chamber ?

ASD is  the most common acyanotic heart disease  with  left to right shunt . Highest qp/qs  are  seen  with ASDs

The shunt  begins  from left  atrium  and goes on to complete a circuit.

LA——-ASD———RA————RV———-PA———-PVs———LA

In this circuit all chambers  enlarge except the LA . (Inspite of the fact about 200-300 % cardiac output traverses this chamber )

Why ?

Post -test

The most popular answer in the above poll  is LA is  a transit chamber .

If it is so . . .  RA is equally  a transit chamber ,  why it enlarges significantly ?

What is the fundemental difference between facilitated PCI and Pharmaco Invasive approach ?

For STEMI management there are  6 management protocols available

1. Thrombolysis
2. Primary PCI
3. Rescue PCI
4. Facilitated PCI
5. Pharmaco -Invasive approach
6. CABG

*CABG is rarely used except in  severe mechanical complication.

There is some  issues in differentiating  facilitated PCI and  Pharmaco Invasive Approach.

What do we facilitate ? How we do it ?

PCI in acute STEMI is done in a thrombotic milleu. So we get sub optimal results .Hence to facilitate it we try using

either 2B-3A antagonists, Newer Heparins, or even thrombolytic agents before submitting them for PCI

Where is this facilitation done ?

Facilitated PCI is done in small hospitals where  there  is no cath lab or cath lab is available only during office hours.

Facilitation can be done in either in same hospital or on the way to big hospital

Is there a time window to start  this ?

The main aim was to was to facilitate the PCI .Hence time window was not considered vital in few studies (Wrongly though !) ideally it should be started as early as the first contact . Since facilitation can be started earlier the time window is 0-24 hours .

What happened to the concept of f-PCI ?

It died a premature death  and  last rites were  completed when the FINNESE trial was out .

But it left behind a daughter concept ie in selected patients if the facilitation is done early , especially in those patients who are going to get the subsequent PCI late ,or in high risk individuals  , the initial  pharmacological facilitation* was indeed useful.)

*If  facilitation was with   fibrinolytic agents (Not 2a/2b )  .It is very important the benefits of facilitation is mainly  attributed to the time gain in achieving partial opening of IRA  making it more complete salvage of the subsequent PCI .

This aspect later on named as PIA .

Pharmaco- invasive approach(PIA)

We know p PCI is a race against time .We also  know fibrinolytic therapy  fares well in this race  but   pPCI  beats in   effectiveness  .

So what prevents us to combine the swiftness the fibrinolysis and the robustness of pPCI ?  That is  like getting the best of both world .( It is not that easy thing accomplish after all 1+1 in medicine is rarely 2 !)

In it’s core principle it  is same as f-PCI . But facilitation is done only with fibrinolytic agent (Not 2B-3A) . Pharmaco Invasive strategy can be started in any small hospital/ In the ambulance /. It  is routinely followed by PCI whether the initial thrombolysis is successful or not . PIA should not be done before 3 hours window if  a timely pPCI is feasible.  Hence PIA has a typical time window of 3-24 hours .

Summary

f-PCI is combining  various anti-platelet and fibrinlytic strategy prior to PCI . It was found  to be useless if it is used routinely in all cases of pPCI. (Rather 2B-3A  was useful  if  only the facilitation was done within the cath lab to prevent procedure related issues) .Time window can be between 0-24h .

Pharmaco Invasive approach (PIA)   is actually a type of f-PCI where  fibrinolytic agents are used routinely which is followed by mandatory angiogram and PCI in all deserving cases.Many still  believe the facilitation in PIA is primarily accured in  shortening the   time to reperfusion  rather than altering the thrombus load and morphology  ! Time window is usually between 3-24 hours.

Why don’t we have pre-formed RCA catheter ?

Interventional   cardiology has  grown leaps and bound in the last few decades  .We are able to clip the wings of mitral valve  without surgery when it prolapses

We  can deliver a huge aortic valve and fix it with wires .

But  . . . we have no proper  preformed   guiding catheter  that can  sit into RCA ostium directly   and snugly  for a long time to enable complex RCA angioplasties !

An now try this one .

 

Here is  a  pending patent for  a preformed RCA catheter

Does the Atria really lose it’s mechanical function compleley during Atrial fibrillation ?

The mechanical atrial function   during atrial fibrillation remain a mystery . In fact , the general  belief  is during  AF  the mechanical function of atria is zero. This is why AF  is promotes stasis and   LA clot formation. It may appear theoretically correct  , still   AF especially coarse  still imparts some amount of  mechanical motion .But this usually does not translate to any useful hemodynamic function .

If atrial booster pump is lost (which is said to be 25 % of  LV filling )  suddenly one expects dramatic symptoms  especially if there is associated LV dysfunction or aortic valve disease .

But in real world AF is well tolerated arrhythmia in most  .  We know by land  mark trials AF  is as good as sinus rhythm  if the rate is  is under control

This is a definite evidence the AF  may not compromise  LV filling   even if   it nullifies  the  atrial contractility .

There is one  more evidence for  retention of atrial mechanical activity in spite of AF .It is well recognised , pre-systolic accentuation is preserved  in many cases of mitral stenosis with AF.

*Crazy hemodynamics : For an attached LA clot to  dislodge ,   one needs some amount of LA contraction isn’t ?  Unfortunately  a fibrillating  atria always  tend to  have this one ! This again is a senseless  proof for some  mechanical activity of LA during AF !

How is this possible ?

Is it a  purely volume dependent filling   ? ( Or )  is it  the  Intrinsic LA starling forces that do not depend electrical atrial activation .

This is definitely an  issue to ponder over . A good LV contraction makes the atria empty more completely . This would  somehow  mean , LV relaxation  is facilitating atrial function . During  AF the LV  handles effectively  the additional burden  imposed by the loss of   25  %  booster pump of atria ( Accelerated LV relaxation ? )  A  constantly  changing  RR interval makes LV diastolic function a more complex event .

Final message

Atrial fibrillation is  a well tolerated  arrhythmia in vast  majority of patients  . This  implies either of the two things.

1. The so called  physiological atrial  booster pump is redundant  or dispensable in otherwise healthy heart
2. The booster pump is indeed important  . . . but it is less  affected by AF as long as the rate is under control !

It is to be  strongly emphasized , Heart rate and  LV function  will ultimately determine  , how one is going to tolerate the AF  !

It is  a small gesture  from LV  to LA  at it’s hour of crisis  . . . in return  for  it’s lifetime assistance  as a booster pump ! 

Postamble

How  rate control  prevails over rhythm control in spite  zero atrial contractility in the  former  ?

Comments welcome !

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