Here is a video recipe !
Posted in dr s venkatesan -Personal, general medicine | Tagged best cardiologist india, cardiologist, cardiology fellows training, crash course on cardiology, dr s venkatesan, drsvenkatesan, ethical cardiologist, good cardiologist, madras medical college, teaching video in cardiology, venkatesan sangareddi | 5 Comments »
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.
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.
Hacking 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 .
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 !
Posted in bio ethics, Cardiology - Electrophysiology -Pacemaker, Cardiology -Technology | Tagged dick cheny and ICD, homeland seral pacemaker hacking icd, Pacemaker and ICD hacking, remote cardiovrsion, remote monitoring of pacemakers icd, wirless connectivity of icd | Leave a Comment »
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,
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 !
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 !
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.
Posted in Cardiology -Interventional -PCI, Cardiology -Therapeutic dilemma, Cardiology -unresolved questions | Tagged aorto ostial lesion, aorto ostial stenting, coronary ostial stenting, merit medical ostio pro stent system, ostial dissection in rca, ostio pro coronary stent system, proximal left main disease, rca stent projecting to aorta, stent, stent lost in aortic root, stent migration, stent projection in aortic root, stenting, tips and tricks cath lab left main stenting, tips for aorto ostial stenting | 1 Comment »
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 !
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 ?
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
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 !
Posted in Atrial fibrillation, cardiac source of embolism, stroke | Tagged aortic arch type and embolic risk, cardiac emboli, cardiac source of emboli, carotid artery origin angle and risk of stroke, clot deflection in stroke, embolic stroke, fate of clot from heart, Ischemic stroke | 1 Comment »
Caring shall be an inbuilt character in the Noble profession ,need not be a value added service or a separate medical specialty !
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)
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.
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.
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.
Posted in Uncategorized | Tagged brady asystolic cardiac arrest, cardiac resuscitation, cpr, electrical vs mechanical sudden cardiac death, electro mechanical deaths, electro mechanical dissociation, emd, suden mechanical death |