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Coronary Physiology and Imaging

Strain Imaging in Planning for Multi Vessel PCI
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Dr. Rakesh Gupta

Director & Chief Cardiologist

JROP Institute of Echocardiography, Delhi



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Dr. Rakesh Gupta

This is about a history of about 01/09/16.


A 55-year old female presented with hypertension and hypothyroidism on irregular medications who presented to causality with headache, palpitations and vertigo. Blood pressure is pretty high. She was in CHF obviously Lasix and other medical therapy was given.


Look at the ECG ordered here. She was suffering from anterior wall MI and at this point, she was given a thrombolysis because choice of doing a PTCA was not available and soon after that, you look at the ECG which was done subsequently for this young lady where the ST segments were elevated before thrombolysis and after thrombolysis that was an exception.


Well, one hour down the line, she had significant settlement of ST segment anterior changes and subsequently next day morning, she was subjected to a coronary angiogram


Well, I am not an expert international cardiologist. I do only 10 to 15% percent of my practice for angiogram and 99% of practice for noncoronary angiogram. This is a right view and let us look at the other two vessels. At inches if you happen to say that this lady is suffering from a triple-vessel disease.


Do you agree with this? And as usual majority of these patients are subjected for or sent for CABG and this is what was done for this lady. She was discharged on medicine, when statin, aspirin, clopidogrel beta-blocker or whatever you have in your environment along with antibiotics, we will send them home. Look either you get a CABG done or multivessel PTCA done or else you go. That is why exactly she was not willing for a CABG. Here she presented to us at this time and this was the ECG for this lady when she came to us for evaluation. Practically, everything has settled down except for QS complexes in lead 2 and 3. Now look at the echo in one go, 4-chamber, 2-chamber, and a 3-chamber echocardiography of this lady. Almost a normal ejection fraction, very good contracting LV, and even LV function was reasonably normal for this lady.


And if we happen to look at para symbolics view, LV function was reasonably normal. So my question again to the audience is what do we do now? Should we continue the medical therapy, should we go for a CABG or should we do anything else?. And we look for a 2D scan for this young lady and if we happen to look at 2D scan of this young lady was almost more than 19.9% and that was again a normal. Well, we went on to do a stress echocardiography to evaluate this patient before and after stress and that was what the image is before stress and after stress


Subsequently, can you play that again. This is what exactly happens when you give a steering and gear to somebody else to drive a car. 2-chamber before and afterwards. Now 3-chamber view saying that any opinion what is left now. She had the borderline wall thickening abnormalities in basal inferior and basal septums. We went on to look at 2D scan for this lady and if you happen to look at the 2D scan of this lady, it was reduced now from 19.9 to 16.5 with significant deformation appear in basal septum, basal inferior and to some extent basal posterior. And here is a post stress echo with the color Doppler showing significant mitral regurgitation for this young lady. This is the polar map before and this is the polar map afterwards stating that possibly right coronary artery is the most culprit artery even right now. Well, that is what we pursued, we have been doing this study for the last, almost a year. We recruited almost time period was in December 2014 to January 2016, 59 selected cases who were enrolled in this study during this period. They agreed to be the part of the study. All of them were chronic stable angina. However they started experiencing angina lately despite optimal medical therapy. All the cases were for -CABG as per the CAG status. They underwent stress echocardiography with 2D strain. Polar map was studied in all cases, 26 cases opted for selective angioplasty, after informed consent, to the culprit vessel as assessed by 2D strain in early recovery period after stress. That was the demographic profile male and female distributions and first 12 cases were very difficult to handle with because they had only the options like suppose it does not happen, suppose the culprit vessel does not optimize revascularization, if symptomatology persists, what will happen and that was what exactly we did. We had 12 cases during the first six-month period of December 2014 through June 2015 and now the followup of these 12 cases are available as on today. 11 have showed no significant post angioplasty stress-induced angina. However, still on medical therapy because we have not completed, we did a partial. One case still complains of ongoing angina despite optimal medical therapy and he had to be subjected to CABG There was no need of medicolegal problems because he was given already a consent that we are doing a partial investigations. Out of these 14 cases, angioplasty to culprit vessel was done in July 2015 to December 2016. Their followup is still awaited.


In conclusion stating that this is one modality which is pretty useful which we follow that is still ongoing trial, people who have a triple-vessel disease refusing to undergo CABG. We can help them identify the culprit vessel. Like my previous question and my answer to my previous question was what and how do you decide about all this. And this is not a difficult thing and that is what we have been doing in Delhi. I am sure like, I would like to invite you to be the part of this multicenter trial


Here is my number. If you want you can send your patients to us. They will get back to you. I am not an interventional cardiologist at all. So the patient would be yours, but it will be a good work to come out from a serious side or a good study which could be from own country, and that is all. I wanted to say thank you very much for your patience.



  • Heart Attack
  • MI
  • ECG
  • Hypertension
  • Bypass Surgery
  • Stent

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