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Here is a  video recipe  !

Please click here to  see more videos from my you tube site

It is often said life is a cycle , time machine rolls without rest and reach  the same  point  again and again . This is  applicable for the  knowledge cycle as well .

We  live a life ,  which is infact a  “fraction of a time”(<100years) when we consider the evolution of life in our planet for over 4 million years.

Man has survived and succumbed to various natural and  self inflicted diseases &  disasters. Currently,  in this  brief phase of life  , CAD is the major epidemic , that confronts  modern  man.It determines the ultimate  life expectancy . The fact that ,  CAD is a new age  disease   and  it was  not  this rampant ,   in our ancestors  is well known .The disease has evolved with man’s pursuit for knowledge and wealth.

A simple example of how the management of CAD over 50 years will  help assess the importance of  “Time in medical therapeutics”

  • 1960s: Life style modification and Medical therapy  is  the standard of care in all stable chronic  CAD The fact is medical and lifestyle management remained the only choice in this period as   other options were not available. (Absence of choice was  a blessing as we subsequently realised  ! read further )
  • The medical  world started looking for options to manage CAD.
  • 1970s : CABG was  a major innovation for limiting angina .
  • 1980s: Plain balloon angioplasty a revolution in the management of CAD.
  • 1990s: Stent scaffolding of    the coronaries  was  a great add on .Stent  was too  dangerous  for routine use  was to be used only in bail out situations
  • Mid 1990s : Stents  reduced restenosis. Stents are  the greatest revolution for CAD management.Avoiding stent in a PCI  is unethical , stents  should be liberally used. Every PCI should be followed by stent.
  • Stents have potential complication so a good luminal dilatation with stent like result (SLR)  was  preferred so that we can avoid stent related complications.
  • 2000s: Simple  bare metal stents are not enough .It also has significant restenosis.
  • 2002: BMS are too notorius for restenosis and may be dangerous to use
  • 2004 : Drug eluting stents are god’s gift to mankind.It eliminates restenosis by 100% .
  • 2006:  Drug eluting stents not only eliminates restenosis it eliminates many patients suddenly by subacute stent thrombosis
  • 2007 : The drug is not  the culprit in DES it is the non bio erodable polymer that causes stent thrombosis. Polymer free DES  or   biodegradable stent , for temporary scaffolding  of the coronary artery  (Poly lactic acid )  are likely to  be the standard of care .
  • All stents  are  potentially dangerous for the simple reason any metal within the coronary artery  has a potential for acute occlusion.In chronic CAD it is not at all necessary to open the occluded coronary arteries , unless  CAD is severely symptomatic in spite of best  medical therapy.
  • 2007: Medical management is superior to PCI  in most of the situations in chronic CAD  .(COURAGE study ) .Avoid PCI whenever possible.
  • 2009 :The fundamental principle of CAD management  remain unaltered. Life style modification,  regular  exercise ,  risk factor reduction, optimal doses of anti anginal drug, statins and aspirin  is the time tested recipe for effective management of CAD .

So the CAD  therapeutic  journey  found  it’s  true  destination  ,  where it started in 1960s.

Final message

Every new option of therapy must be tested  against every past option .There are other reverse cycles  in cardiology  that includes the  role of diuretics  in SHT , beta blockers in CHF etc. It is ironical , we are in the era  of rediscovering common sense with sophisticated research methodology .What our ancestors know centuries ago , is perceived to be great scientific breakthroughs . It takes  a  pan continental , triple  blinded  randomised trial   to prove physical activity is good  for the heart .(INTERHEART , MONICA  studies etc) .

Medical profession is bound to experience hard times in the decades to come ,  unless we  look back in time and “constantly scrutinize”  the so called  scientific breakthroughs and  look  for genuine treasures for a great future !

Common sense protects more humans than modern science and  it comes free of cost  too . . .

Complex coronary lesions require  not only  expertise it needs better hardware .A key  factor is the support from  guide catheter.Innovations are hall mark  Interventional cardiology community.Every few years a hard ware breakthrough is expected.

Boston scientific has an answer for improving frequent guide catheter destabilisation in complex anatomy and lesions .A dramatic new concept for guide catheter support .They have named it  in a hollywood fashion “Guidezilla”

Major advantage : Extending the tip of the guide with an anchor to  facilitate smooth balloon approach to the  lesion which  i avoids repeated disengagement of guide catheter.

Watch this animation . It comes with a music stunning too !

In this wireless networked world nothing is personal, not even your heart beat.Modern pacemakers and ICDs have wireless connectivity with the manufacturers.This is value added service for regular monitoring and solving  any technical issues.

assets_174815Hacking  a device like pacemaker and ICD  and instant deactivation or triggering a new event   is a distinct possibility .It was shown in a fictional TV series “Home land” that prompted the  ex American wise president Dick Cheny to switch off all wireless function in his ICD. Now ,the US homeland security  cyber emergency  response team has decided to probe the issue .

pacemaker hacking icd

Perils of technology is taking us to new uncharted territories , while your  SA   AV node are at risk of being  remote controlled !

Meanwhile Medtronic has clarified they have increased the security features and pacemaker /ICD hacking is not an issue to be worried . But the threat is genuine !

Reference

1. Frenger P Hacking medical devices a review – Biomed Sci Instrum.  biomed 2013.2013;49:40-7

3.Fox news

When  I was suggesting a middle-aged business man who has suffered a massive MI,  though recovering   he seemed to be a depressing man.He was  still fuming about the illness.

I told him he has  in fact recovered faster than others , he has  to believe  in himself , concentrate on his work  and take these medicine regularly .Finally , I told him to develop the will power which is vital,

will power

After the scheduled consultation , he thanked me , before leaving  he asked me candidly and jokingly   ,every thing is fine doctor ,  which pharmacy sells that will power ?

I stopped him at the door , “It is  not sold  anywhere , it is  lying  dormant  right inside your brain store . You have to just do the shopping , which is open 24/7  and best  part is it is always available free of charge and unlimited too !

drugs and thoughts modern medicine psychology mind power healing faith will power 003

I  advised him to have a look at the  Speaking tree  from Times of India which has  so many resources and surely he can acquire will power  in  plenty !

speaking tree

Aorto ostial  stenting requires extra caution and special technique. It always  worry us  what if  few mm of  metal might project into Aorta when we stent a RCA or left main ostium.

To  prevent this ,Merit- medical  has innovated a catheter that help us position the stent exactly at the ostial level .It is  done  with a help of an octopus like buttressing arm that support the aortic wall when the stent is deployed .

Watch the video.

 

Reference

Merit-medical 

One of my patients with atrial fibrillation  recently developed a  fairly  moderate  sized right MCA stroke that resulted in dense left sided hemiplegia .He was on warfarin , but the stroke was confirmed to be ischemic,the etiology was fixed as cardio embolic .After a  smart  recovery he asked this question.

Why did the clot  from  my  heart preferred  to enter the  brain doctor ?  Is there no other place for it  to go ?

I  told him in simple terms , “It is  your destiny and  the clot’s wish”.  In fact , you are some what blessed as the clot did not enter  the left side of the brain .If it had gone, your speech would have severely affected and you may  not be asking this question to me ! It is true the clot do have other options to  embolise ,  however they are still  trouble some !

cardiac source of emboli embolus ischemic stroke animation embolic

What is the diameter of internal carotid artery , and cerebral artery ? The common size of LA appendage clot almost match with this !

It can go straight down to your leg , kidney , intestines or upper limbs .All are equally dangerous  and present dramatically . Very rarely  it can enter  coronary  arteries  bringing a heart attack rather than a brain attack .If it is going to the legs you are at risk of acute monoplegia instead of chronic hemiplegia .Peripheral embolism are very painful .Intestinal ischemia evokes a most excruciating pain one can  ever encounter !  Luckily  stroke is not painful.God is kind enough ,he foresaw  cerebral ischemia to be more common and hence  made it pain-free ! (There is no cerebral angina equivalent  !)

Having said that , I felt we should get a scientific answer to my patients query .

What determines  the destination  of these emboli in transit from heart ?

 

cardiac source of emboli embolus ischemic stroke animation embolic peripheral renal mesentric lerish syndrome 002

A large clot often fails to traverse the Aortic arch branches and invariably reach the periphery .

The dynamics of a cardiac emboli hitting the cerebral arteries can never be known in live human vascular tree. The following factors might play a role.

  • Clot size and morphology
  • Anatomy of aortic arch -Right MCA is in immediate capture  zone .
  • Arch type and curvature radius
  • Arch  branch ostial size , shape
  • Vertebral arterial embolism is rare because it  is a second order branch.
  • Dessication and disintegration of clot in  transit is possible leading to multiple destination.
  • Most shaggy looking large clots fail to enter carotid instead reach the peripheral circulation.
  • Vegetations, tumor debri behaves differently as the density and mass of emboli has a some effect on the transit velocity and momentum.

Variations in Aortic arch anatomy

aortic arch branching pattern A to Z

Image courtesy : Anatomy Atlases by Michael P. D’Alessandro, and Ronald A. Bergman, from university of Iowa. http://www.anatomyatlases.com

It is  surprising, human beings can have as many types of Aortic arch as  English  alphabets . Then,there are innumerable ways for cardiac clots to embolise too  !

 

 

 

 

 

 

Caring shall be an inbuilt character in the  Noble profession ,need not be a value added service or a separate medical specialty !

image

When  a life leaves the body  silently in CCU , an  undulating  flat line in the monitor has a hidden scientific tale  to tell !

 

A  56 year old obese women died a instant death immediately after engaging the Left main ostium  after first injection of 5cc dye. The monitor showed only  a short pause, few sinus beats , a long pause , asystole and death . In the last 2 minutes of survival she threw a random wave forms of suggesting EMD . At any point of time she never showed any evidence for ventricular fibrillation . 1o minutes of intense resuscitation failed that included temporary pacing , repeated shocks  and ventilation.(ECMO /LV assist excluded)

asystole_bad_day_in_the_cath_lab_tshirt-p235709389664476041uye8_400

What is the mechanism of death ?

  • Is it electrical or mechanical ?
  • Acute mechanical stunning / the stone heart ?
  • Is it a primary electrical asystole ? (Acute sinus arrest or AV block )

Post hoc analysis of CAG did not show any significant clues except a tight distal left main.Apparently the catheter has triggered the event .( Or is it the  dye ? as some body suggested it as anaphylaxis  ?)

Even though we conveyed the message to the relatives,  it’s was an unexpected massive heart attack , obviously we were not convinced with our  uttering  ! Mind you , she had  normal LV function but had recurrent angina prior.

asystole ecg 004

Image courtesy modified from http://www.ijaweb.org 2012 for representation purpose only.

We know if cardiac arrest is due to VF, it tends to give us  at-least some time and sense. Further,the VF protocols are more clear and success rate is more .

There is always an issue of  fine VF vs  asystole.If the flat line is indeed VF , there is more chance of revival as we try to pump adrenaline to make the fine VF  into coarse one  and shock again .The sequence can continue few times.

It is well known  asystole has a  dismal outcome .Even among the asystole there is some hope* if asystole is purely   electrical . (Like Stokes Adams in CHB or electrolytic asystole like hyperkalemia etc ) .But if asystole is due  mechanical cause , death ensues in spite of prompt temporary pacing .

* Important note : We have this  common  form of  treatable  mechanical asystole .It is called cardiac tamponade .It always present  with extreme bardycardia and asystole. It is extremely  rare to see a tamponade to present with VF. A prompt needle tap will do the job .It is vital  to recognise this in cath lab as our efforts are rewarding .

I would recommend a hand held echo machine , to hang like a catheter in every cath lab , ready to screen unexplained cardiac arrests with zero delay !

Why some hearts respond with VF  , while others go for asystole  with acute coronary insult ?

  • A million Rupee question ! We are yet to find a legible answer .What is probable is  the the heart doesn’t  even have energy to fibrillate !
  • The underlying disease need to be so intense .In this case it was left main stenosis supplying a truncated LAD and LCX. We could also see it supplying twigs to RCA  suggesting it to be a total occlusion .
  • So ,when a  “physiologically single” coronary artery that precariously  supply the entire heart is suddenly insulted the heart behaves violently with runs of VT/VF. Our ignorance is complete when we realise  the heart  can do the opposite as well .It does not react at all , goes for a deep slumber and result in electro-mechanical sudden death.
  • It is expected , in acute mechanical  deaths one may encounter flash pulmonary edema if the LV alone gets stunned. However , if both right and Left ventricle come to standstill in a synchronised sudden fashion , lungs will be as silent as deep sea . We believe this is what happened in our patient and it can be logically correlated  as  the critically narrowed left main was supporting the  RCA  as well.

Final message

Sudden cardiac deaths  9 out of 10 times is electrical . Majority  of them is  due to fibrillation. Next comes the electrical asystole ,Rarely (is that really rare ?) an ultra fast  sudden death due to mechanical asystole (Non -Tamponade ) is  possible , as experienced in our patient .

These mechanical asystole  are yet to be decoded.Whether it is a form  of Acute stunning , electro -mechanical uncoupling or mechano electrical standstill is not clear.

 

 

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