Here is a video recipe !
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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 . . .
- Whatever happened has been good.
- Whatever happens is good
- Whatever will happen is also good.
Doing multivessel PCI during acute STEMI is forbidden except in cardiogenic shock . (or in some very unstable patients without cardiogenic shock)
- 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 !
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 !
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 !
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
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,
Posted in Cardiology -Interventional -PCI, Cardiology -unresolved questions, Hardware techniques tips, Infrequently asked questions in cardiology (iFAQs), radial coronary angiogram PCI | Tagged aortic scraping and cholesterl embolism, brachio cephalic artery right, innominate artery and radial coronary angiogram, palques in innominate artery, plaques in right brachio cephlaic trunk, radial coronary angiogram, radial vs femoral catheterisation, right mca stroke in right radial angiogram, right vs left mca stroke, right vs left radial angiogram | Leave a Comment »
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.
In this circuit all chambers enlarge except the LA . (Inspite of the fact about 200-300 % cardiac output traverses this chamber )
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 ?
For STEMI management there are 6 management protocols available
- Primary PCI
- Rescue PCI
- Facilitated PCI
- Pharmaco -Invasive approach
*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 .
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.
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
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 .
Atrial fibrillation is a well tolerated arrhythmia in vast majority of patients . This implies either of the two things.
- The so called physiological atrial booster pump is redundant or dispensable in otherwise healthy heart
- 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 !
How rate control prevails over rhythm control in spite zero atrial contractility in the former ?
Comments welcome !
Posted in cardaic physiology, cardiac physiology | Tagged atrial booster pump, atrial contribution for lv filling', atrial fibrillation, cardiac cycle, cardiac physiology, mechanical activity during atrial fibrillation, phases of diastole, wiggers cardiac cycle | 2 Comments »