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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 . . .

Human beings can defy fate  in a regular fashion as the  modern science is exploding and creating   infinite possibilities !

  • We can give a fresh  life to a dying man by  multiple organ transplants just like changing  a crashed mother board in a PC !
  • We can isolate vital germ cells , fuse them, clone them and even  create new form of life !
  • We can  keep a man in deep coma  for years and bring back to life !

Still , a sudden cardiac death that happens in a remote place in an unexpected manner is still in the God’s domain ! Cardiac arrest and sudden cardiac death is the  most common mode of acute human loss in our planet .(Read a link :Ignorance based cardiology )

When  the heart goes for convulsions due to electrical  instability , the only solution is immediate  CPR followed by electrical shock .All you require is about 200 j of electrical energy over the chest .This is to achieved within 5-10 minutes.How and where do you get that energy in that short time span ? Is 911/108 services that efficient ?

*Can your fully charged  mobile phone  deliver it ?  Unfortunately not yet !

Public access AEDs (Automatic external defibrillator) are there in many  commercial places.But ,they are not  universal and foolproof.

Come 2015, we have a marvel of a technology waiting  to happen !

How about delivering  a light weight  defibrillator through a drone  ?   to the exact place where it is needed .With the accuracy of GPS  technology  steadily improving , a self powered , auto- responding drones from a near by base station  is a reality .

flying defibrillator aed sudden cardiac cpr

This drone . . . delivers life !

All that is required is a phone call . The drone with defibrillator is  delivered  in few minutes .Of course , a bystander help is required .An experimental pilot project is being tried in Holland What a break through it could be when  its stream lined ?

Man proposes ,God  disposes ” so sure it is !  Are we close to challenge the super power ?

It is said , modern men will play god in near future with perfection.Can it ever be like this ? “God proposes and  man disposes ?  No . . . it can never be!  If a drone comes from nowhere to save a human life, it is also an act of God ,through a   “Human enriched  technology.

VSD with Pulmonary atresia is a complex form of cyanotic heart disease .Though it’s  a close  companion of Tetrology of Fallot  physiologically, it is a vastly different entity in embryological and anatomic terms.

TOF is cono truncal anomaly where abnormal anterior displacement of conal septum result in malalignment VSD, RVOT obstruction ,aortic override and RVH.

While ,pulmonary atresia with VSD  is not a primary cono truncal anomaly, the defect occurs much earlier than TOF in fetal life , where the origin of PA fails to materialise,(Fetal arteritis?) and which triggers a series of anatomical disarray in pulmonary arterial circulation.  The PA growth arrests in various levels (Somerveille Types) .It is important to realise while the PA may be patent , pulmonary valve is always atretic and disconnected from RV.

In severe forms there is Zero pulmonary artery content .The lung is perfused in chaotic manner. This situation akin to “TAPVC” in arterial side  and result in  total anomalous pulmonary arterial connection.

pulmonary atresia vsd mapcas major aorto pulmonary collaterlal unifocalisation single multiple stage tapac

Natural History of PA with VSD .

The blood supply of lungs is maintained by  MAPCAS.Since , the  fetus is not dependent on its lung for survival,  life goes on well , till  birth  and face the harsh reality that  it has no independent blood supply for  lungs from RV  and has to depend on collaterals from aorta.

Survival depends upon the  the quantum of collateral .( Size , number, arborisation pattern etc). Life is shortened in most babies and  lost by 1 or two years . Exceptions are always there.Survival has  been reported up to third decade in a few with a balanced pulmonary flow.these are the ones we catch up in young adults some times.

In effect , MAPCAS are the life line of these children  , paradoxically  the  fate of these children  piggyback  on the  behavior of the MAPCAS .

MAPCAS  are not natural vessels that is  meant to receive blood at  systemic pressure. They are fragile and thin and when exposed to high pressure react pathologically.

Following anatomical and physiological effects occur in MAPCAS .

  • Collaterals  fail to grow with child
  • Obstruction to  MAOCAS can develop(Often at ostial)
  • Collateral can be extensive causing pulmonary vascular injury.
  • Regional and segmental pulmonary arterial HT can occur
  • MAPCAS can suddenly rupture and cause fatal hemolysis
  • Collaterals perfusing more than normal resulting in volume overload of LV and failure

Principles of  Surgery

The principle  of surgery is to disconnect the arterial   pulmonary  vascular  blood supply and connect all lung segments with pulmonary  arterial supply and ultimately connected  to right ventricle to restore the physiology.

Single vs Multiple staged surgery

The original  concept was to do multi stage surgery , believing in the principle every stage give us time for pulmonary vessels and lung  to grow .It involves extreme commitment of surgical team in identifying and understanding the pulmonary  vasculature and the systemic collateral arborisation. The factors that is taken into account includes the presence of confluent PA , MAPCAS induced lung segment injury  and its maturity . When pulmonary vessels are inadequate , autologus  pericardial rolls are used as alternatives.

There is no point in vascularising  a zone of lung  with  physiological  low pressure neo pulmonary circuit which is unlikely to  to work because of immaturity of distal veesels  or its  already damaged by the harsh pressure of MAPCAS!

We have realised the  hemodynamci behavior of lung segments supplied by  MAPCAS and the subsequent undoing of it  is so unpredictable. The current concept is to recruit maximum  lung segments  and aim to provide revascularization through  physiological manner.

An early single stage unifocalisation is  suggested as a best option.(Reddy VM, J Thorac Cardiovasc Surg. 1995;109:832–45). Single stage repair is attractive not only in long-term  hemodynamic advantage but also  in the  logistics . In multi stage repair ,only about 20-30% of children ultimately complete the treatment for various reasons.

It is heartening to note one of huge accumulated experience for surgical management of PA with VSD has happened in the  southern Indian cities  of Chennai and  Hyderabad where i live.

Kudos to Dr Murthy and team for the pioneering work .Incidentally ,Dr KM Cherian is the legend in the filed of cardiac  surgery and in my opinion  he should get the title of the Father of pediatric cardiac surgery in India !

And  this seminal paper from his team  shares  one of the largest  experience   who underwent single stage  unifocalisation for PA with VSD in 124 patients.

tof vsd with pulmonary atresia unifocalisation

What is the cardiologist  role in VSD and PA ?

Cardiologist are expected to play  a limited role . They can’t provide any cure as such.A meticulous cath study is all that required from them for the surgeon.

Selective  MAPCAS angiogram  requires special expertise ad through knowledge of anatomy .The MAPCAS are clustered around few specific  zones.Now MRI and CT scan also can delineate the anatomy.

What is the  surgical outcome ?

it is steadily improving globally.But only a hand full centers in the world can undertake such complex procedure(Lucile packard Children’s hospital Stanford is pioneer )

Hemoptysis in PA and VSD

It is a rare but an important issue .This can occur any time in the natural history even post operative. Most are managed conservatively .Interventional approach with embolisation is possible in expert centers.(K.Greaves et all)

Can  the  natural history be better than these complex unifocalisation surgery in these tender children ?

Statistically , it is possible in few cases, but to identify those children you need to get an appointment with God ! If parent’s take such a decision it should be welcomed and cardiologists and surgeons  should not lure them with scientific excess !

Final message

The surgical correction of PA with VSD continues to be complex .Meticulous  recruiting and unifocalisation of PAs and creating confluence , connecting the RV through a conduit may be the key.However, ultimately  what is going to matter is the how the lung responds to these surgery  hemodynamically !

It appears to me the whole process is  more of a vascular surgery of lungs rather than  heart !


  3. An excellent resource on MAPCAS  from Sao Paulo , Brazil
pulmonary atresia mapcas vsd unifoclisation confluence direct and indirect aorto pulmonary rabinovitch



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 !


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.




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  !








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