Question and Answers

What is thrombostar catheter?

• 6 Fr lowest profile
• Best internal diameter
• Round lumen and tip
• Best suction
• Core stylet inside to cross bends, curves, tortuosity
• Monorail within 2 cm of tip
• Hydrphylic coating in last 30 cm to helps slide down stenotic lesions to aspirate.

Finally best thrombus aspiration catheter in terms of suction of thrombus, flexibility, crossibility, pushebility, internal lumen as compare to other thrombo comic devises.

What is the problem of fibrotic lesions during PTCA?

Fibrotic lesions even if non calcified may not dilate with a NC balloon. And very high pressures balloon make dissect the vessel.

What is the problem of a DES?

• Drug disappears in 3 months time and taken care of problem of restenosis
• Polymer may remain permanent and become nidus for thrombosis and if DES is not endothelialized well, the metal and polymer create SAT and late stent thrombosis even after 2 to 3 years specially if DAP is discontinued.
• Sometimes polymer is inflammatory and if stent is not endothelialized then it can cause stent thrombosis.

What is ideal DES?

• Easy to deliver
• Polymer should disappear in four weeks time
• Drug should disappear in 28 days (maximum time of restenosis)
• Non-inflammatory stenosis

Which is a good approach in SVG PTCA?

• In fuzzy ulcerated lesions do direct stenting
• Otherwise predilate with small balloon and then implant of stent

What are the problems with 3.5 mm DES stent specially cypher?

• Difficulty in advancing DES across lesion
• Difficulty in removing balloon after deploying the stent
• With no proper guide support and guide wire, it is difficult to advance the stent

What is the benefit of PTCA in cardiogenic shock?

• Even 50 to 60 % improvement in TIMI flow improves the acute and long term outcome in LV function, mortality and morbidity.

Cardiogenic shock with RVMI and acute MR : option of treatment

• Best option is to stent the accluded RCA in AMI. There are chances that acute MR may disappear.

What is the approach of PTCA in AMI with TVD

• Culprit vessel PTCA first
• If Hemodynamics remain unstable, then only you do PTCA to another critically accluded vessel

What are the clinical situations prone to stent thrombosis?

• Diabetes
• Resistance to anti-platelets
• Discontinuation of anti platelets
• AMI
• Smaller final MLD
• Bifurcation stenting
• Patient with renal failure

Which are the conditions where long term DAP a MUST?

• Bifurcation stenting
• Long DES
• IDDM
• Renal failure

Innumerate anti-thrombin's

• Aspirin and clopidogrel
• LMWH
• IIb/IIIa glycoprotein inhibitor
• IV Bivaluridin

What are the causes of Hematoma in groin after introducing sheath in femoral arteries?

• Peri sheath oozing
• A small arterial branch puncture before and wire could not go and there was no adequate compression at the puncture site. So blood keeps oozing out of the side branch.

Which is a better carotid stent?

• Self expanding stent is better and it is best to Postdilate stent with a balloon
• Metallic balloon expandable stent are avoidable in the neck due to neck movements.

How to avoid Perforation of RV with temporary Pacing wire specially in RVMI?

• Use balloon tip pacing wire to 6 Fr bard pacing wire. Confirm position in LAO pacing wire to face towards the septum / spine

What is the deference between XB3 (Cordis) and EBU 3 (Metronic)?

• XB3 is like JL 4 and EBU 3 is like JL 3.5 guide catheters

What are the salient points of whisper wire?

• It is best wire for bends , curves and tortous vessels
• Best wire for retrograde thro collaterals for CTO
• The end of the wire is stiff so in very small branches it may cause perforation

What is the reason of a stent balloon not advancing forward after stent deployment?

• If balloon is getting stuck within the stent then inflate balloon and deflate and then it will easily go down to vessel
• The balloon sticks within the stent and it's not going forward if stent is not full expanded in that segment.

An RVMI with CHB - how long can you keep a temporary pacing wire?

• Maximum 5 to 7 days
• Longer you keep the wire more chances of perforation

What are the problems you face with angioplasty in ACS in patients with low platelet count?

• Some patients lower the platelet count with aspirin, clopidogrel and inj clexane
• Low platelets are reported more with clopidogrel then inj clexane
• Inj integrillin causes greater reduction in platelets
• Monitor platelet count when giving patient aspirin, clopidogrel, inj clexane and inj integrillin
• In patients with tendency to lowering platelets one can continue aspirin, clopidogrel and inj clexane. Inj integrillin can be started 2 to 3 hours, during and 2 hours after the procedure. If the platelet count after the procedure lowers less than 75000 than it is important to stop inj integrillin

Stern Warning on the eve of 'World Diabetes Day

Most of the diabetes patients will develop heart problems!

"It is unfortunate that if Diabetes is not controlled it will lead to heart problems. Nearly nine out of ten patients of Diabetes will get heart ailments", warns Dr. S.A. Merchant, a leading Interventional Cardiologist. People with diabetes also tend to develop heart disease or have strokes at an earlier age than other people. If you are middle-aged and have type 2 diabetes, some studies suggest that your chance of having a heart attack is as high as someone without diabetes who has already had one heart attack. Women who have not gone through menopause usually have less risk of heart disease than men of the same age. But women of all ages with diabetes have an increased risk of heart disease because diabetes cancels out the protective effects of being a woman in her child-bearing years.
 
Dr. Merchant, one of the leading cardiologist who is attached to Leelavati Hospital, Saifee Hospital, Raheja Fortis Hospital, Umrao Hospital. With regular patients in Maharashtra & Gujarat and now from abroad- Middle East & East Africa specializes in the complete array of heart related problems including- Cardiac Catheterization and Angiography, Coronary Angioplasty with drug eluting stent, Valvuloplasties and TAVI ( Transfemoral Aortic Valve Implant), Carotid, renal and peripheral below knee stenting,, Permanent pacemaker implant and arrhythmia management, Soluble Scaffolding for Complex Coronary Artery Disease.
 
People with diabetes who have already had one heart attack run an even greater risk of having a second one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death. High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).
 
Diabetes itself is a risk factor for heart disease and stroke. Also, many people with diabetes have other conditions that increase their chance of developing heart disease and stroke. These conditions are called risk factors. One risk factor for heart disease and stroke is having a family history of heart disease. If one or more members of your family had a heart attack at an early age (before age 55 for men or 65 for women), you may be at increased risk.
You can't change whether heart disease runs in your family, but you can take steps to control the other risk factors for heart disease listed here:

• Having central obesity
• Having abnormal blood fat (cholesterol) levels.
• Having high blood pressure.
• Smoking

 
It is appalling that nearly 15 per cent diabetics (1.5 crore diabetics) in India are below the age of 40 years. This staggering number is really alarming and is a warning bell for the development of appropriate diabetes and metabolic disorders, for such kind of young-onset type 2 diabetes
 
Chart 1:   AGE Wise

AGE	TOTAL	PERCENTAGE (%)	CUMULATIVE PERCENTAGE
0-19	61	1.7	1.7
20-25	16	0.4	2.1
26-30	48	1.3	3.4
31-35	156	4.2	7.7
36-40	269	7.3	14.9
41-45	385	10.4	25.4
45+	2756	74.7	100.0

 
In fact, diabetes has become a full-blown epidemic in India. In many parts of the world, diabetes spawned a host of problems like patients lacking care facilities and finding difficult to get insulin, blood pressure tablets and other medicines that avert risk of complications
 
TYPE 2  DIABETES AMONG WOMEN
 
Worldwide, the rate of occurrence of Type 2 Diabetes is similar in both men and women, although they are slightly higher in men < 60 years of age and in women>65 years of age. It is said that 382 million people worldwide are living with diabetes and a big chunk of them are from lower and middle income groups.
 
However, as per the analysis in India concludes that 70% Indian men get appropriate diabetes treatment while only 30% Indian women are getting appropriate treatment.

Chart 2:   DATA - GENDER

GENDER	TOTAL	PERCENTAGE (%)
MALE	2784	70.0
FEMALE	1123	30.0

 
A startling revelation was made by the International Diabetes Federation regarding the number of diabetics in India. It said that an estimated 65 million adults with diabetes are there in India.  And this number is set to soar to 109 million by 2035.
 
About 2/3^rd  diabetics (6.66 crore diabetics) in India have one or more comorbid coditions. Diabetics do not suffer from diabetes alone. A comorbid condition refers to one or more diseases or disorders that occur together with the primary condition or disorder.

Chart 3:  DATA - COMORBIDITY
 

COMORBID CONDITIONS	TOTAL	PERCENTAGE (%)
HIGH BLOOD PRESSURE	1536	43.8
HIGH BLOOD CHOLESTEROL	485	13.8
HYPOTHYROIDISM	225	6.4
CORONARY HEART DISEASE	285	8.1
DIABETIC NEUROPATHY	81	2.3
ATHEROSCLEROSIS	33	0.9

 
The problem of diabetes in India is further compounded with about 50 per cent diabetics ( 5 crore diabetics) in India have high blood pressure
 
"Blood pressure" is the force of blood pushing against the walls of the arteries as the heart pumps blood. High blood pressure raises your risk for heart disease, stroke, and other problems.
 
Chart 4: DATA - BLOOD PRESSURE
 

CONDITION	TOTAL	PERCENTAGE (%)
HIGH BLOOD PRESSURE	1536	43.8

 
Nearly 15% diabetics (1.5 crore diabetics) in India have Hypercholesterolemia. (Refer Chart 5) Hypercholesterolemia is the presence of high levels of cholesterol in the blood. Hypercholesterolemia can contribute to many forms of disease, most notably cardiovascular disease.
  80% diabetics (8 crore diabetics) in India have abnormal Cardiometabolic Risk Score.   Chart 
 
6:  DATA -  Cardiometabolic Risk
 

CARDIOMETABOLIC RISK SCORE FROM TOTAL LIFESPAN R.I.S.C.(TM) TESTS IN DIABETIC PATIENTS
RANGE	CMR	PERCENTAGE
0-4 (Low Risk)	429	20.4
5-8 (Moderate Risk)	941	44.7
9-11 (High Risk)	561	26.7
12-18 (Abnormal Risk)	174	8.3

 
What is the Cardiometabolic Risk Score?
 
Diabetes and other risk factors could collectively lead to:

• Angina (Chest Pain)
• Myocardial Infarction (Heart Attack)
• Arteriosclerosis (Hardening of Arteries)
• Coronary Artery Disease (Heart disease)
• Atrial Fibrillation (Heart rhythm disorder)

 
8.     60% diabetics (6 crore diabetics) in India have Autonomic Nervous System Dysregulation   (Refer Chart 7)
 
The autonomic nervous system (ANS) controls a number of functions in the body such as heart rate, blood pressure, digestive tract peristalsis, and sweating, among others. Dysfunction of the ANS can affect these vital functions.
Autonomic Dysregulation could cause:
 

•  Inability to alter heart rate with exercise

• Sweating abnormalities (too much sweat or insufficient sweat)

•  Digestion difficulties (loss of appetite, bloating, diarrhea or constipation)

• Urinary problems

•  Sexual problems

• Vision problems

 
Chart 7:   DATA - Autonomic Nervous System Risk
 

AUTONOMIC NERVOUS SYSTEM RISK SCORE FROM TOTAL LIFESPAN R.I.S.C.(TM) TESTS IN DIABETIC PATIENTS
RANGE	ANR	PERCENTAGE
0-4 (Low Risk)	519	24.7
5-8 (Moderate Risk)	912	43.3
9-11 (High Risk)	447	21.2
12-18 (Abnormal Risk)	227	10.8

 

Control Diabetes or be prepared for Heart Problems: Dr. S.A. Merchant, Interventional Cardiologist

Mumbai,  October, 2014: “If you have diabetes, you are at least twice as likely as someone who does not have diabetes to have heart disease or a stroke”, warns Dr. S. A. Merchant, a leading Interventional Cardiologist. People with diabetes also tend to develop heart disease or have strokes at an earlier age than other people. If you are middle-aged and have type 2 diabetes, some studies suggest that your chance of having a heart attack is as high as someone without diabetes who has already had one heart attack. Women who have not gone through menopause usually have less risk of heart disease than men of the same age. But women of all ages with diabetes have an increased risk of heart disease because diabetes cancels out the protective effects of being a woman in her child-bearing years.

People with diabetes who have already had one heart attack run an even greater risk of having a second one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death. High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).

Diabetes itself is a risk factor for heart disease and stroke. Also, many people with diabetes have other conditions that increase their chance of developing heart disease and stroke. These conditions are called risk factors. One risk factor for heart disease and stroke is having a family history of heart disease. If one or more members of your family had a heart attack at an early age (before age 55 for men or 65 for women), you may be at increased risk.

You can't change whether heart disease runs in your family, but you can take steps to control the other risk factors for heart disease listed here:

·         Having central obesity. Central obesity means carrying extra weight around the waist, as opposed to the hips. A waist measurement of more than 40 inches for men and more than 35 inches for women means you have central obesity. Your risk of heart disease is higher because abdominal fat can increase the production of LDL (bad) cholesterol, the type of blood fat that can be deposited on the inside of blood vessel walls.

·         Having abnormal blood fat (cholesterol) levels.

o    LDL cholesterol can build up inside your blood vessels, leading to narrowing and hardening of your arteries—the blood vessels that carry blood from the heart to the rest of the body. Arteries can then become blocked. Therefore, high levels of LDL cholesterol raise your risk of getting heart disease.

o    Triglycerides are another type of blood fat that can raise your risk of heart disease when the levels are high.

o    HDL (good) cholesterol removes deposits from inside your blood vessels and takes them to the liver for removal. Low levels of HDL cholesterol increase your risk for heart disease.

·         Having high blood pressure. If you have high blood pressure, also called hypertension, your heart must work harder to pump blood. High blood pressure can strain the heart, damage blood vessels, and increase your risk of heart attack, stroke, eye problems, and kidney problems.

·         Smoking. Smoking doubles your risk of getting heart disease. Stopping smoking is especially important for people with diabetes because both smoking and diabetes narrow blood vessels. Smoking also increases the risk of other long-term complications, such as eye problems. In addition, smoking can damage the blood vessels in your legs and increase the risk of amputation.

Dr. S . A.  Merchant has suggested regular checkups to prevent Diabetes and in turn Heart Problems

·         Fasting and Post Meal blood sugar, Hb 1 Ac

·         Sr Cholestrol, Sr.Triglycerides, Sr Creatinine, T3 TSH

·         Urine for Micro-albumin,Creatinine Clearance Test

·         ECG, 2-D Echo, Stress test

·         Eyes-Fundoscopy, Slit-Lamp, Retinoscopy

·         Carotid Artery Doppler

·         Ultrasound Kidneys

·         Lower Limb Arterial Doppler

·         Ankle –brachial blood pressure, Periscope

·         Sensitometer/ Vibrometer/ Foot Scan

Dr. Merchant, one of the leading cardiologist with regular patients in Maharashtra  & Gujarat and now from abroad- Middle East & East Africa specializes in the complete array of heart related problems including- Cardiac Catheterization and Angiography, Coronary Angioplasty with drug eluting stent, Valvuloplasties and TAVI ( Transfemoral Aortic Valve Implant), Carotid, renal and peripheral below knee stenting,, Permanent pacemaker implant and arrhythmia management, Soluble Scaffolding for Complex Coronary Artery Disease.

Press Release

Protect your Body and Heart from Diwali Crackers: Dr. S.A. Merchant

Mumbai, October, 2014:  As one awaits Diwali the festivals of lights, sounds and colors. the  slight  apprehension remains as to burns people suffer as well as to the noise generated.

“However what is not known is a deafening noise can badly affect the human body and specially lead to heart diseases. This danger remains with both normal healthy people as well as those suffering from high blood pressure, diabetes, and hypertension”according to Dr. S.A. Merchant, leading Interventional Cardiologist.

The loud noise from crackers may trigger heart attack in those who have angina (chest pain due to reduced blood supply in the coronary arteries). The sudden shock of a loud blast may shoot up the blood pressure of those with hypertension (high blood pressure) and this may even precipitate a stroke.

While it is difficult to directly point fingers at crackers for causing heart disease in an otherwise healthy person, it is a known fact that noise pollution causes anxiety, which results in stress. Stress increases the level of certain chemicals like catecholamine, steroids and interleukins, which raise blood pressure, serum cholesterol and clotting tendency of blood, all of which increase the potential for heart attack, adds Dr. S.A. Merchant who has seen a steady increase in heart patients due to noise pollution every year.

For patients having ischemic heart disease (reduced blood supply due to narrowing of coronary arteries) or who have suffered earlier heart attack and are taking medicines, there is risk of increasing the severity of chest pain and this may even precipitate a fresh heart attack. People who have undergone angioplasty or bypass surgery are somewhat protected from heart attack but still run the risk of rupture of plaque and new blockage. 

Those who suffer irregular heart rhythm (cardiac arrhythmia) may experience an increase of symptoms like palpitation (uncomfortable pounding sensation in chest), dizziness, shortness of breath or sudden loss of consciousness for brief period (black out). For those having serious rhythm disturbances like Ventricular Tachycardia may even suffer from cardiac arrest, where the heart stops pumping and this needs immediate resuscitation to prevent fatal consequences. 

For those with heart failure (a condition where the pumping action of the heart is compromised due to underlying heart, lung or kidney condition), the loud sound may increase the heart rate and blood pressure, forcing the heart to pump faster and harder, thereby increasing the load on an already weakened organ and produce symptoms like shortness of breath, chest pain, palpitation, accumulation of fluid in the body etc. The risk increases when there are repeated blasts of loud crackers in close vicinity, so watch out! 

Dr. Merchant, one of the leading cardiologist with regular patients in Maharashtra  & Gujarat and now from abroad- Middle East & East Africa specializes in the complete array of heart related problems including- Cardiac Catheterization and Angiography, Coronary Angioplasty with drug eluting stent, Valvuloplasties and TAVI ( Transfemoral Aortic Valve Implant), Carotid, renal and peripheral below knee stenting,, Permanent pacemaker implant and arrhythmia management, Soluble Scaffolding for Complex Coronary Artery Disease.

“Please take these warnings seriously”, warns Dr. S.A. Merchant who has seen younger persons being affected by heart problems as well as an increase among women, who were earlier considered safe.”

Festivals are meant to brighten up our lives. A little planning and precaution help you enjoy it from your heart.