Video

voice very similar to that of shahrukh khan ❤❤❤❤❤

Looks no significant LVH

Машаллах ❤

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Can you show me the Doppler ?

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Super cardio.....❤️❤️

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Perfect

This is amazing

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Perfectly explained

Best to learn

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Perfect sir

Great sir

Perfect Sir

Perfect 👍👍

Perfect 👍👍

I think it is risky to inject inside LV with thrombus!!!!!

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A must during CPR of pregnant woman

Thank you Dr Shaib for educating masses and breaking myth that blood pressure patients must obstain from rice.

Cute

Jack in rain 😂😂

🎉🎉🎉

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Great 👌

Poliomyelitis

CABG

Helpful Dr Sahab

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nominalgretnominay

CAD Risk-Factor Modification All patients should be instructed about risk-factor modification and medical therapies for secondary atherosclerosis prevention before leaving the hospital. The interventional cardiologist should emphasize these measures directly to the patient and family. Failure to do so suggests that secondary prevention therapies are not important. The interventional cardiologist should contact the primary care physician regarding secondary prevention therapies initiated and those to be maintained, including aspirin therapy, hypertensive control, diabetic management, aggressive control of serum lipids to a target low-density lipoprotein goal of less than 100mg/dL following AHA guidelines, abstinence from tobacco use, weight control, regular exercise, and ACE inhibitor therapy as recommended in the AHA/ACC consensus statement on secondary prevention. Follow-up Schedule and Stress Testing • Access site is checked on the first office visit,2 to 4 weeks following PCI. • Stress testing is neither routinely nor annually performed after PCI, unless symptoms appear. • If symptoms or signs of ischemia are present early after PCI,coronary angiography is repeated. There is no indication for annual exercise testing in asymptomatic patients. AHA and ACC practice guidelines recommend selective evaluation in patients considered to be at particularly high risk (e.g., patients with decreased LV function, multivessel coronary artery disease, proximal left anterior descending disease, previous sudden death, diabetes mellitus, hazardous occupations, and suboptimal PCI results). For many reasons, stress imaging is preferred to evaluate symptomatic patients after PCI. If the patient's exertional capacity is significantly limited, coronary angiography may be more expeditious to evaluate symptoms of typical angina. Exercise testing after discharge is helpful for activity counseling and/or exercise training as part of cardiac rehabilitation. Neither exercise testing nor radionuclide imaging is indicated for the routine, periodic monitoring of asymptomatic patients after PCI without specific indications. Medical Therapy After PCI Anticoagulant Drugs Anticoagulant drugs (heparin, enoxaparin) are needed only for the brief intraprocedural period. Unless indicated by unusual circumstances (e.g., continued intracoronary thrombus formation), only bolus heparin without later IV infusions is used. In some labs, low-molecular-weight heparin (enoxaparin) is replacing bolus unfractionated heparin for PCI. Warfarin is not used for PCI but may be needed for other reasons such as atrial fibrillation or severe LV dysfunction. Orally administered anticoagulants (warfarin) after PCI are no more effective than aspirin for preventing restenosis or abrupt closure. Antiplatelet Agents Platelet deposition is partially inhibited by selected antiplatelet regimens (aspirin and clopidogrel, ticlopidine, or prasugrel). Acute re-occlusion is more frequent in patients who have not received aspirin before angioplasty. Late stent thrombosis is also more frequent in patients not receiving clopidogrel. Antiplatelet agents of the thienopyridine family (clopidogrel, ticlopidine, prasugrel) inhibit platelets by blocking adenosine diphosphate (ADP)-stimulated aggregation and are highly effective for preventing subacute thrombotic occlusion after stenting. A rare associated side effect of ticlopidine, and less so of clopidogrel, is thrombotic thrombocytopenic purpra. Clopidogrel is the currently preferred oral antiplatelet drug. Recommended antiplatelet regimens include aspirin (80 to 365mg/day) and clopidogrel (75mg orally daily). Prasugrel is a third-generation oral thienopyridine which irreversibly antagonizes the platelet A5diphosphate P2Y twelve receptor. It can replace Plavix in patients who are nonresponders or who have demonstrated stent thrombosis on therapy. It is not recommended for patients who weigh less than 60 kg, who have had a cerebrovascular accident, or who have any propensity for bleeding. Loading dose is 60mg Per oral and daily dose is 10mg orally. Given in the intensive care unit or catheterization laboratory only, the intravenous glycoprotein-receptor-blocking platelet drugs, abciximab, tirofiban, and eptifibatide, block the final common pathway of platelet activation of the platelet receptor (called glycoprotein 2b/3a) and are highly effective in blocking platelet adhesion to vessel wall and aggregation or clumping together). Reduced acute and subacute adverse event rates are reported for all three drugs. All high-risk interventions should consider using abciximab with heparin.

Pre-PCI Workup Noninvasive testing for ischemia provides the objective basis from which to proceed with PCI in stable patients. Several types of stress tests are available. The most common are (1) exercise stress with or without perfusion imaging or echo left ventricular (LV) wall motion as indicated; (2) pharmacologic stress study (e.g., dipyridamole); and (3) two-dimensional echo cardiogram (as indicated for assessment of LV function or valvular heart disease). In the absence of objective evidence of ischemia, invasive assess- ment of the ischemic potential of a stenosis can be obtained during coronary angiography measuring translesional physiology for pressure- derived fractional flow reserve (FFR) determination. Pre-PCI Preparation-Holding Area • Patient preparation (intravenous access,meds,consent) • Patient and family teaching (procedure,results,complications) • Cardiothoracic surgeon consultation, particularly for high-risk, multi- vessel disease, or decreased LV function • Appropriate laboratory data (type and cross-match, complete blood cell and platelet counts, prothrombin time [PT], partial thromboplas- tin time [PTT], electrolytes, blood urea nitrogen [BUN], creatinine) Patient Preparation in Catheterization Suite • Electrocardiogram ([ECG]; inferior and anterior wall leads): 12-lead (radiolucent) ECG. • One or two IV lines. • Skin-prepare both inguinal areas or wrist for radial artery (venous access for temporary pacing no longer routine; consider for high-risk patient, acute myocardial infarction, left bundle branch block requir- ing RCA PCI; Rotablator or thrombus aspiration device). • Aspirin (325mg PO);failure to administer aspirin before PCI is associ- ated with a two to three times higher acute complication rate. • Plavix (600mg PO,best 24 hours beforehand);best outcomes are asso- ciated with Plavix preloading. • Continue patient's routine antihypertensive medications. • Heparin 40 to 70 U/kg bolus (or 40 U/kg bolus if GPIIb/IIIa blocker used). Target activated clotting time (ACT) more than 200 seconds. Heparin is critical for PCI, despite controversies regarding dosing and unpredictable therapeutic responses. Higher levels of antico- agulation are roughly correlated with fewer complications during coronary angioplasty, albeit at the expense of increased bleeding complications at higher heparin doses. Weight-adjusted heparin pro- vides a clinically superior anticoagulation method over fixed heparin dosing. • Consider glycoprotein IIb/IIIa blockers. • Premedication (e.g.,fentanyl [25-50mg IV] andVersed [1-2mg IV]).

the issue of Ruptured or Tethered Balloon Loss of inflation pressure during expansion of the stent can indicate balloon perforation. A ruptured balloon must be exchanged for a new one. If balloon rupture occurs after the ends of the stent are flared and anchored in the artery wall, the balloon can be deflated, rotated two or three times inside the stent, and gently pulled back inside the sheath and removed. A new balloon catheter is introduced through the sheath and positioned inside the partially expanded stent. Inflation of the new balloon catheter then completes the expansion and deployment of the stent. Alternatively, a rapid high-pressure inflation can deploy the partially opened balloon/stent enough to fully expand the stent and withdraw the balloon. A tethered balloon may be caught on the edge of the stent. The ends of the stent may not have been expanded and anchored securely in the arterial wall. The balloon should be deflated, advanced slightly to the stent edge, rotated, and gently withdrawn.

1. Loss of guidewire access to a stent may result in a complica- tion, especially if the stent has been inadequately expanded or when new lesions have been produced distal or proximal to the implanted stent. Recrossing a recently deployed stent is facili- tated by using a soft guidewire with an exaggerated tip loop to prolapse through the stent. Care should always be taken so that the wire does not enter under a stent strut between the strut and the arterial wall. Once the guidewire has crossed the stent, a sec- ond problem may be encountered of inability to advance a bal- loon for high-pressure post-stent deployment. 2. Recrossing stents with balloons may be difficult when the proximal border of the stent is on a tortuous vessel segment, forcing the tip of the dilatation balloon into the vessel wall where it is blocked by the stent struts. Several approaches can be used to overcome this problem. The guide catheter can be repositioned in a more coaxial manner. A stiffer guidewire can be advanced to reshape the curve of the artery. The bal- loon can be withdrawn slightly, rotated, and readvanced dur- ing inspiration or coughing (the balloon's profile should be as low as possible). Several operators have recommended put- ting a curve onto a stiff part of the guidewire and using it to advance across a tortuous segment proximal to a stent and placing a curve on the balloon by forming it with the finger and using a technique similar to that of putting a gentle curve on a guidewire.

Expansion Failure or “Persistent” Stent Narrowing The inability to fully expand the stent or have an appearance of narrow- ing after implantation may be due to: 1. Tissue prolapse through cell sites 2. Calcification or rigid vessels 3. Dissection at stent margins 4. Unsuspected thrombus formation within or adjacent to the stent, which may appear as narrowings related to stent implantation During the balloon inflation phase of stent implantation, full expan- sion of the balloon should always be observed. If an indentation per- sists, higher balloon inflation pressures or a larger, short balloon should be used. Failure of full stent expansion is usually the result of an inade- quate predilatation approach. In cases where stent deployment appears suboptimal, IVUS imaging will confirm the mechanism of persistent nar- rowing due to tissue prolapse, incomplete apposition, heavy calcifica- tion, or, in some cases, thrombus.

Technical Manipulations When a Stent Fails to Advance General • Best technical manipulation: Secure a more stable guide position or, if possible, the guide can be deep-seated safely. A potential late complication is ostial stenosis due to endothelial trauma. • Constant forward pressure is exerted on the stent catheter while pulling the wire back to decrease friction inside the stent catheter lumen and to straighten the stent catheter. • Additional proximal segment dilation or plaque removal facilitates stent advancement. Wire Manipulations • Advance a second stiffer wire to straighten the artery (the buddy wire technique). This stiff wire can cause wire bias. • Advance the stent on the second stiffer buddy wire. Occasionally stents may advance more easily over a softer wire. • Shape the wire along the curve of the artery to lessen wire bias so there is less friction or resistance at the outer curve of the vessel and the path of the wire is more coaxial with the path of the vessel. • Use a “Wiggle” wire. Stent Manipulations • If the problem is due to tortuosity of the proximal segment, change the stent to a shorter one. • Select a different type of stent with better flexibility. • Gently bend the stent to conform it along the curve of the artery. • Guide manipulations. • Change to a guide with a different curve, to achieve better backup, and more coaxial to allow less friction at the ostium. • Use a larger or smaller guide to achieve better backup. Techniques Facilitating Recrossing of a Stented Area by a Balloon or Another Stent General • Best technical manipulation: Steer the wire into a different direction, or to a different branch to lessen wire bias and increase more wire centering. • Rotate the balloon catheter while advancing it and let the catheter enter the stent by itself through its rotational energy (like torquing the Judkins right catheter). Guidewire Manipulations • Bend the wire and place the bent segment near the ostium of the stent to be crossed to position the wire more at the center of the entrance of the stented segment and to decrease wire bias. • Insert a second stiffer wire to straighten the vessel. • Change the current wire to a stiffer one. Balloon/Stent Manipulations • Use a shorter balloon or stent. • Use a more flexible balloon or stent. • Use a fixed-wire balloon to cross the stent. • Use a fixed-wire balloon to track alongside a buddy wire. • Mount a stent on a balloon with the tip partially inflated. • If only the balloon needs to enter the stented segment, inflate the balloon with 1 to 2atm so the balloon centers the wire in the lumen and facilitates the crossing of the wire and balloon.

Technical Manipulations When a Stent Fails to Advance General • Best technical manipulation: Secure a more stable guide position or, if possible, the guide can be deep-seated safely. A potential late complication is ostial stenosis due to endothelial trauma. • Constant forward pressure is exerted on the stent catheter while pulling the wire back to decrease friction inside the stent catheter lumen and to straighten the stent catheter. • Additional proximal segment dilation or plaque removal facilitates stent advancement. Wire Manipulations • Advance a second stiffer wire to straighten the artery (the buddy wire technique). This stiff wire can cause wire bias. • Advance the stent on the second stiffer buddy wire. Occasionally stents may advance more easily over a softer wire. • Shape the wire along the curve of the artery to lessen wire bias so there is less friction or resistance at the outer curve of the vessel and the path of the wire is more coaxial with the path of the vessel. • Use a “Wiggle” wire. Stent Manipulations • If the problem is due to tortuosity of the proximal segment, change the stent to a shorter one. • Select a different type of stent with better flexibility. • Gently bend the stent to conform it along the curve of the artery. • Guide manipulations. • Change to a guide with a different curve, to achieve better backup, and more coaxial to allow less friction at the ostium. • Use a larger or smaller guide to achieve better backup. Techniques Facilitating Recrossing of a Stented Area by a Balloon or Another Stent General • Best technical manipulation: Steer the wire into a different direction, or to a different branch to lessen wire bias and increase more wire centering. • Rotate the balloon catheter while advancing it and let the catheter enter the stent by itself through its rotational energy (like torquing the Judkins right catheter). Guidewire Manipulations • Bend the wire and place the bent segment near the ostium of the stent to be crossed to position the wire more at the center of the entrance of the stented segment and to decrease wire bias. • Insert a second stiffer wire to straighten the vessel. • Change the current wire to a stiffer one. Balloon/Stent Manipulations • Use a shorter balloon or stent. • Use a more flexible balloon or stent. • Use a fixed-wire balloon to cross the stent. • Use a fixed-wire balloon to track alongside a buddy wire. • Mount a stent on a balloon with the tip partially inflated. • If only the balloon needs to enter the stented segment, inflate the balloon with 1 to 2atm so the balloon centers the wire in the lumen and facilitates the crossing of the wire and balloon.

Definitions of PCI Success Percutaneous coronary intervention (PCI) success may be defined by angiographic, procedural, and clinical criteria. Angiographic Success • Angiographic success in a stented artery is a minimum stenosis diameter reduction to <20%. Procedural Success • A successful PCI should achieve angiographic success without in-hospital major clinical complications (e.g., death, myocardial infarction [MI], emer- gency coronary artery bypass surgery) during hospitalization. MI is often defined as the development of Q waves in addition to elevation of troponins three times the upper limit of the laboratory's normal value. Cardiac troponin T and I as measurements of myocardial necrosis are more sensitive and specific than CK-MB. Enzyme elevation in the absence of new Q waves is counted as MI, peri-procedural. There is no consensus on what level of troponin alone is clinically important enough to change major management following the interventional procedure. Clinical Success • A clinically successful PCI is an anatomical and procedural success with relief of signs and/or symptoms of myocardial ischemia after recovery from the procedure. The long-term clinical success requires that the patient have persistent relief of signs and symptoms of myocardial ischemia for more than 6months. Restenosis is the principal cause of lack of long-term clinical success when short-term clinical success has been achieved. After the balloon expands the stenotic area, the balloon catheter is exchanged for a stent-carrying balloon catheter. The stent is a metal scaffold, mounted in a compressed form on another balloon catheter, and delivered in the same manner as the first balloon catheter was deliv- ered. The stent is deployed by inflation of the balloon as was performed for dilating the stenosis. The stent should be carefully positioned. It is inflated with the same pressure gauge syringe (8-16atm pressure) for 10 to 20 seconds. A full opening of the stent with complete strut apposi- tion to the vessel wall is important for good short- and long-term results. After the stent struts have been expanded and implanted into the artery wall, the balloon is deflated, and the delivery catheter and guide- wire are removed. Intravascular ultrasound (IVUS) imaging is often used to confirm appropriate vessel-stent matching and full stent strut apposition (contact without space against the wall). After IVUS and final angiography have been performed, the guide catheter is removed. The femoral or radial arterial sheath is removed, and hemostasis is obtained in the laboratory. The patient is then transferred to a recovery area and then to the patient's room. If no complications occur, the patient is discharged the next morn- ing. The patient usually returns to work shortly (<2days) .

Dissection at the Stent Margin. Stent dilations sometimes cause a plaque fracture or dissection at the edge of the stent and vessel, which requires additional stents to stabilize the newly produced dissection (Fig. 1-14). Plaque fracture may result from misplacement of the bal- loon post dilation, especially if the balloon is clearly oversized relative to the angiographic vessel size. Plaque fracture can also occur even when the balloon is positioned within the stented segment, especiallyin calcific lesions or vessels. In more elastic or soft lesions, this is less likely to occur, but it can be seen at the stent margins when the stents are deployed on bend lesions. Plaque Prolapse. Plaque prolapse through stent struts may occur in 5% of coil-type stent implantation. Although the coiled stents have advantages in flexibility, the stent structure provides less complete radial support to the vessel wall. Further dilation does not improve the stent lumen CSA. An additional stent within the primary stent is necessary

Incomplete Stent Expansion. Adequate stent expansion is depen- dent on the plaque burden. Optimal stent expansion in lesions with 50% to 70% diameter stenosis or lesions with a spiral dissection can be easily accomplished because there is not much atheroma. In lesions with more than 90% diameter stenosis, optimal stenting is more dif- ficult to achieve and is associated with a higher percentage of asym- metrical stent expansion. Incomplete stent expansion (i.e., when the stent struts do not contact the intimal surface) can occur, particularly in ectatic vessels (at poststenotic dilation or aneurysm sites) and in the ostial left anterior descending artery (LAD), where the operator is cau- tious about performing a high-pressure balloon inflation in the left main trunk (Fig. 1-13). In the latter case, dilation of the ostial lesion with only the shoulder of the balloon does not provide sufficient expansion force to implant the stent fully.

Asymmetrical Stent Expansion. Stent expansion should be symmet- rical in soft plaques. Very hard plaques (fibrotic or calcified), seen in approximately 20% to 30% of lesions, are not easily compressed by the balloon/stent, resulting in asymmetrical stent expansion into the nor- mal arc of the vessel. In lesions with a significant arc (= 270 degrees) of dense or hard fibrocalcific disease, asymmetrical stent expansion occurs with a minimum to maximum lumen diameter ratio (symmetry index) of less than 0.7. In such lesions, further inflation leads to focal overstretching in the less diseased arc of the vessel. The symmetry index can worsen after further dilation, especially if an oversized balloon is used (Fig. 1-12). Using a balloon that is 0.25 to 0.5mm smaller than the size of the vessel, and very high pressures (>18 ATM), may improve the symmetry index but will not necessarily increase the CSA of the lumen at the stent site. Asymmetrical overexpansion is associated with a risk of vessel rupture. The risk is highest if a larger balloon is used. If the stent lumen CSA is acceptable relative to the distal lumen CSA and the stent is well apposed, efforts to make stent symmetry perfect should be avoided

Stent Expansion Strategies There are two methods of optimizing stent expansion and improving the CSA of the stent lumen: (1) high pressure and (2) a larger diameter balloon. When an oversized balloon is used, there is an increased likeli- hood of coronary vessel rupture or dissection. Using high pressure with a balloon that is appropriately sized to the vessel allows stent expan- sion to occur within the natural confines of the vessel. To avoid com- plications, the ratio of the balloon to the angiographic reference vessel should be approximately 1.0. If a balloon/vessel ratio is more than 1.0, a short, noncompliant balloon with medium pressure (12-16atm) is pref- erable. When a balloon larger than the angiographic vessel diameter is used for final stent optimization, it should never be larger than the dis- tal IVUS minimum vessel diameter (measured media to media). When there is a large differential between the size of the proximal and distal vessels, as may occur in the left anterior descending artery before and after the second diagonal, careful balloon selection is important. In gen- eral, using slightly lower pressure in the distal part of the stent segment and a higher pressure for the proximal portion of the stent is all that is necessary. Care should be taken not to dilate beyond the distal edge of the stent with an oversized balloon. Occasionally, if there is significant vessel tapering, dilation with two balloons of different diameters should be considered. Noncompliant balloons are preferable to compliant balloons for final dilations for several reasons. Noncompliant balloons will expand and dilate uniformly, even in focal areas of resistant lesions, and they are more likely to maintain a uniform diameter even at high pressures. Thus noncompliant (NC)balloons allow for optimal stent expansion without overexpansion of the balloon in adjacent unstented segments, which contributes to dissection. In addition, experience with IVUS has shown that 25% of stents have improved stent expansion with an increase in pressure from 15 to 18atm or more.