Diseases Conditions Archives | Dr C RAGHU Cardiologist

transcatheter-aortic-valve-replacement.jpg

  • 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.

      Keywords:

      Open heart surgery

      Mechanical valve

      Pacemaker

      Valve Thrombosis

      Infective endocarditis

      Echocardiograms

      Carotid ultrasound

      Ct Aortogram

      Artificial aortic valve

      TAVR procedure

      Fast recovery rate

      Small incision

      Cardiologist

      Mitral valve replacement

      Who are eligible to undergo TAVR procedure?


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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.

Causes:

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.

Symptoms:

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:

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.

Prevention:

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.

Treatment:

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:

Medications
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

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


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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.

Symptoms:

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)

Causes:

  • 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

Diagnosis:

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.

Prevention:

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

Treatment:

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.

Prevention:

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.

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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.

Causes:

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

Diagnosis:

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.

Echocardiogram

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.

Prevention:

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.

Treatment:

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”.

Medications:

  • 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.

Surgery:

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.


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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)

Complications:

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.

Symptoms:

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.

Diagnosis:

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.

Prevention:

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:

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

Medications:

  • 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.


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Thromboembolism refers to a condition where a blood clot formed in the blood vessel unplugs itself and flows in the blood stream to block another blood vessel leading to obstruction of blood flow. Although clotting is a normal bodily function, if a clot occurs where it is not required, it may lead to serious problems.

Types of Thromboembolism:

The type of thromboembolism differs depending on the area in which the clot may appear. It can obstruct the blood flow in the veins, arteries, brain, gastrointestinal tract or kidneys.

Thromboembolism can be further classified as below:

Venous Thromboembolism:

A venous thromboembolism is a thrombus (blood clot) formed in a vein. The blood flow in the veins is slow when compared to arteries which can increase the likelihood of the blood clots forming in these vessels.

It can be categorized into three different types

  • Superficial Vein Thrombosis
    The clot may occur in a superficial vein, close to the surface of the body. Usually, it is not serious until it enters the deep veins.
  • Deep Vein Thrombosis (DVT)
    Deep vein thrombosis occurs within the deep veins, and mostly occurs within the legs.
  • Pulmonary embolism (PE)
    It is a medical emergency in which the thrombus blocks the blood vessel in the lungs.

Renal Vein Thrombosis (RVT)

A renal vein thrombosis is a thrombosis that occurs in the veins that drain blood away from the kidneys. These clots reduce the ability of the kidneys to clean and filter the blood.

Arterial Thrombosis (atherothrombosis)

Arterial thrombosis is much less common than venous thrombosis. It can have similar risks. Usually arterial thrombosis may lead to necrosis of the tissue.

A thromboembolism in the coronary artery can cause a heart attack. If blood supply to the brain is disrupted, the patient may suffer a stroke.

Symptoms:

Signs and symptoms of venous thromboembolism include the following

DVT

  • Pain in arm or leg, usually in the thigh or calf
  • Swollen leg or arm
  • Reddening or warming of the skin
  • Red streaks on the skin

PE

  • Shortness of breath
  • Chest pain under your rib cage that can get worse when you take a deep breath
  • Rapid heart rate
  • Feeling lightheaded or passing out
  • Accentuated second heart sound

Arterial Thrombosis

  • Muscle pain or spasm in the affected area
  • Numbness and tingling in the arm or leg
  • Pale color of the arm or leg (pallor)
  • Weakness of an arm or leg

If the condition is severe, it may lead to blister formation and shedding of the skin, leading to tissue necrosis.

Symptoms of a clot in an organ vary with the organ involved but may include:

  • Pain in the part of the body that is involved
  • Temporary decrease in organ function

Causes:

The blood clots can occur due to injury to a vein, consequence of a surgery, use of certain medications and lack of movement of the limbs.

In the case of PE, the blood clot may block the blood vessels of the lungs. The affected portion of the lung may die due to loss of blood supply, the condition is called as pulmonary infraction, making it difficult to provide oxygen to the rest of the body.

Occasionally, the blood vessels can be blocked by substances other than blood like collagen, part of a tumour, air bubbles etc.

Risk factors:

The common risk factors include

  • Inheriting a blood-clotting disorder
  • Prolonged immobility which may be due to bed rest or long trips
  • Injury or surgery
  • Pregnancy
  • Birth control pills or hormone replacement therapy
  • Being overweight or obese
  • Smoking
  • Cancer
  • Heart failure
  • Inflammatory bowel disease
  • Family history of deep vein thrombosis or pulmonary embolism

Diagnosis:

The diagnosis of thromboembolism includes the following tests which could be considered depending on the type:

D-dimer: The blood sample is tested for the presence of D-dimer which is a marker for the presence of blood clots.

Duplex Ultrasound: This is an imaging test in which the presence of clots is identified using ultrasound waves.

Pulse oximetry: In this test, a sensor attached on the end of the finger of the patient helps to measure the level of oxygen in the blood.

Arterial blood gas: The blood drawn from the artery is checked for oxygen levels present in it.

Chest X-ray: This test may not be useful in finding the presence of clots, but can help to rule out a clot.

Other diagnostic tests may include ELISA, pulmonary angiography, venography, echocardiography, helical computed tomography of pulmonary vessels etc.

Treatment:

Treatment of thromboembolism includes:

Blood thinners: These are anticoagulant drugs which prevent formation of new clots while the body works to break up the previous clots present. They include heparin, low-molecular-weight heparin, apixaban, edoxaban, rivaroxaban, and warfarin.

Clot-busting drugs: These are intravenous injections to dissolve the clots in the case of life-threatening situations. They include drugs belonging to the class of tissue plasminogen activators.

Surgical and other procedures:

  • Removal of clot: Surgery is considered only if the condition is life threatening. The clot is removed using a catheter threaded through the blood vessel.
  • Vein filter: A catheter can also be used to position a filter in the inferior vena cava which helps to stop the clots from being carried into the lungs.

Prevention:

If the patient is at a risk of the condition, the following preventive measures may be considered to reduce the occurrence:

  • Use of blood thinners
  • Use of compression stockings
  • Use of intermittent pneumatic compression devices that automatically squeeze the legs to keep blood flowing

Other preventive measures include

  • Regular exercise
  • Maintaining healthy weight
  • Cessation of smoking

Consideration during travel include

  • Walk every 1 to 2 hours
  • Stretch legs and move around on the seat
  • Drink lots of fluids
  • Avoid smoking and consumption of alcohol before journey

disease-condtions-varicose_veins.jpg

Varicose veins are the twisted, swollen and bulging veins that appear in blue, red and skin color, just beneath the surface of the skin. They occur mostly in the legs and feet, causing aching pain and discomfort in the legs.

Larger varicose veins appear rope-like and make the skin to bulge out. Inner varicose veins usually do not appear, but cause aching pain and swelling in the legs. Spider veins are the type of varicose veins which are most common and occur superficially, surrounded by the patches of flooded capillaries.

Causes:

Arteries have a thick layer of muscle or tissue to supply oxygenated blood to different parts of the body. Veins carry blood back to the heart and it should work against the gravity, so they rely on surrounding muscles pressure. Valves in the veins open to move the blood towards the heart and then close to prevent the back flow of blood.

Any damage/abnormality in the functioning of the valves will lead to pooling up of blood in the vessels, causing them to stretch and twist, resulting in varicosity. It mostly occurs due to prolonged standing and walking, which builds up pressure in the veins of the lower legs.

Signs and Symptoms:

  • Dark purple or blue color veins
  • Twisted and bulging veins that appear on the surface of the skin
  • Aching pain and heaviness in the legs
  • Burning, throbbing, muscle cramping and swelling in the lower legs
  • Worsened pain after sitting or standing for a long time
  • Itching around affected veins
  • Skin discoloration around a varicose vein
  • Web-like reddish blue varicose veins called spider veins

Risk factors:

The factors that increase the risk of developing varicose veins are:

  • Age: As the age increases, the functioning of the valves in the veins may be damaged, resulting in pooling up of blood in the lower leg veins, leading to varicose veins.
  • Gender: Hormonal changes in women during pregnancy, premenstruation and menopause will relax the vein walls, which increases the risk for varicose veins. Use of hormonal birth control pills also increases the risk.
  • Pregnancy: Blood volume increases during pregnancy to support the developing fetus, but can also produce a side effect of enlarged veins.
  • Family history: If any family member has varicose veins or deep vein thrombosis, it increases the risk.
  • Obesity: Being overweight will increase the pressure in the veins of lower legs.
  • Standing or sitting for long periods of time will reduce the free flow of blood in the blood vessels and results in clot formation.

Complications:

  • Ulcers: Skin ulcers may form near the ankle, which is an indication of vascular disease.
  • Blood clots: Clots may occur in the veins deep inside the legs, causing swelling and leg pain. The condition is referred as thrombophlebitis.
  • Bleeding: Sometimes, the superficial veins may burst, causing bleeding.

Diagnosis:

A physical examination is performed, and the patient is enquired about the nature of leg pain diagnose varicose veins. The family medical history of varicose veins and information about their daily lifestyle activities is gathered. Certain tests may be needed to confirm the diagnosis of varicose veins, and include:

  • Ultrasound test: This is a non-invasive test, which uses sound waves to create the images of internal organs of the body. This test helps to identify the blood flow in the veins and also identify the clots and weakened or leaky valves in the veins.
  • Venogram: This test is a type of angiogram, which uses contrast dye to clearly view the blood flow through the veins, mainly if physician suspects the presence of large clots in the veins.

Treatment:

Initially, after the diagnosis of varicose veins, the doctor would recommend some lifestyle modifications that can relieve pain and reduce worsening of the condition, such as:

  • Perform exercises
  • Elevate the legs.
  • Avoid tight fitting clothes that can prevent the free circulation
  • Avoid long periods of standing or sitting

Compression stockings: It will compress the leg veins and muscles and improve the blood flow efficiently, without forming any clots in the veins. The stockings are available in different sizes and lengths and can be bought without prescription in the local pharmacy.

Sclerotherapy: This procedure is mainly used for severe varicose veins, and involves injecting a chemical solution near the varicose veins, which helps in closing and scarring of the veins.

Laser treatment: This technique uses bursts of light reflected onto the vein, which makes the vein slowly fade and disappear. This test is mainly used to treat smaller varicose veins.

Catheterization: This procedure uses a thin, flexible tube (catheter) that is inserted into the enlarged vein, which uses radiofrequency or laser energy, mainly to collapse the larger varicose veins.

High ligation and vein stripping: Veins are tied off before it joins a deep vein and then it is removed through an incision.

Ambulatory phlebectomy: Series of small punctures are made in the skin under general anaesthesia, to remove the smaller varicose veins.

Endoscopic vein surgery: A thin tube attached with a camera is inserted into the vein to view and close the varicose veins and then removing them by making small incisions on the skin, under general anaesthesia.

Prevention:

Varicose veins cannot be prevented completely, but can be reduced by following some measures like:

  • Exercising regularly and losing extra weight
  • Eating a high-fiber and low-salt diet
  • Avoiding high heels and tight hosiery
  • Elevating the legs.
  • Changing the position regularly, when sitting or standing for long periods

disease-condtions-pda.png

Patent ductus arteriosus (PDA) is a congenital heart condition in which there is an opening between the pulmonary artery and the aorta. The ductus arteriosus is a small connection in the fetal heart helps oxygen rich blood to by-pass the immature baby’s lungs and flow into the body. This connection naturally closes shortly after birth. The connections that fail to close, are called patent ductus arteriosus, where the oxygen-rich and oxygen-poor combines together resulting in an increase in the workload of heart and various other complications.

It is the sixth most common type of congenital heart disease, and is frequently diagnosed in infants; although it may remain unknown until childhood or even adulthood.

Symptoms:

The symptoms depend on the size of the patent duct and the gestational age of the neonate. A small patent ductus arteriosus can remain unrecognized until adulthood, whereas, a large patent ductus arteriosus may lead to life threatening conditions such as heart failure.

In neonates, a heart murmur on auscultation during regular checkup may indicate PDA.

In infants, a large PDA would show the following symptoms:

  • Inability or difficulty in feeding, leading to poor growth
  • Sweating on crying or eating
  • Persistent fast breathing or breathlessness
  • Cough
  • Lower respiratory tract infections
  • Pneumonia
  • Easy tiring
  • Rapid heart rate

The symptoms in the case of adults with undiagnosed PAD include heart attack, atrial arrhythmia or with the occurrence of shunting of unoxygenated blood from pulmonary to systemic circulation.

Causes:

In most of the children the cause of PDA is unknown, but genetic factors were thought to play a causative role. Every baby is born with ductus arteriosus which eventually narrows and closes within three to four days after birth. It may take longer time for closure in the case of premature babies. But if the duct doesn’t close, it may lead to an increase in the blood flow to the heart and lungs of the baby, which might enlarge or weaken the heart muscle.

Risk factors:

The risk factors of having patent ductus arteriosus include:

  • Gender: PDA is more common in girls than in boys.
  • Prematurity: It is more common in babies who are born before the gestational term than in full term babies.
  • Family history: A family history of heart conditions and other genetic disorders, such as Down’s syndrome may increase the risk of PDA.
  • Rubella infection: If the mother is affected with rubella infection during pregnancy, the virus may cross the placenta and spread through the baby’s circulatory system potentially damaging blood vessels and organs including the heart.
  • High altitude birth risk: Babies born at altitudes higher than 10,000 feet are at an increased risk.
  • Congenital heart problems: Babies with congenital heart problems such as hypoplastic left heart syndrome, transposition of the great vessels, and pulmonary stenosis are at high risk

Diagnosis:

A heart murmur heard during a regular checkup may lead to further work-up for PDA.

The following tests Are recommended for diagnosis of PDA:

  • Chest X-ray to assess the condition of the heart and lungs, and also to rule out other conditions
  • Echocardiogram to assess the heart, its valves and chambers for any defects and see if the heart is pumping properly
  • Electrocardiogram (ECG) to assess the electrical activity of the heart to diagnose any heart defects or rhythm problems
  • Cardiac catheterization to rule out other congenital heart defects found during an echocardiogram or in a case where the catheter procedure is considered for the treatment

Treatment:

Treatment is generally not considered, as the PDA usually closes on its own in the case of a premature baby. Close monitoring is considered for full term babies, children and adults with small PDA and with no other health complications. During follow-up, if the baby does not have any other complications, it is considered to be closed. On the other hand, if the baby has certain heart problems or defects, the ductus arteriosus might be lifesaving.

In a premature baby, it may take one to two years. But in full term babies, PDA that remains open after several weeks rarely closes on its own.

Medicines such as indomethacin or ibuprofen may be considered. These medicines work well for some newborns. The earlier treatment is given; greater are the chances for it to succeed.

Medical procedures may be considered in the case where medications are not effective. A transcatheter procedure is used to block blood flow through the vessel. An open heart surgery might be considered if the catheter procedure is not suitable to repair PDA.

Prevention:

Patent ductus arteriosus may not be prevented, but certain measures should be observed for a healthy pregnancy.

  • Early prenatal care
  • Healthy diet
  • Regular exercise
  • Avoiding consumption of alcohol, illegal drugs and cigarettes.
  • Getting vaccinated as recommended.
  • Optimal diabetes control.

disease-condtions-device_closure_for_vsd.jpg

The heart consists of four chambers, of which upper two chambers are called as atria and lower two chambers are called as ventricles. Right and left chambers are separated by a wall of muscle called a septum. Right two chambers pump the deoxygenated blood to the lungs and left two chambers pump oxygenated blood to the different parts of the body.

Ventricular septal defects (VSD) is a common type of congenital heart defect, which is characterized by an abnormal opening or a hole in interventricular septum, the dividing wall between right and left ventricles. The oxygen-rich blood from the left ventricle will enter into the right ventricle through the opening, thereby getting mixed with deoxygenated blood and then enters into lungs. This will force the heart and lungs to work harder.

Causes:

The exact cause of VSD is unknown. During fetal heart developmental stage, the heart develops from a large tube which eventually divides into chambers and walls. Any abnormality in this process will lead to the formation of a defect in the septum. If the defect is in the interventricular septum, then it is said to be ventricular septal defect. There may be one or more VSDs.

Types:

Based on the location and development of VSD, it is classified into following types:

  • Conoventricular Ventricular Septal Defect: It occurs just below the pulmonary and aortic valves.
  • Perimembranous Ventricular Septal Defect: It occurs in the upper part of the ventricular septum.
  • Inlet Ventricular Septal Defect: It occurs adjacent to the tricuspid and mitral valves. This type of defect might be associated with atrial septal defect.
  • Muscular Ventricular Septal Defect: It is the most common type of VSD, which occurs in the lower muscular part of the interventricular septum.

Signs and symptoms:

Small defects in the septum do not show any symptoms because it closes on its own gradually during childhood. Large defects shows signs and symptoms usually after birth within few days or weeks or months.

The first sign of VSD is heart murmur, which is a whooshing sound that can be heard using a stethoscope. The other symptoms include:

  • Fatigue (tiredness)
  • Arrhythmias (abnormal heart rhythm)
  • Fast breathing or breathlessness
  • Poor feeding
  • Poor weight gain
  • Pale skin
  • Enlarged liver

Risk factors:

Ventricular septal defects mostly occur due to defective genes and chromosomes, that may be hereditary. Environmental factors during pregnancy may also play a role in development of VSD in the fetus.

Complications:

Large or medium septal defects if left untreated, may lead to life threatening complications such as:

  • Heart failure, as heart need to work harder to pump enough blood to the body.
  • Pulmonary hypertension (increased blood flow to the lungs results in increased blood pressure in the lung arteries).
  • Endocarditis (infection in the endocardium of heart).
  • Other heart problems such as abnormal heart rhythms and valve problems.

Diagnosis:

If heart murmurs are detected during the physical examination, the patient may be advised further testing to conform the diagnosis.

  • Echocardiogram: This test is the primary tool for the diagnosis of VSD, as it can be used to determine the size, location and severity of the ventricular septal defect. Sound waves are used to produce the detailed images of the heart.
  • Electrocardiogram (ECG): This test records the electrical activity of the heart and helps to identify the abnormal heart rhythms and defects in the septum.
  • Chest X-ray: X-rays are used to view the images of heart and lungs. In VSD, this test helps to determine the enlarged heart and extra fluid in the lungs.
  • Cardiac catheterization: The test involves inserting a thin, flexible tube into the blood vessel at the groin or an arm, which is guided to the heart, to identify any congenital heart defects and to determine the function of the heart chambers and its valves.
  • Pulse oximetry: Oxygen levels in the blood can be measured using a small clip which is placed on the fingertip.

Treatment:

Usually treatment is not needed for small VSDs, as they close on their own gradually after birth. Babies with larger VSD need surgery to prevent any further complications. The treatment for ventricular septal defects include:

  • Medications such as diuretics like furosemide are used to reduce the amount of fluid in the blood that is pumped to the lungs and in the circulation. Beta blockers like metoprolol, propranolol and digoxin are used to maintain the regular heartbeat.
  • Surgical procedures include surgical repair, catheter procedure and hybrid procedure.
    Surgical repair involves open heart surgery, in which the doctor uses a patch or stitches to close the hole, performed under general anaesthesia.
    In catheter procedure, a catheter is inserted into a blood vessel and then passed to the heart. The defect is closed using a specially sized mesh device.
    Hybrid procedure uses both surgical repair and catheterization procedures to close the hole, with the help of a heart-lung machine and a catheter placed through an incision.

Prevention:

Ventricular septal defects cannot be prevented, but following certain measures during pregnancy may be helpful to prevent the risk of VSD. The measures include:

  • Prenatal care before pregnancy: Consult a physician before planning for pregnancy and inform him about the family history of any congenital defects and the medications using currently, so that he may give suggestions or recommend some lifestyle modifications to avoid the risk of heart defects.
  • Healthy diet: Having a balanced diet including vitamins and folic acid during pregnancy will help in giving birth to a healthy child without any heart defects.
  • Regular exercise under the supervision of a gynecologist is necessary during pregnancy.
  • Avoid alcohol, tobacco and harmful drug use during pregnancy to prevent the risk of VSD.
  • Get vaccinated: Check whether you are vaccinated for vaccine-preventable infections before getting pregnant.
  • Control diabetes: Monitor your sugar levels regularly to prevent the risk of heart defects.

disease-condtions-device_closure_for_asd.jpg

Heart consists of four chambers, of which upper two chambers are called as atria and lower two chambers are called as ventricles. Atrial septal defect (ASD) is a type of congenital heart defect, in which there is an abnormal opening or a hole in interatrial septum (dividing wall between two atria). This opening allows the passage of pulmonary venous blood from left atrium to right atrium, causing mixing of oxygenated and deoxygenated blood in right atrium and increasing the flow of blood to lungs. The increased blood flow may increase the workload of the lungs, and eventually cause lung damage.

Causes:

The exact cause of ASD remains unclear. However, it is believed that during fetal developmental stages, a hole is present in the interatrial septum, which gradually closes before birth or during infancy. If the hole persists, it is called an atrial septal defect.

Types:

Based on the location and development of ASD, it is classified into four types:

  • Ostium secundum ASD (75%): It occurs in the middle part of the interatrial septum.
  • Ostium primum ASD (20%): It occurs in the lower part of the interatrial septum, adjacent to atrioventricular (AV) valves.
  • Sinus venosis ASD (4%): It occurs in the upper part of the interatrial septum, near the veins that drain into the right and left atrium.
  • Coronary sinus ASD (<1%): It occurs in the interatrial septum between the coronary sinus and the left atrium.

Signs and symptoms:

Usually after birth, babies who have ASD may not show any associated signs and symptoms. But, symptoms may appear during adulthood around the age of 30 years. Most of them don’t have any symptoms even after many years.

Some of the common symptoms associated with ASD are:

  • Heart murmur, a swishing sound that can be heard through a stethoscope
  • Heart palpitations
  • Arrhythmias (abnormal heart rhythms)
  • Fatigue (feeling tired mainly after exercise)
  • Shortness of breath
  • Swelling of legs, feet or abdomen
  • Stroke
  • Lung infections such as pneumonia

Risk factors:

Genetics and environmental factors usually play a role in congenital heart defects. Some conditions during pregnancy may confer high risk for heart defects, these conditions include:

  • Right-sided heart failure
  • Arrhythmias
  • Increased risk of a stroke
  • Shortened life span
  • Pulmonary hypertension (increased blood flow to the lungs results in increased blood pressure in the lung arteries)
  • Eisenmenger syndrome (pulmonary hypertension causing permanent lung damage)

Diagnosis:

Most ASDs are diagnosed incidentally during regular heath check-ups. If a heart murmur is heard during auscultation, you may be advised to undergo further tests to confirm the diagnosis of ASD:

  • Echocardiogram: It is a specific diagnostic test for ASD, and provides a detailed image of the heart and blood flow through its chambers. The echocardiogram may show the blood flow through the interatrial septum and the hole size in the septum.
  • Chest X-ray: It helps to identify enlarged heart and lung changes.
  • Electrocardiogram (ECG): It involves recording the electrical activity of the heart, to help identify arrhythmias.
  • Cardiac catheterization: A thin, flexible tube called catheter is inserted into the blood vessel at the groin or arm and is guided to the heart. This test is helpful to determine the function of heart and its valves, and to measure the blood pressure in the lungs.
  • Magnetic resonance imaging (MRI): It uses magnetic and radio waves to create three dimensional images of the heart and other organs. This test is recommended if the ASD is not clearly diagnosed with echocardiogram.
  • Computerized tomography (CT) scan: It uses a series of X-rays to create detailed images of heart; mainly used if echocardiogram doesn’t help to diagnose ASD clearly.

Treatment:

Treatment of ASD depends on the age at diagnosis and the size, location and severity of the defect. Small ASDs might not need any treatment because it closes on its own. The doctor may recommend surgery if the atrial septal defect is large, even with fewer symptoms to prevent problems later in life. Treatment of ASD includes medications and surgery.

  • Medications usually do not help in closing the hole, but reduces the signs and symptoms associated with ASD and risks of complications after surgery. Drugs such as beta blockers (to maintain regular heartbeat) and anticoagulants (to prevent the formation of blood clots) are used.
  • Surgery includes cardiac catheterization and open-heart surgery.
    In cardiac catheterization, the doctor closes the hole in the septum with a mesh patch or a plug in the defect place using a catheter. The heart tissue then grows around the mesh slowly, sealing the hole permanently. This procedure is mainly performed to repair only the secundum type of atrial septal defects. Defects not amenable to closure with device may need open-heart surgery.
    In open-heart surgery, the defect may be closed with stitches or a special patch. This procedure is done under general anesthesia, mainly for repairing primum, sinus venosus and coronary sinus atrial septal defects.

Prevention:

Atrial septal defects cannot be prevented, but following certain measures during pregnancy might be beneficial to prevent the risk of ASD, such as:

  • Immunity test for rubella: If the person is not immune to rubella, it is necessary to get vaccinated.
  • Monitoring current health conditions and medications use: Pre-existing health conditions and usage of any medications should be carefully monitored during pregnancy to prevent the risk of ASD.
  • Reviewing family medical history: If a person has a family history of congenital defects, it is advised to visit a genetic counsellor before becoming pregnant to know the risks of atrial septal defects.

 

 




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Designed & Developed by R R Deepak Kambhampati.