Interventional Cardiology 101.......Coronaries of Diabetics

 

https://youtu.be/FkT5-ZTEVoc

Normal Left Coronary Artery. 

The central big long vessel, the Left Anterior Descending artery [ LAD ] supply the main "piston" of the heart, the ''main driver or pump" of blood moving out of the heart chambers to all part of body, via the major blood vessel , the Aorta.

The LAD supplies mainly the  anterior segment of the left ventricle. The Left Circumflex branch supply the back portion of the left ventricle. This cine shows normal circulation of both arteries with rich healthy branches.

You imagine your heart as big as your fist, these arteries sit on your heart, astride on the heart, like a 'mat rempik' on his 'motor bike'.

The LAD and the L Circumflex  branch join together to form the Left Main , which got itself inserted to the root of the big vessel the Aorta, receiving highly oxygenated blood just gushing out from the pumping left ventricle. This flow into the LAD and LCirx , which then move on on into the small arterioles and vessel which ramifies into the ventricular muscle wall, to supply oxygen and energy , ATP's, required by the hard working , non stopping muscle fibres of the heart.

When your heart stop pumping , you also STOP!!!

https://youtu.be/rlnfnX91jBQ

Compare that left coronary system with this one angio I did on an obese diabetic pt of mine, who just celebrated his 40th birthday, married, with 4 young children in toe. ..in his Left Anterior Descending artery itself I can see 4 significant lesions to be ballooned and stented. 

The Left Circumflex branch has one narrowing  which need ballooning plus DEB ballooning [ drug eluting balloon ] or small stenting. The view in the extreme left appears crowded because there is late appearance of distal circulation of the right system. It should not be there. The fact it can be seen from this left shots means the Right Coronary Artery is totally occluded....

This young man has severe triple vessel disease, at an early age.

He has had maturity onset diabetes since age 30.

Currently he is in deep 'shit'...he needs revascularization...1st choice would be bypass surgery. Given his relative young age, I have great  reservation about sending a young man for bypass, but it still remain 1st choice from the viewpoint of extent and severity of the blockages in the both the left and the right coronaries.

To me the left side is easily dowable even though I may end up implanting 3 stent there, but his right total occulsion as seen from the left coronary shots poses special difficulty for us 'plumbers'.

1stly, we may not be able to the cross the occlusion with our guidewire, a necessary pre requirement before we can balloon or stent the lesion. The guidewire acts as a 'railway  sleeper and line for the balloon and stent deployment.

Nonteheless, if this young man refuse surgery , I will do him in 2 stages.

1stly the left system. If I am happy, with the result, I may not even attempt to open the right, since it is already well covered by the retrograde flow from the left.

Of course some 'purists' amongst the plumbers would insist on doing the right, whatever the cost, even though there is a high risk of wire perforation of the artery, since the occluded portion in the right appears too long for comfort.

To me the right coronary is already a 'lost cause'.

The young man has had a 'silent' heart attack in the past on the right side...something common in a diabetic...damage to that side has been done...and now he has some blood supply to the right side from the diseased left. If I correct the left, the right side will get better supply., full stop!

Bypass surgery in this young man , though the 1st option, is not even ideal. The LAD would need sequential graft with a LIMA graft, since there are multiple blockages in the LAD.

Like everything, even bypass surgery has  a 'shelf life'.

By 10 to 12 years, some graft may reblock.

Stents and ballooning also have its  problems....restenosis...though it is easily repeatable.

We are looking at shelf life and shelf life.....whatever we do!

This is not an ideal world...the world of a diabetic with coronary problem.

I approach coronaries like playing 'gin rummy'.

To me, CABG is the all important 'JOKER'.

If I can delay using my 'JOKER', I will delay playing it, and by time 1st with balloons and stents.

'Gedebuk gedebak gedebuk gedebak' young diabetic with coronaries problem give special headache to both us 'plumbers as well as to surgeons!

Diabetes with obesity are causing major problem in the young people this millennium further compounded by a relative lifestyle of physical inactivity.

There will be an epidemic of diabetes amongst the younger generation now since the IT, the handphones, and the video games have produce a whole generation of obese, 'couch potatoes' amongst our children.

My Dear Maryam & Sarah

 

[      https://www.youtube.com/watch?v=06TMMKjCfD0   ]

my dear maryam & sarah,

both you young punks 'floored' atok last week when you guys asked atok about 'the arash'.

frankly, atok dont know exactly, where 'the arash' is as, its immensity is beyond atok's imagination.

but what atok know is that atok must pay your  school  at sungai buluh a visit, and congratulate both your class teachers......

for giving both atok's cucus great education and aqidah grouding,  at these tender age of 5 and 7 respectively. the founders and patrons of the school , syabass to them all!!

during atok's time at 7, atok's teacher was just teaching atok, " this is a man, and this is a pen. a man and

 a pen ", from the the then famous book from longman of uk.

this earth to both of you , and to even atok,is huge.....super, super  huge.

just to fly from KL to London will take minimum 14 hours and that is only around 8,000 kilometres 

away!

but in the whole scheme of things,this planet earth is nothing.......it is very very tiny, just like a 

speck of dust, compared to the universe. 

the size of this universe is a figure with 25 zeros kilometres  behind that number, in dimension.

...and later in the year both your ugama teachwer will teach both of you a short ayat from surah al

 baqarah, ayat 255 to be precise, that is when you finish you muqaddam, insyaaallah.

in that ayat allah talks of HIS 'foot stool', known as 'the kursi'.

beyond the 'kursi' is the 'arash'

adults as old as atok, [and to you guys atok must be very very old, as you already consider both 

your parents already ancient ], had from time immemorial being arguing to no end about the

 nature of the 'kursi' and

 the 'arash', so if you two young guys cannot comprehend, it is nothing to worry about.

the 1st group of people  take the meaning of 'kursi' and 'arash', point blank, as what are

 mentioned in the quran.

the other group name called this group as the 'literalists'. another name given to them is '

 neosalafist '.

when the other group are  awee bit angrier and a wee bit impatient with thye 1st group because 

oftentimes the 1st group can behave like 'arseholes' and 'pain in the neck', the 2nd group called 

them 'wahabis'.

not a nice name to give,  a deragotory term, but that is the real world out there and even older

 people can got hot in between

 their collars!

the 2nd group, who like to call themselves, 'ahlil sunnah wal jamaah' think 'kursi' and 'arash',

 the understanding are much much beyond them, and that reflect the super immensity of allah's 

being and attributes.

a famous thinker and poet from amongst them known as rumi, 10 centuries ago, term it as 

'the place of the placeless, and a time of the timeless'.

more imaginative from amongst them put it in a more understanding way,[ as described in the utube ]

"imagine the universe as a ring, lost in the sahara desert...that sahara desert is the kursi.

now imagine the kursi as a ring. throw it in the sahara desert....that is the arash!! "

.....but they are quick to point out that this expression is only allegorical and figurative.

..........even at that  time and even with that expression,they feared to be termed

 'anthropomorphic' by later day people.

dont ask atok what 'anthropomorphic' means.

go ask your dad!

atok......

ps: " atok love you guys immensely!! "

...off pirates, highway men, glc chairmen and al qawiy yun amin....

" One of the two women said: O my father! Hire him! For the best (man) that thou canst hire is the strong, the trustworthy." (al qasas,26) 

.....al qawiy yun amin...


Mosses after flooring and accidentally killing the coptic man [ belonging to the same tribe as pharaoh, ' the qifti' tribe ] while trying to settle between the man and an israeli man , escaped to the hills beyond pharaoh's reach. Pharoah's men searched every nook and corner of Egypt for him.

Homicide was a  crime punishable with long imprisonment in old Egypt.
Am Israeli killing a Qifti was high treason....a most heinous crime, unthinkable and must be an example off !!

There amongst the hills,he met two ladies, both daughters of nabi Shuaib, tending to their flock of sheep., queing at the waterhole. Nabi Shuiab, impressed by his daughters encounter with that strange young man , send his people to search high and low for Mosses.

Al qawiy yun amin, in any culture, transending time, are two qualities not just ideal for any employee, in those mearge difficult hills bordering Egypt, were hard to come by in such tough environment, that nabi Shuiab considered ideal as a potential son in law. Age was catching up very fast with the elderly frail gentleman.

Shuaib's men finally met Mosses in some 'warong' somewhere, and as they say , the rest is biblical history!







"  And the king said: Bring him unto me that I may attach him to my person. And when he had talked with him he said: Lo! thou art to-day in our presence established and trusted. (54) He said: Set me over the storehouses of the land. Lo! I am a skilled custodian." ( surah yusuf :55 ) 

.. al hafiz un alim...

Yusuf  not only was not only able to interpret dreams, he was , apart from being 'al qawiy yun amin '   , also possessed two additional prequalications:..al hafiz un alim..
He had all the skills, knowledge and wisdom to navigate very difficult circumstances.
He openly offered himself to the al aziz of that  time to circumvent the seven year long expected super tough time for Egypt. This period predates Mossess time and Egypt in that era was still runned by al aziz, who were all god fearing, and had not reached the arrogance and the intransigence of the pharoah yet.

al aziz readily accepted Yusuf's offer, and as history had it, Yusuf became the chancellor of the ex chequer, and despite seven long lean years, Yusuf's  wisdom, strategy and skill ful statecraft, ensured old Egypt had a soft landing at the end of the very trying time.

Fast forward ourselves to this current millenium, and zoming in on the current year 2020, in this very trying era of COVID 19 and potentially global collapse of economies, large and small, one cant help but be touched by a sense of panic, however supreme optimist one tries to be!

In the centre of the storm we have POTUS whose only claim to fame, if one has the benefit of history to look back to in the decades and years to come, is that just ' baik sikit pada' Lord Sutch of the Monster Roving Loony Party of the UK of the roaring 80's.
I say if we are lucky because if this chap got re elected in the coming election, we may even see a third world war. A military  accident in the now crowded South China Sea, or if China  become successful in dislodging the US dollars as the central currency in the global oil market may send this mad lunatic in Washinton to war.

I do not think this chap can comprehend the gravity of MAD [ mutually assured distraction].
He has neither the al amin, nor al hafiz or al alim.
As to al qawiy, just may be he has, with the likes of Stormy Daniels ' dan ladies ladies  yang sewaktu dengan nya '.

Coming back home, I am also very worried.
Our current political numero uno, to be ' very very polite and generous ', and I am going to be at my most polite best this early morning, he may have the al amin, the al hafiz and the al alim bits; but regretably, he don't have an iota of the al qawiy. His ailment is very serious.
Of course Dr Jemilah, who was my student 4 deades ago would vehemently disagree with me.
In this a free country, she is free to do that.
If I am his scientific adviser I would not even asked him to even think of his current post.

Across the other side of the equation, we have a very  untiring old man who has gone well passed his expiry date, and at present quite toothless and has lost most of his 'marbles'. 
Along side him is a chap who thought he has to be pm even long time ago when he was in sixth form and whom , the untiring old man thought is not ' morally fit ' to be one!

Across the board, back to the numero uno's side we have highway men and ex pirates heading the glc's
Go down a wee bit further we have the lembu people, the tabung haji peole , the wilayah and etc  and etc all wishing the pirates and the ustaz will have pru 15 soon and their cases exonerated and declared or decreed ' all clean' by a future fumbling AG

And finally way back behind the scene, ' tanpa malu dan segan ', we still have bossku still weaving his wizardry playing the ' wayang kulit '...

What ails our nation?
Sampai begini rupa kita tak ada rasa malu dan segan ' stabuk' , to add my favourite teganu   expression, [ i am kelantanese but i love teganu kite ], kat Allah dan makluk2 Beliau seantero dunia !!!!!!

So much for al amin, al qawiy, al hafiz and al alim this morning.......



Dr Nik Isahak Wan Abdullah
Subang Jaya

Dear Ru and Joe......'' On lailatul Qadr "

Dear Ru & Joe,

Papa am excited this evening when you guys told me ,you two, are  interested in the 'Lailatul Qadr '. That is the true spirit my sons!

We are now in the last 10 days of the Ramadan....The Lailatul Qadr phase, better than 
' seribu bulan '.
This not a metaphor. It is real. 
Only in this part of the Nusantara, we collectively take as 'figurative'.

In the middle eastern diaspora, the advisories both in the uqran and hadith, are taken very seriously. If you happened to be in 'the Haram' on the 27th of Ramadan, there is not an inche of wastered  space within 1 km radius of Baitullah, even 2 hours before magrib.!!!!


I am afraid the Lailatul Qadr phase is all about waking up in the wee hours of morning and doing your tahajud prayers mainly and taddabur quran, ideally  from 12 midnight onwards right up to sahur.

Papa termed it as a 'lottery' for the Muslims but one of papa's friends took exception to that expression, but I am not interested to get into arguments involving ' pedantics with him. He is an al mu"tazilah moderen , so , let him be lost in his discourses and pedantics! 
You and me , we don't have time for that.

The best way of course is to do the Rasullallah's way, [ pbuh]. His night prayer was only 11 rakaats , according to a well known hadith as narrated by Saiditina Aiishah.
But what a prayer it is !!

After fatihah, our nabi  read surah al Baqarah, followed by Ali Imran, and An Nisa; then the second rakaat , following the al fatihah, he read surah al Maidah and so on and on.
By the time nabi [pbuh] finnish his Qiam, which is only 8 at the most, before his witr's 11, he must have finish the whole quran, allahualam.

You and me,  we are 1000 times very much lesser mortals.
We cannot even string out the 1st 10 surah of the muqadam ayat by heart, let alone by heart surah Abasa.

What is the solution then?
You guys can follow one of the many recommended by renowned tok gurus , like Ustaz Kamus, Dr Haerun Din, etc and etc

Papa have my own personal way , dictated by the time available from the time I take the ablution to sahur time.
Now that this the last 10 days, I try to wake before 1.00 am which give me a a good 4 hours
before your mom start calling for sahur.

Given papa's relative  'illiteracy in the quran', my main zikr  and doa actually is in making use of allah's most beautiful names!

So those enumerated here are  really a personal ' choices ', tailored to papa's current need , sensitivity and limitations of ilm.

.............

1. 1st cycle of tahajud prayer followed by astagfirullah , say 100 times, then

Ya Latif   129 times [ dont argue with  the number, you ca do 100, 200 or 1000. 129 respond to the cumulative addition of the numbered numerals that make ya Latif...Khiai Muhammad Bhakiet's recent discourse is referred ]

Ya Salam, 136 time...[ again the number is arbitrary...]

Ya Fattah, Ya Razak, Ya Wahab, Ya Ghoniy, Ya Mughni.....say 100 times, again the numbers are arbitrary , dictated by time.

Ya Zaljala Liwal Ikram

Ya Qadim, Ya Daim, Ya Ahad , Ya Wahid , Ya  Somad ....say minimum 100, again arbitrary.

Ya Rahman, Ya Rahim..... [ 100x ]

Subha na llah al Malikul Quddus,  [ 100x ]

La ila hailla Anta, ya Hayyu  Ya Qayyum [ Shaykh hamza Yusuf's favourite litany, which papa picked up. he must have picked it up from his Mauritanian desert sojourn under a famous murabit there!]



Ya Muhyi... 68 times [ refers to Khiai Muhammad Bhakiet who I think took from his tok guru and tok guru, and tok guru... finally from Imam Al Ghazali ]

Allah, Allah, Allah.......if you have the stamina, 1000 time [ synchronised with your breath....but we will talk about this some other time  ]

.............


2nd cycle of tahajjud prayer, followed by

..al Fatihah, 41 times [ great for doa purposes....doa whatyever doa after the rcitation , if you like ]

..Doa nabi Yunus, " la ila hailla anta  subha nakainni kuntuminaz zolimin .''...45 times

...'' Subha nallah wabi handihih subha nallah hil Azim, astagfirullah '', 100 times


..'' .La ila haillallah huwah dahu la sari kalah lahul mulku walahul handu yuhyi wayumit wahuwa ala kulli shai in Qadir '', say a 100 time , minimum, more if you have the time


3rd cycle of tahajjud prayer, followed by


......al Fatihah 7 x, An Nas 7x. al Falak 7x, Kul Huwallah 7x, Kul Ya 7x, Ayatul Kursi 7x and 
finally the last 3 ayat of al Baqarah 7x

[ papa's replacement of actually reading the big surah from the quran, since papa still ' merangkak' with the quran like  a new mualaf ]


........our ubiquitous surah Yasin

.....'' Hasbunallah wani' mal Wakeel '' , 450 times

...Your favourite short selawat to the nabi, 100, 500, 1000 time...the more the better.



4th cycle of tahajjud, followed by 


.......la ila haillallah  hal malikul haqkul mubin....100x

....kalimah toyyibah, '' La ila haillallah '' , 1000 times



.....end your tahajjud prayer phase with this very potent wirid cum doa, as related by ibnu abbas in termidzi and ibnu majah, also one of papa's favourite short wirid cum doa, a panacea of all ills and doa.
papa like the cadence of the wirid and also it contain at least four to five of allah's most beautiful names:

la ila haillallah hul azhi mul halim
la ila haill llallah u rabbul arsil azim
la ila haillallah rabbus samaa waa tiwal ardhi rabbul arsil karim



If time permits, papa do 4 rakaat of solat hajat, over 2 salam...
[ handed down by the late allahyarham Ustaz Dato Ismail Kamus...!st rakaat, after fatihah, followed by 10 kulhuwallah; 2nd rakaat, 20 kulhuawallah, then salam. In the 2nd set , 30 kulhuwallah and in the last rakaat, 40 kulhuwallah.
On completion of the 4 rakaat, another 50 kulhuwallah.....then followed by a short , doa with respect to what is your hajat. YEs, I know, papa's 'wahbis friends will have a field day here, but I have a four full hours to 'fill' before the sahur!! ]



BY now it would have been around 430 am, you still have 20  minutes to do 4 rakaat of Solatul Tasbeeh, washed down with 10 minute or of Solat Taubat , 2 rakkaat.


Just say 
Taubat again 

...May be repeat  Doa Nabi Yunus,

...and read one short ayat from surah al Ghafir, ayat 42...'' wa ufawwithu amri illallah innallah ha ...Basirun bil ibad '',  many times as a form of zikr...[  I leave all my affairs with Allah, HE is all seer of his servants ]


........'' allahuma inna ka affuwon tu hibbul afwa wa' fu anni  ''

...Wash off with the usual 'Rabbana atina........."..

[ sons, in Lailatul Qadr, try to avoid asking too many worldly wants, imaging you guys are whispering sweet nothings to your LOVER,  THe BELOVED,.....we just want to close to HIM...nothing else matters! ]


[ It would be  5 am now , and your mom will be calling for you to have sahur..]


My advice to you guys.
At this juncture don't ever get closeted by anyone tok guru.
Go for safety in numbers!

So many of them plying the tubes nowadays, especially the younger ones who are IT savvy.
They may not be the best tok gurus  to start beefing up your ugama knowledge.

They may end you up wearing 'blinkers' throughout you earthly life and be a ' kera sumbang ' in this already peaceful society. 
You can see many of these 
kera sumbang' in the masjids nowadays, percolating to one corner, looking at their hand phones, while the rest do their collective doa and wirid, following the imams!

Have an open mind and learn from as many tok gurus as you can. 
Collect your ' big data' first. 

WHEN YOU REACH MY AGE, IF YOU Still DECIDE  to be the  closeted  safety of the Wahabis , go ahead.

Or you think the rest of the people are not thinking people, you can decide to take the ' arrogant route ' and join as the  al MU'tazilah Moderen, go ahead, but mind you , you are on a slippery slope from here on!

At the end of the day I want you guys to have the right ' equipments ' to be able to appreciate the exquisite joys  and pains of Rumi,  the steadfastness of ibn Arabi, and be able to comprehend the ' inner demons  and crises ' of Al Ghazali,;....at the same time be able to accept and chuckle and enjoy ' kampong ulama ' like Azhar idrus and Ustaz Abdul Somad et al; and can also tolerate  narrow minded guys like Maza or Rasul Dahri and comprehend their utter confusion of their ugama.

You are on safe ground after your life  long of ' big data collection ',  insyaallah

Ramadan , I want you 2 guys to think off , as a great open university!
The Lailatul Qadr phase, is a ' test', also a test of your tenacity of purpose.

Insyaallah, the lessons learnt, could percolate down into you lives, to revived in the next Ramadan, as we slowly, slowly , creep into our varying phase of ghaflah [ heedlessness ] as as is common of us , the Homo Sapiens!


Happy hunting, sons!!
Post ramadan, continue your tahajjud, albeit with shorter wirid, and zikr.
If Allah opens up your 'hearts', HE will make your get addicted to this routine.
If that happens, don't forget to tell papa about it!
😉😉😉

This is not the end of the lailatul qadr story.

It is supposed to be tranformational :

Be a God  fearing person!

If you are the boss, a Godfearing boss!

If you are destined to be a 'gurkha' for life, a Godfearing 'gurkha', etc etc and etc....



Papa

Harta Kita Yang Sebenarnya | KH Muhammad Bakhiet