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 | 6 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 . . .
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 .
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.
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.
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 !
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 !
Posted in cardiology congenital heart disese | Tagged aorto pulmonary collaterals, hemoptysis in mapcas pulmonary atresia and vsd, K S murthy KM cherian madras medical mission Innova children's hospital pulmonary atresia vsd tetrology, mapcas, single vs multiple stage unifocalisation, tof with pulmonary atresia, unifocalisation single vs multiple staging pulmonary atresia, UNOFOCLAISATION | Leave a Comment »
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 »