rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Although the risks of coronary angiography have declined over the years by increased clinical experience and advanced technologies, it still requires attention, knowledge and experience due to being an interventional diagnostic method. A safe coronary angiography begins with the selection of the appropriate catheter for the anatomical structure of the patient and the evaluation of the pressure when the catheter is placed in the coronary ostium. Coronary pressure waves are complementary requirements of angiography. The recognition, evaluation and precautions to be taken for abnormal pressure waves directly affect the mortality of the patient. One of the first clues to the presence of stenosis in the left main coronary artery (LMCA) is abnormal changes in pressure when the catheter is seated in the ostial LMCA. This often occurs as a “ventricularization” or “damping”. For decades, ventricularization was mostly experienced as a stenosis by invasive cardiologists [1]. Recognition of abnormal changes in pressure and precautions to be taken prevent catastrophic outcomes in patients
https://crimsonpublishers.com/ojchd/fulltext/OJCHD.000518.pdf
For more open access journals in Crimson Publishers
please click on https://crimsonpublishers.com/
For more articles in open journal of Cardiology & Heart Diseases
please click on https://crimsonpublishers.com/ojchd/
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Although the risks of coronary angiography have declined over the years by increased clinical experience and advanced technologies, it still requires attention, knowledge and experience due to being an interventional diagnostic method. A safe coronary angiography begins with the selection of the appropriate catheter for the anatomical structure of the patient and the evaluation of the pressure when the catheter is placed in the coronary ostium. Coronary pressure waves are complementary requirements of angiography. The recognition, evaluation and precautions to be taken for abnormal pressure waves directly affect the mortality of the patient. One of the first clues to the presence of stenosis in the left main coronary artery (LMCA) is abnormal changes in pressure when the catheter is seated in the ostial LMCA. This often occurs as a “ventricularization” or “damping”. For decades, ventricularization was mostly experienced as a stenosis by invasive cardiologists [1]. Recognition of abnormal changes in pressure and precautions to be taken prevent catastrophic outcomes in patients
https://crimsonpublishers.com/ojchd/fulltext/OJCHD.000518.pdf
For more open access journals in Crimson Publishers
please click on https://crimsonpublishers.com/
For more articles in open journal of Cardiology & Heart Diseases
please click on https://crimsonpublishers.com/ojchd/
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
Do you know what is a cerclage cable? During hip replacement and treatment of associated peri-prosthetic fractures, it is often necessary to hold the bone or fragments of bone together to create a stable environment for healing to occur. This is typically done with metal wires or cables using a technique called Cerclage. A cerclage wire or cable is wound around a bone or bony fragments to hold them together to allow them to heal.
cardiac bio markers are important diagnostic and prognostic tool in acute coronary syndrome. several new emerging bio markers are coming with more sensitivity and specificity.
differentiating between supraventicular tachycardia and ventricular tachycardia in wide complex rhythm is always confusing and management is totally different. correct diagnosis will make dramatic difference in patient management.
Brugada Syndrome is a inherited sodium channel disorder leading to life threatening ventricular fibrillation in young population. diagnosis and ICD therapy could be life saving.
kawasaki disease is disease of pediatric age group leading to involvement of coronaries in 25% of case. some of presented as fetal complication. early diagnosis and treatment useful measure to prevent complications.
takayasu arteritis is inflammatory disorder of medium sized arteries of unknown etiology, prevent in young female. lead to life threatening complication and long lasting morbidity. early diagnosis and treatment prevent complication and improve quality of life
Trans catheter intervention is emerging field in cardiac intervention. due to complex anatomy of mitral valve understanding of anatomy and three dimensional imaging is most important aspect of successful intervention and could be life saving in high risk surgical candidate
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
there are several limitation in VKA,to over come these problem NOACs came in picture but still limited indication for NOACs currently,required further study inter and intra comparison between anticoagulants.
ebstein anomaly is rare congenital disorder,with variable presentation in neonate to adults,early diagnosis and timely take decision make remarkable difference in patients life.
diabetes is most prevalent disease in asia, incidence of heart failure is also increasing in diabetic population, understanding the pathophysiology is very important to deal with these cases.
atherosclerosis is one of most common cause of aortic ds,screening of abdominal aorta in vulnerable population is very useful for prevention and early detection of future omplication.
ARVD is one of important coardiomyopathy in our clinical practice,early diagnosis, risk stratification and early diagnosis of CHF, management of VT will make big difference in patient life
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. INTRODUCTION
• RA technique developed by David Auth in the early 1980s.
• designed to work on the principle of differential cutting.
• incomplete stent expansion is a well-known predisposing factor for further ISR
and thrombosis.
• lesion preparation using RA prior to stent deployment in balloon heavily calcified
undilatable lesion is mandatory.
3. Mechanism of Percutaneous
Translminal Rotational Atherectomy (PTRA)
• operates on the principle of "differential cutting“.
• hard, fibro calcific plaque ablated by a rotating burr while softer tissue in the
treated coronary segment deflects away from the device and remains relatively
unaltered.
• Plaque is ablated and pulverized into particles generally < 10 to 15 microgm in
diameter that can uptake by the reticuloendothelial system.
4. Device Specifics
• 1. Rotalink® burr catheter-
• elliptical, nickel-coated brass burr attached to a hollow flexible 4.3F drive shaft,
which is encased in a Teflon sheath.
5. • sheath protects the artery proximal to the lesion from the rotating drive shaft
• allows flush solution to be pumped to lubricate the drive shaft and burr.
• ablative distal surface is embedded with 20 micro. diamond chips, with 5 micro.
protruding from the surface.
• Proximal nonablative surface of the burr is smooth.
• back end of the Rotalink burr catheter is connected to a Rotalink® advancer,
which allows the operator to extend and retract the burr within the vessel.
• delivers air or nitrogen through a pneumatic hose to the turbine housed within
the Rotalink advancer to spin the drive shaft and the burr.
10. 3.Rota wire
burr can be advanced over the 0.009-inch section, but its forward
movement is delimited by the wider wire tip .
RotaWire™ guidewires have no lubricious coating, no shaping ribbon, and are
easily kinked.
11. Technique
• Patients are pretreated with aspirin and possibly a calcium channel blocker to
counteract PTRA-induced vasospasm.
• glycoprotein (GP) IIb/IIIA receptor antagonists have shown benefit in limiting
speed dependent platelet activation.
• Rotaglide™ , a lipid emulsion, can be added to the flush solution to reduce
friction, limit heat generation, and facilitate device deliverability.
Influence of a platelet GPiib/iiia receptor antagonist on myocardial hypoperfusion during rotational atherectomy as assessed by myocardial Tc-
99m sestamibi scintigraphy. ] Am Call Cardio/ 1 9 9 9 ; 3 3 : 998-1004.
12.
13. • Over time, effluent heat increases due to friction in the system
• Increased heat in artery is associated with h platelet aggregation
• Rotaglide emulsion minimizes heat buildup
• Baseline temperature is low compared to standard saline flush
• Baseline temperature remains stable
40
45
50
55
60
65
0.00 1.00 2.00 3.00
Temp(C)
Time (min)
Temp with saline Temp with RotaGlide
Rotaglide Lubricant
Heat Generation
14. • temporary pacing wire can be used in PTRA of the RCA or dominant LCX due to
the risk of profound bradycardia.
• adenosine release with red cell fragmentation lead to bradycardia
• guiding catheter with a gentle curve and an inner diameter at least 0.004 inch
longer than the anticipated largest burr diameter is recommended.
15.
16. • Rota Wire floppy is chosen in order to minimize guidewire bias
• phenomenon observed when a stiff guidewire straightens a curved vessel
segment and causes deeper cuts or dissection as the burr is forced against the
tautly stretched lesser curvature of the vessel.
• floppy guidewire may fail to adequately constrain burr's passage around tight
bends , leading t o uncontrolled cutting on the greater curvature of the vessel.
• final burr-to-artery ratio should generally not exceed 0 . 7 (e.g. , 2 . 1 5-mm burr
in a 3 .0-mm vessel).
17. • preprocedural "DRAW "checklist, consisting of the following steps-
• “drip"-Adequate flow of the pressurized heparinized flush through the Teflon
sheath is visualized.
• "Rotation“- holds the catheter carefully so that the burr tip is not in contact with
the sterile drapes
• the system should be tested by depressing the foot pedal and having an assistant
adjust the turbine pressure to achieve the desired burr speed.
• "Advancer"-Test whether the advancer moves the burr freely.
• "Wire"-Ensure that the wire clip is in place on the wire and test whether the
brake locks the wire in place during rotation.
18. • Once the burr has been advanced to 1 to 2 cm proximal to the target lesion, the
advancer lever should be unlocked and pulled gently back to near its proximal
limit as the entire catheter is withdrawn gently by 1 or 2 mm.
• Under fluoroscopy, the burr is then activated by the foot pedal and adjusted to
the desired "platform" speed (generally 1 6 0 ,000 to 1 80 ,000 rpm for burrs <2
mm, 140,000 to 160 ,000 rpm for burrs > 2 . 0 mm) before engaging the lesion.
• essential to avoid speed drops of > 5 ,000 rpm during advancement.
• compressed air or nitrogen source to the console is confirmed to have a pressure
of at least 500 PSI.
19. • prefer advancing with a "pecking" motion in which brief (1 to 3 seconds) periods
of plaque contact are alternated with longer (3 to 5 seconds) periods of
reperfusion provided by pulling the burr back from the plaque.
• While removing facefoot pedal is then used to activate the lower speed
"dynaglide" mode, and the burr is removed while depressing brake release
button.
25. Coronary atherectomy recommendation
• Class IIa
• 1.rotational atherectomy is reasonable for fibrotic or heavily calcified lesion that
might not be crossed by a balloon catheter or adequately dilated before stent
implantation.(level of evidence C)
• Class III
• 1.should not be performed routinely for denovo lesion or ISR (level of evidence
C).
26. • Occlusions not passable with guide wire.
• Last remaining vessel.
• Severe LV dysfunction.
• Saphenous vein grafts.
• Angiographic thrombus.
• Significant dissection at treatment site.
Contraindications
27.
28. Complications
• Bradycardia and Atrioventricular
blocks
• Slow Flow Or No Reflow And
Vasospasm
• Dissection
• Perforation
• Side branch occlusion
• hypotension
Rotabalator System
Failure
•Burr Entrapment .
•Burr Detachment.
•Rota Guide Wire
Fracture.
29. Management of Bradycardia And
Atrioventricular Block
• Prevention
• Limiting ablation times (<15-20sec)
• Pretreatment with Atropine
• Deactivate the burr when slowing of heart rate is noted
• Ask the pt to cough.
30. Slow flow and No Reflow
• most challenging adverse sequelae.
• observed in 5% pts
• Mechanism-
31. Prevention of slow and no flow
• Deploying burr in step method to minimize the effect of plaque burden for given burr size.
• Gentle advancement and intermittent retraction helps in preventing
drop in rpm <5000
significant generation of heat
reestablishment of flow for particle clearance
• Limiting the ablation time to 15-30 seconds.
• Increasing the time between the ablations
• Slower speed (140,000 rpm) associated with lower platelet aggregation , so beneficial.
• Prior use of GPIIb/IIIa very usefull (abciximab).
32. Dissection
• Incidence 10%
• mod to severe angulated lesions dissections are more commonly
noted, burr dose not follow the natural course of the vessel.
• Guide wire vector would cause the orientation of the burr to be out of
planes, and result in tangential ablation with potential dissection
• placement of the guide wire plays paramount role in establishing the
cutting vector of the device .
33. • Goal is to set the optimal central vector for burring.
• Because increased tension (rigidity) on the wire can cause psudolesions
in the vessel and increased stiffness of the vessel can cause tension on
the wire and it will affect the advancement of the burr.
• Angiogram should be performed after the placement of the wire to assess
the interaction between the two.
34. Guide wire “unfavorable” bias can increases the chances of dissection and burring of
the normal tissue
35. HOW TO MINIMIZE THE “BIAS”
• Retracting the Rota guide wire to proximal position may improve co axial
alignment at the lesion site and prevent psudolesions formation distally
36. Perforations
• Incidence 0.7% reported from multicenter registry.
• Mechanism:- Oversize burr OR Tangentially oriented burr due to trajectory of
guide wire .
• More common in severely angulated lesions,
• This can occur even in elastic vessels , since the strain or penetration of guide
wire in to the wall will exceed the elasticity of vessel wall and ablation of tissue
will occur and potential perforation .
37. Management
• minimize guide wire bias by proper co- axial guide catheter and guide
wire placement
• Relaxation of the guide wire is important.
• Undersize the burrs in severely angulated lesions especially those are
straightened with guide wire or showing psudolesions.
• “pecking” technique should be used to avoid excessive cutting.
38. Rotablator System Failure
• Despite mechanical complexity of the system ,device failure is a rare
event.
• These are
burr entrapment
burr detachment
guide wire fracture
39. Burr Entrapment
• 1.Can occur if a burr slips across the lesion without the burring
(coefficient of friction is less at the high speed than at the rest ).
• Ledge of the calcium behind the elliptical burr causes “Kokesi” effect.
• 2.get entrapped in the tortuous segment of the lesion
And vasospasm.
40. Management Of Entrapped Burr
• Vigorous use of vasodilators
• Pulling back rotablator system manually
• Sometime it will be successful with manual traction with on dynaglide or off
dynaglide rotation
41.
42.
43.
44. conclusion
• Require skilled operator.
• RA increase the cost and duration of procedure.
• Judiciously used in indicated case and well aware of contraindication is necessary for
avoiding complication n achieving good results.
• Used in heavily calcified complex PCI for appropriate stent expansion.
• Slow flow n no reflow is frequently seen complication.
• Life threatening complication is also not uncommon.
• Beyond immediate procedural success, data have not shown consistent long-term
benefit of lesion modification by RA for restenosis and MACE.
• more recent series, RA use has fallen to 3% to 5% in select high-volume centers and <1%
in others.
• IVUS or OCT may prove useful in identifying features of plaque morphology predictive of
benefit