For Patients - DrCRaghu


Management of Heart Failure (HF) continues to be challenging despite the formidable advances in medical and intervention therapy. Establishment of the four pillars – Angiotensin Converting Enzyme (ACE) inhibitors/Angiotensin Receptor Blockers (ARB)/Angiotensin Receptor blocker-Neprilysin inhibitor (ARNi), Beta blockers, Mineralocorticoid Receptor Antagonist (MRA) and Sodium Glucose Co-Transporter2 inhibitors (SGLT2i) in the recent decade has paved way for the effective management of HF. The adaptation of these drugs into clinical practice continues to be low despite the robust evidence in clinical trials. Agents that increase cardiac contractility (inotropes) for the treatment of Heart Failure with reduced Ejection Fraction (HFrEF) – defined as left ventricular ejection fraction (LVEF) of less than 40%, have paradoxically increased the mortality rates instead of improving1. This is due to the increase of myocardial oxygen consumption as well as myocardial injury whilst increasing contractility. The established four pillars of HFrEF management improve the efficiency of heart function through indirect mechanisms rather than directly improving the cardiac contractility.

The Drug
Omecamtiv Mecarbil belongs to a new class of cardiac positive inotrope agents called “myotropes” that improve cardiac contractility without increasing the myocardial oxygen consumption. Phase 2 trials – COSMIC HF and ATOMIC HF with this agent have established the efficacy of this agent. Considering the adverse effects observed previously with other inotrope agents a phase 3 study, is essential for this molecule to be adapted into clinical practice. The recently published Global Approach to Lowering Adverse Cardiac Outcomes through Improving Contractility in Heart Failure (GALACTIC-HF) trial, conducted on 8266 patients demonstrated a modest but significant benefit with this agent.

GALACTIC HF analysis
Patients with LVEF less than 35% who are on established medical therapies received Omecamtiv Mecarbil versus placebo in this study. The study agent showed an 8% reduction in the combined event rate of cardiac mortality and HF hospitalization over and above that achieved with the four pillars. At the same time, this agent did not increase myocardial injury or infarction or arrhythmia rates. The benefit of this agent was observed predominantly in those with LVEF <28% in the primary analysis2. Patients admitted into Intensive Care units were also benefitted despite their predicted poor expected outcomes. In a recent sub group analysis, the benefit was most pronounced when the LVEF < 25% and for those in sinus rhythm without increasing sudden cardiac death3. Improvement in LVEF in modest numbers was also found. The use of SGLT2i in only 2% of patients is the limitation for this trial – SGLT2i were not proven to be beneficial in the management of HF when GALCTIC HF trial was conducted.

Take Home Message
Omecamtiv Mecarbil is an important addition rather than an alternative to the established therapies for HFrEF4. Marked benefit seen in patients with LVEF <25% and sinus rhythm highlights the importance of using this agent in select groups leading to a personalized approach to HF therapy5.


  1. Ahmad T, Miller PE, McCullough M, et al. Why has positive inotropy failed in chronic heart failure? Lessons from prior inotrope trials. Eur J Heart Fail 2019; 21: 1064-78.
  2. Swedberg K. Stimulation of Contractility in Systolic Heart Failure. N Engl J Med. 2021; 382: 178-179.
  3. Teerlink JR, Diaz R, Felker GM et al. GALACTIC-HF Investigators. Effect of Ejection Fraction on Clinical Outcomes in Patients Treated With Omecamtiv Mecarbil in GALACTIC-HF. J Am Coll Cardiol. 2021 Jul 13; 78: 97-108.
  4. Teerlink JR, Diaz R, Felker GM, et al. Cardiac myosin activation with omecamtiv mecarbil in systolic heart failure. N Engl J Med 2021; 384:105-16.
  5. Ferreira JP. Omecamtiv Mecarbil: A Personalized Treatment for Patients With Severely Impaired Ejection Fraction. J Am Coll Cardiol. 2021 Jul 13; 78: 109-111.

Key Words:

Heart Failure
Personalized Heart Failure treatment


  • The aortic valve guards flow of blood from the heart to the rest of the body. The major blood vessel that carries blood to the various organs of the body is the aorta and hence this valve is named aortic valve.
  • Aortic stenosis is a condition where the aortic valve narrows due to various causes. Most commonly ageing consequent degeneration of aortic valve causes the narrowing thus restricting blood flow to other organs.
  • Transcatheter Aortic Valve Replacement (TAVR or TAVI) is a procedure where the damaged valve is replaced by an artificial valve.
  • TAVR is a minimally invasive procedure and does not require splitting open of chest or general anaesthesia.
  • Through an incision, in the groin, an aortic valve mounted on a catheter will be introduced into the heart.
    • Aortic valve degenerates with ageing due to wear and tear. This happens usually beyond the age of 65 years. Many at that age have associated issues like previous heart surgery, kidney dysfunction, blocks in blood vessels supplying heart and brain, age-related frailty, lung problems etc. These issues make them a high risk for open-heart surgery.
    • Initially, TAVR was indicated for high-risk patients but for the past 5 years is being used in intermediate-risk and selected low-risk cases also.
    • Then, an artificial valve is directed into the aortic valve, where it can be expanded and further takes over the function of a diseased valve resulting in improved blood flow.TAVR became a revolutionary popular procedure?
      • High riskforopen-heart surgery
      • History of kidney or lung diseases and cannot undergo invasive procedures/surgery
      • Having previous valve replacement surgery that gets narrowed again.

      Who are not eligible to undergo TAVR procedure?

      • Previous mechanical valve surgery at the aortic valve location.

      What are the risks of the TAVR procedure?

      Generally, the TAVR procedure is safe and effective. However, some problems may occur in 1-3% of cases based on an individual’s characteristics which include:

      • Bleeding due to damage of blood vessels
      • Brain stroke
      • Infection
      • Heart attack
      • Kidney failure
      • Failure of the new artificial valve

      What are the potential complications of the TAVR procedure?

      • Paravalvular regurgitation
      • Pacemaker implantation
      • Valve thrombosis
      • Bleeding
      • Infective endocarditis
      • Death

      These can potentially affect 0.5-7% of patients.

      What are diagnostic tests to undergo before the TAVR procedure?

      • Electrocardiogram
      • Echocardiogram
      • Transesophageal echocardiogram
      • Carotid Ultrasound
      • CT aortogram

      What happens during TAVR procedure?

      • Small incisions are made in the groin for catheter insertion. Ongoing X-ray imaging will guide the catheter towards the aortic valve and the balloon at the end of the catheter may be inflated to open the aortic valve.
      • Then an artificial aortic valve will be directed through the catheter and placed over the diseased valve and deployed.
      • Echocardiography will be done to check for the functioning of the new aortic valve.


      What happens after the TAVR procedure?

      • Vitals such as Blood pressure, heart rate, temperature, respiration rate, blood oxygen level will be monitored, the patent is restedin the ICU for 24 hours.
      • Patient hospital stay will be 2 to 4 days.
      • If the catheter insertion is at the groin area, you may ask for not bend or cross your legs
      • Infections and bleeding manifestations are checked at the insertion site
      • You will be instructed to keep hydrated that will help you in washing off the contrast dye
      • Blood tests, Chest X-ray,Electrocardiogram(ECG), Echocardiogram will be done


      How long does my TAVR procedure last?

      • TAVR is a durable procedure and lasts for 10 to 20 years in the absence of complications.
      • Compared to surgical replacement of the aortic valve, TAVR provides a larger valve area and hence chances for re-narrowing are less.


      What is the uniqueness of treatment of TAVR by Dr C Raghu?

      • Availability of multimodality imaging leading to accurate diagnosis of the problem and associated co-morbidities.
      • One of the earliest cardiologists in India to have performed TAVR.
      • The first operator in South India to have performed TAVR in a patient with a previous mitral valve replacement.
      • Excellent pre-procedure planning leading to a highly successful result.


      Open heart surgery

      Mechanical valve


      Valve Thrombosis

      Infective endocarditis


      Carotid ultrasound

      Ct Aortogram

      Artificial aortic valve

      TAVR procedure

      Fast recovery rate

      Small incision


      Mitral valve replacement

      Who are eligible to undergo TAVR procedure?


The heart has 3 layers of tissue:

  • Pericardium – The thin outer layer that protects the heart
  • Myocardium – a thick muscular middle layer that contracts and pumps out blood
  • Endocardium – a thin inner lining

Inside the heart, there are four chambers- the upper two are right and left atria and lower two are right and left ventricles. The atria receive the blood that comes to the heart and the ventricles pump blood out from the heart. The right and left side of the heart is separated by a septum.

The heart also has 4 valves which allow unidirectional flow of blood every time the heart beats.

  • the tricuspid valve is between the right atrium and right ventricle.
  • The pulmonary valve is between the right ventricle and the pulmonary artery.
  • The mitral valve is between the left atrium and left ventricle.
  • The aortic valve is between the left ventricle and the aorta.

The electrical system of heart:

The pumping action of the heart is controlled by the heart’s electric system. As an electrical impulse moves through the heart muscles, the various chamber of heart coordinate and pump out blood.

An electrical stimulus is generated by the sinus node (also called the natural pacemaker) which is located in the right atria of the heart. This stimulus activates the atrial muscles. The electrical stimulus then travels down through the conduction pathways and causes the heart’s ventricles to contract and pump out blood. The atria contract first, just a few milliseconds before the ventricles. This allows the blood from the atria to enter into the ventricles which is pumped out later.


Cardiac disease is the common cause of death throughout the world. Among these, 85% of death are due to heart attack and stroke.

A heart attack occurs when the cholesterol plaque accumulates in the walls of the coronary arteries (blood vessels that deliver blood to the heart). People with the possible symptoms of a heart attack can confirm the diagnosis by coronary angiography. Coronary angiography is a procedure that combines contrast dye and X-rays to identify the blockages in the coronary arteries.

When is coronary angiography done?

Coronary angiography is an important part of clinical evaluation in patients who have:

  • Persistent angina despite full medications
  • Ischemic heart disease
  • Cardiomyopathy
  • An abnormal heart stress test
  • Unexplained congestive heart failure
  • Acute myocardial infarction
  • Large ventricular septal defects, which may increase the risk of heart failure

It is also used as a pre-operative procedure in individuals with scheduled heart surgery, who have a high risk of coronary artery disease.

Risks of coronary angiography:

The following are the possible complications associated with coronary angiography:

  • Bleeding at the site of incision
  • Blood clots
  • Infection
  • Irregular heart rhythms
  • Kidney damage
  • Risk of stroke

What happens before the procedure?

Coronary angiography is usually performed on an emergency basis. If the procedure is scheduled in advance, then the person may need to follow these instructions:

  • Inform about all the past and present medical conditions.
  • Tell about the current medications.
  • Notify the doctor regarding any allergies.
  • Eight hours before the surgery avoid eating or drinking anything.

How is Coronary Angiography performed?

Before initiating the procedure, a sedative is given through the IV line to calm the person. Local anaesthesia is administered either on the arm or groin region.

Once the anaesthesia sets in, an incision is made to insert the catheter into the artery. By using the X-rays, the catheter is guided to reach the coronary artery. Once the catheter reaches the artery, a contrast dye is injected to highlight the blockage. This blockage is observed on the X-ray monitor.

What to expect after the procedure?

Once the catheter is removed, the incision will be closed with a manual clamp. For the first few hours, you will be in a recovery room, where your vitals are checked. You need to lie straight for a few hours to avoid bleeding from the incision site.

Before discharge, the doctor may give you the following instructions:

  • Consume plenty of fluids to flush out the contrast dye from the body.
  • Take the prescribed medications.
  • Do not lift heavy weights for a few days
  • Avoid strenuous activities for a couple of days.
  • Have a healthy and well-balanced diet.
  • Maintain healthy body weight.

When to seek medical attention?

Visit the doctor immediately on noticing any of the following symptoms:

  • Bleeding
  • Infection at the site of catheter insertion
  • Pain, discomfort, and inflammation at the incision site
  • Change in the colour or temperature at the operated area (arm or leg)
  • Weakness or dizziness
  • Chest pain
  • Shortness of breath


Carotid artery disease is a condition that arises when the fat deposits accumulate and block the blood vessels that deliver blood to the brain. People with carotid artery disease are at higher risk of developing stroke. So, to determine the risk and prevent the associated complications, a procedure known as cerebral angiography is recommended.

Cerebral angiography is a diagnostic procedure that uses X-rays to evaluate the blockage or any brain abnormalities in the carotid arteries (blood vessels in the brain and neck).

When is cerebral angiography recommended?

Cerebral angiography is recommended if the doctor suspects any of the following abnormalities within the brain:

  • An aneurysm
  • A dilated blood vessel in the brain
  • Brain tumour
  • Brain clot
  • Stroke

It is also used to evaluate arteries in the head and neck before undergoing any surgery; to provide additional information regarding any abnormalities that are not visible on other imaging tests, and as a minimally invasive procedure to treat vessel abnormalities.

In some cases, it is done to determine the underlying cause of the following symptoms:

  • Severe headache
  • Memory loss
  • Dizziness
  • Blurred vision
  • Loss of balance or coordination
  • Weakness or numbness

Before the procedure:

Specific instructions are given before undergoing the procedure. These instructions may include:.

  • Any allergies
  • The use of current medicines, vitamins, and mineral supplement
  • The current medical conditions
  • Any food or dietary restrictions before the procedure.

What happens in the procedure?

Before initiating the procedure, the patient’s head is stabilized by using a strap, tape, or sandbags. Based on the age of the person, either local or general anaesthesia, is administered. Once the anaesthesia sets, the doctor will sterilize the groin region and make an incision. Under the guidance of X-rays, the catheter is passed into an artery in the neck.

Once the catheter is placed in the correct position, the contrast dye is injected to highlight the blockage. After the X-rays are done, the catheter is removed, and the incision is closed.

What to expect after the procedure?

Once the procedure is done, the vitals are monitored in a recovery room. The person would be instructed to keep the leg straight if the catheter is administered through the groin region. Pain and inflammation at the site of incision are common, which can be relieved by applying ice packs and taking the prescribed medicines.

What considerations should be taken after the test?

Cerebral angiography is a diagnostic procedure, so there are not much considerations. However, following the below-given tips may ease the discomfort associated with the test:

  • Have a healthy and well-balanced diet.
  • Do not lift heavyweight for a few days or as suggested by the doctor.
  • Perform normal activities 8 to 12 hours after the procedure.

Talk to the doctor:

Call the doctor immediately on noticing any of the following symptoms:

  • Chest pain
  • Dizziness
  • Infection at the catheter site
  • Shortness of breath
  • Skin rash
  • Slurred speech
  • Vision problems
  • Numbness in the face, arms, or leg muscles


Cardiac catheterization is one of the most extensively performed cardiac procedures. If you have chest pain or irregular heartbeat, your doctor may recommend cardiac catheterization.

Cardiac catheterization is a minimally invasive procedure used to detect and treat cardiovascular diseases. This procedure involves the insertion of a catheter (a thin hollow tube) into the large arteries or veins present in the neck, arm or groin, which is then guided to the heart using a special X-ray. Once the catheter reaches the location, diagnostic tests or treatment procedures are carried out.

Why perform Cardiac Catheterization?

Cardiac catheterization is done to find the cause of the signs and symptoms of a heart problem or to treat or repair the heart damage.

This procedure is performed to:

  • Determine the pressure levels in the chambers of the heart.
  • Determine the heart function after a cardiac intervention.
  • Detect blockages in the coronary arteries (coronary angiography) or valve dysfunction.
  • Perform procedures such as angioplasty, ablation therapy or valve repair.
  • Obtain a small piece of heart tissue to examine under a microscope for detecting conditions affecting the heart muscle (cardiac biopsy).

What is the difference between Cardiac Catheterization and Coronary Angiography?

Catheterization is a procedure used to diagnose and treat various conditions. It involves the insertion of a catheter into the arteries and veins to reach the heart and to measure how much blood the heart pumps out, the pressure in each heart chamber, and to detect any defects in the heart. Also, various small instruments can be inserted into the catheter to view the interior of the blood vessels, to remove a tissue sample from the heart for further examination, etc.

Coronary angiography is a type of catheterization procedure, which involves analysing the arteries that supply the heart with oxygen-rich blood. This procedure involves the insertion of a catheter in the arm or the groin, which is threaded to reach the coronary arteries. During insertion, fluoroscopy (a continuous x-ray procedure) is used to guide the catheter to reach the precise position. After the catheter tip is at the right location, a contrast dye is injected into the coronary arteries. This dye can be seen on x-rays, and the outline of the arteries is viewed on a video screen.

How do I prepare for the procedure?

Inform your doctor about:

  • The medications that you are taking, especially blood-thinners or anti-inflammatory medications
  • Any medical conditions that you have
  • Allergies to any dyes or specific medications

Before the procedure:

  • Fast for at least 6 hours, as food and liquid increase the possibility of complications with general anaesthesia.
  • Empty your bladder before heading to the procedure.
  • Remove dentures and jewellery, as they may interfere with the imaging procedures.
  • Your general health status and vital signs will be monitored.

What happens during the procedure?

During cardiac catheterization, an IV cannula is inserted in your arm to administer medications. You will be given a mild sedative to help you relax during the procedure.

The general procedure of cardiac catheterization is given below:

  • The site of catheter insertion (usually the groin) is cleaned and shaved.
  • Usually, local anaesthesia is administered. General anaesthesia may be given before surgical procedures such as valve repair or ablation.
  • When the site of catheter insertion becomes numb, an incision is made, and the catheter is inserted using a catheter sheath.
  • Once the catheter reaches the heart, a dye is administered which outlines the vessels, valves and chambers of the heart.
  • The diagnostic tests or surgical procedures will then be performed for treating the condition.

Vital signs and electrocardiogram will be continuously monitored during the procedure.

Cardiac catheterization usually lasts for about 30 minutes. It may be longer if you are undergoing any other test or intervention using this procedure.

After the procedure is done, the catheter will be removed, and the incision will be closed by stitches. A sterile dressing will be used to prevent infection in the incision site.

What happens after the procedure?

Once the procedure is done, you will be asked to lie flat on the bed for 2-6 hours after the procedure. Your heart rate and blood pressure will be continuously monitored.

Once the anaesthesia wears off, you will be given pain medications. You will be asked to drink plenty of water to eliminate the dye that was administered. Usually, you will be asked to stay in the hospital for a few hours or a day.

After leaving the hospital, follow all the post-procedural instructions given by your doctor. You may resume your normal activities in a day’s time. Some soreness at the incision site is normal; it may reduce within a week.

What are the risks of Cardiac Catheterization?

Cardiac catheterization is a relatively safe procedure. However, like any other invasive procedure, some uncommon risks of this procedure are:

  • Infection
  • Blood clotting
  • Bruising at the incision site
  • Allergic reaction to dye
  • Arrhythmia
  • Air embolism
  • Stroke

Call your doctor if you experience:

  • Severe pain at the incision site
  • Signs of infection: redness, warmth, pus oozing or excessive swelling around the incision site
  • Numbness or tingling sensation in your limbs


Critical limb ischemia occurs due to is a severe blockage of the arteries which leads to reduced blood flow to the extremities (hands, feet and legs). It results in severe pain and even skin ulcers or sores.


Critical limb ischemia (CLI) is an advanced stage of peripheral artery disease (PAD) which results from progressive thickening of an artery’s lining caused by atherosclerosis (buildup of plaque). This eventually leads to narrowing of the artery which reduces normal blood circulation to the extremities.


The early symptoms of ischemia of the limbs which can progress to critical limb ischemia involves pain, burning or cramping in the muscles of the limbs, usually after a physical activity or exercise which goes away with rest.

The following are the symptoms which may be indicative of critical limb ischemia:

  • Severe pain in the limbs or the legs when at rest
  • A noticeable low temperature of the lower leg or foot when compared to rest of the body
  • Toe or foot sores, infections or ulcers which heal slowly
  • Gangrene
  • Shiny, smooth, dry skin in the legs or feet
  • Thickening of the toenails
  • Absent or diminished pulse in the legs or the feet

Risk factors:

The risk factors include the following:

  • Age (over 60 years and post-menopausal women)
  • Smoking
  • Diabetes
  • Obesity
  • Sedentary lifestyle
  • High cholesterol
  • High blood pressure
  • Family history of vascular disease


Diagnosis is dependent on the location of ischemia. A thorough clinical examination is done as the symptoms are the first hint of this severe condition.

The following are the diagnostic methods which may be considered:

  • Ankle brachial index test: It is suggested when the ischemia is in the lower extremities of the body. It is a noninvasive procedure and helps evaluate the blood pressure in the legs.
  • Duplex ultrasound scanning: It is the most effective non-invasive scanning method of the arteries.
  • Magnetic resonance arteriography (MRA): The blood vessels are visualized based on magnetic resonance which enables the evaluation of stenosis.
  • Arteriogram: It is a contrast-enhanced x-ray of the arteries to help determine stenosis.


The following measures may help prevent peripheral artery disease:

  • Maintain a healthy active lifestyle.
  • Avoid or quit smoking.
  • Exercise regularly.
  • Maintain a healthy diet of low fat and low cholesterol.
  • Control blood sugar and blood pressure.
  • Manage stress.


Immediate treatment is required to reestablish the blood flow to the affected areas. The goal of the treatment should be to reduce pain and to improve blood flow to prevent amputation of the leg.

Treatment options include:

Prescribed medicines are aimed to prevent further progression of the disease and to reduce the effect of the factors that contribute to the risk factors involved. Medications that prevent clots or infections may also be prescribed.

Endovascular treatment

These are the least invasive methods which involves usage of a catheter. Angioplasty may be recommended to open the blockages and improve the blood circulation to the affected part of the limb. Laser atherectomy is a method in which laser is used to vaporize small bits of the plaque, followed by a catheter with rotating blade that physically removes the plaque from the artery.

Arterial surgery

It is recommended when the arterial endovascular treatment is not favorable. In this procedure, the diseased arterial part is removed or bypassed with a vein from the patient or with a synthetic graft.


Amputation of the affected part is done as the last resort, and may be needed in about 25 percent of the CLI cases.


Mitral stenosis is a form of valvular heart disease caused by the narrowing of the mitral valve. Mitral valve lies between the left atrium and left ventricle of the heart which is made up of two flaps of tissue called leaflets. It opens when the blood flows from left atrium and left ventricle and closes immediately to prevent the backward flow of the blood. The defective valve fails to either open or close completely.

The most common cause of mitral stenosis is an infection called rheumatic fever. It is an inflammatory condition that usually starts with strep throat and leads to permanent damage of heart valves. Rheumatic fever is now rare in developed countries, but the prevalence is still high in developing countries. It may scar the mitral valve and if left untreated, mitral stenosis may lead to severe heart complications. Mitral stenosis can be classified into three types – mild, moderate and severe depending on the severity.


The progression of mitral stenosis is slow, and the symptoms generally appear after 20 to 40 years after an episode of rheumatic fever. However, an individual with mitral stenosis may feel fine or have minimal symptoms for decades. They include:

  • Shortness of breath, especially during physical effort or when you lie down
  • Chest discomfort or chest pain
  • Fatigue and weakness, especially during increased physical activity and during pregnancy
  • Swollen feet or legs
  • Heart palpitations – sensations of a rapid, fluttering heartbeat
  • Dizziness or fainting
  • Coughing up blood
  • Thromboembolic complications such as stroke

Mitral stenosis symptoms may worsen due to any activity that can cause an increase in the heart rate.

The pressure which is built up in the heart due to mitral stenosis causes fluid buildup in the lungs.

The symptoms of mitral stenosis usually appear between ages of 15 to 40 years. But they can appear in any age or even during childhood.

The signs that can be found during general examination include:

  • Heart murmur observed using stethoscope during clinical examination
  • Fluid buildup in the lungs
  • Irregular heart rhythms (arrhythmias)


  • Rheumatic fever: The major cause of mitral stenosis is rheumatic fever. Rheumatic fever is a complication of strep throat which can damage mitral valve by thickening or fusing the valves.
  • Other causes include:
  • Calcium deposits: People of older age can develop calcium deposits. This leads to calcification of the mitral valve leaflets resulting in mitral valve stenosis.
  • Congenital heart disease: Some babies may be born with a narrowed mitral valve, that may lead to mitral stenosis.

Risk factors:

The individuals with the following conditions are at risk of mitral stenosis:

  • Infective endocarditis
  • Endomyocardial fibroelastosis
  • Malignant carcinoid syndrome
  • Systemic lupus erythematosus
  • Whipple disease
  • Rheumatoid arthritis


The diagnosis of mitral stenosis could follow an invasive or non-invasive method.

The noninvasive procedures include:

Electrocardiogram (ECG):  In this procedure, the electrodes are attached to pads on patients’ skin to measure electrical impulses from the heart which provides information about heart rhythm. The patient is either made to walk on a treadmill or pedal a stationary bike during an ECG to see how the heart responds to exertion.

Echocardiogram: The echocardiogram is a very useful tool to assess the mitral stenosis etiology, morphology, severity, and treatment intervention.

Two types of echocardiogram are performed which include:

  • Transthoracic echocardiogram: This test is used to confirm the diagnosis of mitral stenosis. In this procedure, the sound waves are directed to patients’ heart from a transducer held near the chest which produces video images of heart in motion.
  • Transesophageal echocardiogram: In this procedure a small transducer is attached to the end of a tube which is inserted into esophagus. This provides a closer look at the mitral valve when compared to regular echocardiogram.

Chest X-ray: The chest X-ray is used to observe the size of the heart size, prominent main pulmonary arteries, dilatation of the upper pulmonary veins, and displacement of the esophagus by an enlarged left atrium. If the condition is severe there could be enlargement of all the chambers, pulmonary arteries, and pulmonary veins. The chest X-ray also helps to identify the condition of lungs.

The invasive procedures include:

Cardiac catheterization: Cardiac catheterization is an invasive procedure and is performed when the noninvasive tests are inconclusive or when there is a no correlation between noninvasive tests and clinical findings. It involves threading a thin tube (catheter) through a blood vessel in the patients arm or groin to the coronary artery in the heart and injecting dye through the catheter to make the artery visible on an X-ray. This provides a detailed picture of your heart.

These cardiac tests help in distinguishing mitral valve stenosis from other heart conditions, including other mitral valve conditions. These tests also help reveal the cause of your mitral valve stenosis and whether the valve can be repaired.


The patients with mild mitral stenosis without any symptoms generally do not require an immediate treatment, but are monitored continuously.

Medications are prescribed to ease the workload of the heart and to regulate its rhythm, thus reducing the symptoms.

The following medications may be prescribed:

  • Diuretics to reduce fluid accumulation in the body or lungs
  • Blood thinners (anticoagulants) such as daily intake of aspirin to help prevent blood clots
  • Beta blockers or calcium channel blockers to slow your heart rate and allow your heart to fill more effectively
  • Anti-arrhythmics to treat atrial fibrillation or other rhythm disturbances
  • Antibiotics to prevent a recurrence of rheumatic fever if it is an underlying cause for the condition


The treatment involves surgical or nonsurgical procedures.

Nonsurgical procedures:

Percutaneous balloon mitral valvuloplasty

In this procedure, which is also called balloon valvotomy, a soft, thin tube (catheter) tipped with a balloon is inserted in an artery of the patients arm or groin and guided into the narrowed valve. Once in position, the balloon is inflated to widen the valve, improving the blood flow. The balloon is then deflated, and the catheter with balloon is removed.

Surgical options include:

  • Commissurotomy: An open-heart surgery is performed to remove calcium deposits and other scar tissues to clear the valve passageway.
  • Mitral valve replacement: Mitral valve replacement is considered if it cannot be repaired. In mitral valve replacement, the damaged valve is removed and is replaced with a mechanical valve or a biological tissue valve.


The prevention of mitral stenosis is largely dependent on preventing the occurrence of rheumatic fever, which is the major cause of the condition. However, if one acquires rheumatic fever, the following measures can help live a healthy life.

  • Limit intake of salt.
  • Maintain a healthy body weight.
  • Decrease caffeine intake.
  • Seek prompt medical attention.
  • Cut back on alcohol.
  • Perform regular exercise.
  • Go for regular checkups.


Pulmonary embolism is a blockage in one of the pulmonary arteries of the lungs. The most common reason for pulmonary embolism (PE) is a blood clot (thrombus) that travels to the lungs from other parts of the body (usually a leg) and becomes lodged blocking the blood vessel in the lung.

It is a medical emergency and immediate treatment can greatly increase the survival chances.


When a blood clot or in some cases, a clump of material causes a blockage in an artery of the lung, it leads to pulmonary embolism.

Clump of material other than blood clots include:

  • Fat (of marrow) from a long, broken bone
  • Collagen or other tissue
  • Part of a tumor
  • Air bubbles

In majority of the cases, multiple clots are involved but it is not necessary that all are involved in embolism. The affected part of the lung may die due to disruption of the blood supply. Moreover, it becomes difficult for the affected lung to supply oxygen to the rest of the body.

Signs and symptoms:

Its symptoms vary greatly depending on the size of the clots, the part of the lung affected, or pre-existing heart or lung disease.

Common signs and symptoms include:

  • Shortness of breath- it appears suddenly and becomes worse with exertion.
  • Chest pain- it is not relieved by rest and becomes worse upon cough or deep breath.
  • Cough- the cough may produce blood-tinged sputum.

Other signs and symptoms due to an underlying health condition or disease include:

  • Leg pain or swelling
  • Discolored skin (cyanosis)
  • Fever
  • Profuse sweating
  • Rapid or abnormal heartbeat
  • Lightheadedness

Risk factors:

The risk factors are mostly similar to that of a patient with deep vein thrombosis (DVT) which include:

  • Longer hours of rest as seen in individuals who are hospitalized or even a long period of flight journey
  • Hypercoagulability (increased blood clotting potential) which may be caused by certain medications such as birth pills
  • Smoking
  • Cancer
  • Recent surgery
  • Pregnancy
  • Damage to the blood vessel wall


When a patient is suspected of pulmonary embolism or blood clots in the lung, then several crucial tests may be performed which include:

Pulse oximetry

It the simplest noninvasive way to measure the blood oxygen levels. A blood oxygen saturation level of 95 percent is abnormal.

Arterial blood gas

It is performed on a blood sample taken from an artery and the level of blood gases is evaluated. A partial pressure of oxygen less than 80mm Hg is abnormal.

Chest x-ray

It is done to rule out other diseases such as pneumonia or fluid in the lungs which may be responsible for the symptoms.

Ventilation-perfusion scan (VQ-scan)

It determines whether the person has experienced pulmonary embolism (PE) by evaluating both air flow and blood flow in the lungs. It also decides the probability of the PE which can be high, intermediate or low. A normal VQ scan suggests absence of PE.

Spiral computed tomography of the chest

It serves as an alternative to VQ scan. When PE is suspected, a contrast dye is injected through a vein to make the blood vessels stand out.

Pulmonary angiogram

When symptoms of PE tend to be non-conclusive even after a low or intermediate VQ scan or a normal spiral CT scan, then pulmonary angiogram is a definite test. It an invasive test that uses x-rays to reveal the blockage in the veins or arteries.


It is not particularly used to diagnose PE, but it evaluates the strain on the right side of the heart due to a large PE as well as some heart problems which may imitate PE. About 40 percent patients with PE have abnormalities of the right side of the heart, particularly the right ventricle.


It can accomplished by preventing the underlying conditions which cause PE, such as deep vein thrombosis and also by following the preventive measures which include:

  • Blood thinners or anticoagulants may be recommended for the patients with complications of cancer or after a stroke or heart attack.
  • Maintain a healthy weight.
  • Avoid smoking.
  • Consult a doctor about risk of clots before taking birth pills or hormone replacement therapy.
  • Exercise regularly for better blood circulation.
  • Drink adequate amount of fluids to stay hydrated.


Approximately 10% of the patients who develop pulmonary embolism die within the first hour without immediate treatment.

Immediate treatment greatly reduces the chances of death and shortens the stay in the hospital. The following treatment options are considered:

Compression stockings

These stocking are up to the knee and maintain a pressure on the legs to prevent blood clots. Sometimes they are also referred to as “support hose”.


  • Blood thinners/anticoagulants- They are administered intravenously or in the form of pills depending on the patient’s condition and what works best for them. Blood thinners prevent further formation of blood clots but don’t dissolve the already existing blood clots. Most commonly used anticoagulants are heparin and warfarin. Warfarin is not recommended during pregnancy.
  • Thrombin inhibitors: It is recommended for people who can’t take heparin.
  • Thrombolytic medicines: It is recommended only during life threatening conditions after careful consideration as they can cause sudden bleeding.


Rarely a surgical intervention is used to remove a clot or to prevent it from reaching the lung. This procedure may include:.

  • Inferior vena cava filter- It is opted when the formation of blood clots can’t be resolved by the use of medication (blood thinners). In such a scenario, a filter is placed inside the inferior vena cava which prevents the blood clots to reach the lungs.
  • Catheter- In some emergency cases, a thin flexible tube is introduced into a vein in thigh or arm and it eventually reaches the affected blood vessel of the lung where the blood clot is dissolved by a medicine or it is removed.

Self-injectable at home:

Low molecular weight warfarin are available in self-injectable forms which include dalteparin, enoxaparin and tinzaparin, but it carries the risk of bleeding which has to be taken care of, while using such medications.


When a blood clot (thrombus) is formed in one or more of the deep veins of your body (usually in the legs), it is known as deep vein thrombosis (DVT). Sometimes this clot becomes detached from the inner walls of the blood vessel and travels to another part inside the body. DVT may develop due to an underlying medical condition particularly the one which affects the clotting of the blood.

Causes and risk factors:

It can be caused by the factors which prevent the normal circulation of the blood and it’s clotting, such as long periods of rest (during a particular medical condition), injury to the vein, surgery and certain medications.

The risk factors are as follows:

  • Inherited blood clotting disorder
  • Prolonged bed rest
  • Surgery
  • Pregnancy
  • Contraceptives or hormone replacement therapy
  • Obesity
  • Smoking
  • Cancer
  • Heart failure
  • Inflammatory bowel disease
  • Age (usually older than 60 years but can also occur at any age)


The following are the complications which may arise due to DVT:

Pulmonary embolism: In this, a thrombus present in another part of your body usually a leg, travels to the blood vessel of the lung and blocks the blood circulation, leading to a life-threatening condition.

Post-phlebetic syndrome (post thrombotic syndrome): set of signs and symptoms seen after a blood clot has formed.


The person may be asymptomatic during the formation of the thrombus, however, during post thrombotic period when it has caused damage to the veins, the blood flow to the affected body part may be compromised. The following symptoms are observed:

  • Persistent swelling of the leg or arm (edema)
  • Leg pain or tenderness while standing
  • Skin discoloration in the affected arm or leg
  • Veins in the arm or leg appearing larger than normal

Sometimes the development of a serious health complication such as pulmonary embolism is responsible for the symptoms in the DVT patients which are as follows:

  • Shortness of breath
  • Chest pain
  • Cough (blood may be coughed out as well)
  • Back pain
  • Profuse sweating
  • Lightheadedness
  • Blue nails or lips

These symptoms appear suddenly, and an immediate medical attention is required.


The diagnosis is initiated by a thorough clinical examination and involves review of the patient’s medical history. Based upon these findings, the physician will categorize the patient into low or high risk DVT. Further tests may be considered to rule out other health problems and to confirm the diagnosis, which are as follows:

  • Blood tests: These are considered to evaluate any blood disorders that increase risk of DVT.
  • D- dimer test: In this test, the levels of a protein called D-dimer is assessed. In patients with DVT, high levels of this protein can be found in the blood.
  • Duplex ultrasonography: It is a non-invasive evaluation of the blood flow in the arteries and the veins of a patient. But this test is not preferred for a thrombus located very deep inside the body such as pelvis.
  • Venography: It is a specialized type of an x-ray procedure wherein a dye is injected into a vein of the foot, and the blood clot if present is detected.
  • Magnetic resonance imaging (MRI)- It is performed in patients for whom ultrasound examination is inappropriate or unfeasible. It can even detect a thrombus present in the patient’s pelvis and the thigh.


A recent World Thrombosis Day Ipsos survey showed that there is less awareness of DVT in countries around the world. Thus, the first step in prevention is making the public aware of DVT. The preventive measures are different depending on the person’s condition who are at risk of developing DVT:

During pregnancy

In pregnant women, certain medication may be prescribed if she has risk factors such as likelihood of having a cesarean birth, bed rest, history of DVT, and inherited thrombophilia.

During travel or in longer hours of sitting posture:

  • Drink lots of fluids.
  • Wear loose fitting clothes.
  • Walk and stretch at regular intervals.
  • Use special stockings to improve blood flow and to prevent blood clots but consult your health care provider before using it.


Treatment for DVT includes certain medicines and therapies, which are as follows:


  • Anticoagulants: They prevent further formation of blood clots but don’t dissolve the already existing ones. Most common anticoagulants used are heparin and warfarin. Warfarin is not recommended during pregnancy.
  • Thrombin inhibitors: These are recommended for people who can’t take heparin.
  • Thrombolytic medicines: These are recommended only during life threatening condition.

Compression stockings:

It may be recommended to prevent swelling and to avoid post-thrombotic symptoms in the patients.

Surgical treatment:

Surgical treatment may be performed when medications fail to dissolve the clots.





Call us now if you are in a medical emergency need, we will reply swiftly and provide you with a medical aid.

Copyright © 2019, Dr C Raghu. All rights reserved.
Designed & Developed by R R Deepak Kambhampati.

Copyright © 2019, Dr C Raghu. All rights reserved.
Designed & Developed by R R Deepak Kambhampati.

× How can I help you?