Posts Tagged ‘pci’
Posted in bio ethics, Cardiology quotes, Clinical cardiology, Venkat quotes, tagged acc aha guidelines for ptca, cath lab ethics, Cath lab philosophy, coronary angiogram, corornary stenting, inappropriate coroanry angioplasty, pci on April 30, 2012 | Leave a Comment »
Posted in Cardiology -Interventional -PCI, history of cardiology, tagged abstract and posters, coronary interventions, discovery of ptca, father of interventional cardiology, first ptca, great discoveries in cardiology and medicine, miami 1976 aha conference, pci, poster presentation, ptca on January 30, 2012 | 2 Comments »
We do come across , even senior cardiologists , who tend to undermine the importance of poster presentations in scientific conferences (I know a few , who ridicule it as well ? ) .
Is it not a meanly job for a cardiologist to paste a poster and stand beside it for hours , waiting for scientifically motivated audience !
But , what really matter is the thoughts , concepts and often the hard work that brings these posters to big league conferences .
Please remember abstract posters must cross the hurdle of the conference peer review committee’s scrutiny . Often times the poster arenas has launched some crazy ideas , transform them to great discoveries.
If only , Gruentzig had shied away from the poster he famously pasted on lawns of ACC , Annual scientific sessions ,Florida
1975 . . . the revolutionary concept of PTCA would still be in utero !
I argue the young fellows in cardiology to send as many scientific abstracts as possible in their national or international meets . This is where the the future of cardiology lies ! Simply don’t bother about the critics .
Medical science has grown ( and growing ) in an astonishing pace. Many of the inventions which were considered as major break throughs have fallen on the wayside over the years . Of course , quite a few withstood the test of time .
One of the great inventions of last century is per-cutaneous interventions inside the human coronary artery .
The concept was first conceived and executed by Andreas Gruentzig of Germany in year 1977. Now , at-least a million PCIs are done every year to tackle CAD with greatly improved knowledge base, evidence , hardware, techniques and expertise .
PTCA is an invention worth a Nobel prize . . .well , that’s what we cardiologists feel. The Nobel committee seems to think otherwise .
- PTCA is simply an extension of an old invention. Already the inventors of the cadiac catheterization were conferred with Nobel prize (Forssman, Cournand,Richards) . Hence , it is a sort of duplication of invention . If Gruentzig is conferred a Nobel prize the man who discovered the coronary stent (A plaque scaffolding device) will argue he too deserve a Nobel !
- What Gruentzig did was in-fact a fundamental human response by Instinct ! .When you encounter a mechanical obstruction on the road just try to overcome it . “Here is an obstruction impeding the blood flow , let me remove it” . He did this with a wire and balloon . There is not much intellectual innovation . It was delivery of a mechanical force through a wire . But what the Nobel committee should take it to account is , he did this in live human beating heart and cured of his illness most dramatically avoiding a need for surgery.
- Finally comes the vital question. What is the impact of this invention in the health of mankind. ? How many lives have been saved when compared to other modalities to treat the coronary artery disease ? *.This again is not convincingly answered especially in stable angina , for which Geuentzig originally developed this modality . One popular argument is , in terms of life saved and sufferings relived oral rehydration fluid or penicillin would beat PTCA most convincingly !
* Another possible reason is , the Nobel medical committee is probably well aware of the perennial controversy about role of Medicine vs Surgery vs PCI on the outcome CAD and the superiority of one over the other !
Whatever be the reasoning , Nobel committee has to rethink . Cardiologists all over the world would definitely agree if one man who have made a huge difference in their patient’s life , it must be Gruentzig .
It is well-known Nobel prize is given for path breaking research that break new grounds like decoding cosmic mysteries , expansion of universe , cell signalling , molecular mimicry and the stuff like that .
Still , Gruentzig definitely deserves a Nobel solely for the novelty in his procedure and in the process it helped avoid surgery in vast majority of heart patients.
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, cardiology- coronary care, tagged coronary collaterals, homocollaterals, pci, rentrop classification on December 30, 2011 | 4 Comments »
A middle aged man who owns a petty shop in a small town of south India came to us for stable angina .His RCA looked like this.
Normally if one coronary artery is obstructed the other comes to the rescue .It seems , this RCA do not trust it’s sibling LAD . See how it self supports its own territory .(The most fascinating and mysterious aspect of coronary circulation is the collateral circulation. LAD has big brother attitude . . . it hesitates to help others while RCA is more philanthropic , we know it sends prompt collateral to LAD whenever it is distressed !)
However , there is one advantage of such self-sustenance of RCA (Intra coronary/homo-collaterals ) . If the RCA has to live at the mercy of LAD it runs a risk of neglect at times of distant LAD ischemia as well !
Single vessel disease , total occlusion , long segment lesion , still the PDA is protected and the vital postero- basal area of heart perfused well ! What to do ?
Scientific cardiologists would like to meddle this RCA with multi-pronged guide-wires and other weapons . Non -scientific cardiologists would send him home with medicines . This patient preferred the later ! In the process he saved a lakh , which I believe was meant for his daughter’s education . He profusely thanked me for not hijacking his hard earned money for frivolous reasons . I said he should thank his collaterals and not me , for getting his money back !
This term is quiet often used in the main stream cardiology journals , in work places , conferences , hospitals and even among lay persons . No body bothers to define this terminology. What exactly this term means ?
It may not mean anything . . . to most of us even as the percentage of inappropriate angioplasty is steadily increasing over the years .
What does the term Inappropriate angioplasty mean ?
(Choose the correct answer . . . one or more may be true )
A.It simply means doing unnecessary angioplasties and has no major implication to any one.
B.A form of medical ignorance or an unethical act and should be strongly condemned.
C. An acceptable cardiology practice , need not be discouraged , as it improves the quality of life of physicians !
D. A sure act of “error by commission” that amounts to medical negligence .
E.It is a decent term for a major guideline violation
E. It can be termed as medical malpractice as it amounts to harming the patient with or without intention.
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, tagged bio degradable stents, gruentzig, pci, plan balloon angioplasty, poba, ptca on March 8, 2011 | Leave a Comment »
When PTCA was introduced by Gruntzig in 1977 the whole world was awestruck. All he did was . . . to dilate a coronary stenosis with a balloon. No scaffolding was ever thought off at that time. It was a huge achievement . PCI version 1 was performed for over 20 years in nearly a million patients . Till his death stenting was an unknown concept.
When the stents first came in, it was first used with extreme caution . From the days of bail out stenting, it has evolved into provisional stenting, elective stenting ,and now what is called “mandatory stenting”
When Greuentzig was able to perfuse the obstructed coronary arteries successfully in thousands of patients in the 1980s, with a simple balloon
. . . what is the difficulty for us to replicate it in 2011 ?
Unfortunately advocates of POBA (Plain old balloon angioplasty) are considered to be un-scientiifc cardiologists or even carry a risk of labeled as quacks.
But please remember . . . POBA is alive and doing well too , in spite of the serious threat it faces from the current generation interventionists . It will continue to have an important role in many situations.
1.In patients with multivessel disease while the proximal lesion deserve a stent , POBA is preferred in distal lesions to reduce the overall metal load .
2.POBA has a major role to play in Primary PCI .We need to realise dying myocardium does not demand for stents. It simply requires quick and prompt restoration of blood flow. POBA can achieve this with flying colors in most situations.
3. Further , stenting may be difficult in complex lesions during primary PCI .Experience tells us , it is dangerous to prolong the primary PCI procedure time. Here POBA is the only choice , may be assisted by thrombus aspiration. Stenting may be delayed or even avoided in many STEMI patients. . We know there is huge STEMI population with pure thrombus with no atherosclerosis.
4.Patients with co morbid conditions , who are likely to have a non cardiac surgery in the near future and those who can not take antiplatelet drugs POBA will score over BMS/DES.
5.Finally a POBA costs nothing . .All it requires is a stiff balloon . In this recession prone world and ever increasing incidence of CAD , POBA could be the answer.
6. Acute recoil in POBA (Sudden deaths in POBA is a rare event !) are more of a perceived fear rather than a reality. It can be argued stents are primarily used to make cardiologists job easy and comfortable.
7.Cost effectiveness of plain balloon verses stenting was never properly tested .
When sudden deaths due to subacute thrombois in DES population is accepted with all those attendant pride . . . why not we accept a risk of less sinister event namely the late onset restenosis with POBA.
This is a funny world . The DES fiasco is driving us towards stent less world and a bio degradable stent is already being projected as new savior.
Meanwhile no one can kill POBA thats for sure ! It will ultimately be reinvented with another exotic study soon !
Reporting a coronary angiogram may look like child’s play for most cardiologists. Many do it in less than a minute. (It goes something like this 90 % LAD , 30 % ostial OM1, 50 % mid RCA etc etc ) The famous and meticulous classification of Ellis and Ambrose proposed two decades ago appear largely redundant.
In this review we shall briefly debate an eccentric plaque or lesion .
Pathologically an eccentric lesion will have a disease free arc within an atherosclerotic lesion.If we apply this criteria most of the plaques appear to be eccentric.
In simple terms eccentricity is said to be present when the plaque volume is three times more on one side when compared to opposite side .
The incidence of eccentric lesion is largely under estimated. It can be up to 40 % of all lesions.
It has histological as well as hemodynamic significance.
How to measure eccentricity index ?
Ratio between maximum plaque thickness and minimum plaque thickness (Including the media )
In the above figure : The eccentricity index is measured as the ratio of the maximum to minimum plaque plus media thicknesses. In the eccentric lesion the maximum wall thickness measures 2.6 mm, minimum wall thickness measures 0.2 mm, and eccentricity index is calculated to be 5.2. In the concentric lesion the maximum wall thickness measures 2.2 mm, minimum wall thickness measures 1.6 mm, and eccentricity index is calculated to be 1.4.
What are the associations of eccentric plaque ?
Calcification and hard plaques are more common in eccentrically placed plaques.The most vulnerable point for plaque rupture or disruption is the shoulder region between normal and plaque segment.
- Acute recoil
- Coronary spasm
- Mechanical effects : Asymmetric expansion of stent
- Drug eluting stents
An arc of normal plaque circumference predispose to acute recoil and spasm.this is logical as the normal arc will have a fully functional medial smooth muscle which are prone for spasm.
Does stenting reverse the eccentricity of plaque ?
It may not . The drag effect of major plaque mass may either result in plaque prolapse or asymmetric stent approximation or even stent crushing effect.
How does the the stents elute in an eccentric lesion ?
Stents are not intelligent enough to differentiate the plaque surface and normal surface. We also know these drugs are toxic to normal endothelium and hence are not welcome in the normal arcs of an eccentric lesion.
Since the drug secretion is uniform throughout the circumference it makes the DES a perfect misfit in eccentric lesions As we realise most of the lesions are pathologically eccentric one can guess the long term consequences .
The more we think we know . . . the less is understood .
The images we see daily in cath labs are too simplistic to make vital decisions .There are constant innovations coming up but none seems succeed in imparting common sense to majority us.(Namely direct plaque intervention can never succeed over a diffuse medical disease called atherosclerosis )
A good reference article
Posted in Cardiology -Interventional -PCI, tagged cabg, circulation, complex pci, distal left main, double barrel stenting, europcr, India live coronary, interventional cardiology, jacc, left main stenting, live pci work shop, pci, proximaleft main, ptca, scai, tctmd, trifurcation lesion, unprotected left main on February 13, 2011 | Leave a Comment »
- It is a complex PCI procedure meant for high risk bifurcation /Trifurcation lesions
- Two stents are simultaneously deployed.
- It aims to prevent sudden acute occlusion of one of the major branches .
- It is not an easy procedure , and be used only in rare circumstances .
- Distal left main and ostio proximal LAD/LCX is a classical example.
- Navigation can be difficult , only well experienced operators should attempt it.
*Is there a ready made two lumen stent available ?
It is one of the techniques available to stent unprotected left main
An excellent review in ACC intervention journal for unprotected left main .
Posted in Cardiology -Interventional -PCI, cardiology -Therapeutics, Cardiology -unresolved questions, Uncategorized, tagged contraindication for doing coroanry angiogram, coronary angiogram, drug eluting stent, ectasia, guidelines for doing coronary angiogram, indications for coronary angiogram, pci, ptca, reporting a coronary angiogram, stents on February 6, 2011 | Leave a Comment »
Coronary angiogram is probably the commonest invasive cardiac investigation done world wide. It should run into millions every year. The procedure once thought dangerous is now performed in few minutes in day care centers . While doing a coronary angiogram has become a minuscule task to most cardiologists, interpenetrating it correctly remains a huge task !
Many of the young cardiologists get fascinated in doing a coronary angiogram and hardly spend enough time and mind in interpreting it.
Most of us succumb to the popular occulo coronary reflex and describe a coronary artery lesions as though it is a number game . It is very rarely we use the quantitative angiography tools available in the machine. We need to meticulously analyse the length , morphology , distal flow, thrombus , collaterals etc . (FFR a new avatar tries to do some justice )
Calling atherosclerois by numbers alone, such as 50 % LAD and 70 % diagonal 20 % left main is a huge insult to the deadly & diffuse disease process of atherosclerosis .We are paying the penalty for it .This is the fundamental flaw in our reporting , that makes every coronary intervention redundant.We must first remember we are looking at the lumen not the wall of coronary artery.
Coronary interventions is not about removing obstructions but regression of atherosclerosis load within the coronary artery , prevent progression of it and ultimately reduced cardiac events and improve survival. It is obvious, it can not be achieved by wires and catheters alone . At best they can be adjuncts.One can easily understand why medical therapy scores over wires as it can take care of the overall disease process.
But still , most* of the learned cardiology community considers medical therapy to be an adjunct to coronary intervention , which is a gross ignorance at it’s best !
* This is my perception. If I am proven wrong , I am happy our patients will be benefited !
Do not reduce the importance of coronary angiogram to a farce number game !
Do not get excited by visualizing your patient’s coronary artery. It may make you richer by few thousands. Realise , what you are seeing in a CAG is a fraction of coronary circulation.
It is estimated coronary circulation we visualize daily in cath lab as epicardial coronary arteries is less than 2 % of entire cross section of coronary circulation.
This means we are 98 % blind ! ( or 2 % wise !) .Spend adequate time and mind to interpret it correctly , so that logical and useful ( non ) interventions can be done .This only can make you a true cardiac professional and your patients will respect you.
Does PTCA , a great Innovation for mankind, is facing a threat of extinction ?
It seems so . . . the stents are losing its shine in most situations. A simple evidence . . . for that . . . can be found in answering the following question
What drives the extensive research in biodegradable stents now ?
The simple answer is , we are fed up with the metals inside the coronary artery. We want to get rid of it !
Too much of knowledge , often blunts our senses . Our track record clearly reveals this fact. We needed a major study INTERHEART to tell the world that ,exercise is good and tobacco is bad for heart ! Now ,we forgot a simplest solution for getting rid of metal inside the coronary artery , which is “not to implant the stent” at all ! (Instead we do billion dollar research for making bio – absorbable stents , which in the first place may not be required in the majority !
Read the related article . Does POBA has a role now ? in my site
The only situation , where PCI may withstand the test of time could be in ACS (Both in STEMI and high risk NSTEMI !) PCI is cosmetic in most of the chronic coronary syndromes .
Our fight against human atherosclerosis will have to be , by medical means .PCI at best will provide a supportive role in selected patient group. It requires lots of common sense and scientific ignorance to achieve this. Risk reduction , prevention , optimal medical therapy will have to play a dominant role in the next few decades . This is something similar to the environmental issues we face in protecting our planet .No amount of green industry will protect the earth . It requires better social and behavioral ethics from mankind and their rulers !