Angiography Report - Advice Needed

[somey11]

Hi,

Below the details of Report of Coronary Arteriography  of my father (55 years)
Would like to know what is  the right choice based on the report.

Left Coronary Artery:

Left Main Stem:      Bifurcating Vessel with Mild irregularities.

Left Anterior Descending Artery:
     Moderate ostial disease followed by tight mid stenosis. Fair sized second diagonal branch shows tight ostial stenosis.

Left Circumflex Artery:

    Tight Proimal stenosis followed by total mid occlusion. Distal vessel fills faintly late.

Right Coronary Artery

     dominant vessel with mild generalized irregularities.

LV ANGIOGRAM:

Fair LV systolic function.
Enjection Fraction= 50%



Best Reagrds
Muhammad Usman Ashraf

[aqsabatool2011]

respacted sir!  Fair LV systoli function can it be ok without surgery?  because it is veryy painful proses.

[kenkeith]

Sometimes there are no symptoms with ischemia (lack of blood flow) with  the coronary vessels.  Especially true for older indiviuals and/or diabetics, and heart cell damage is occuring from lack of oxygenated blood (estimated to be about 26% of the heart disorder population).  Without treatment the heart will eventually fail to provide enough oxygenated blood and heart failure.  This would be the worst case scenario.

On the otherhand, your father may have good collateral vessel flow to areas normally supplied by occluded vessels.  Diagonals are normal indicating peripheral flow notwithstanding the LAD occlusions. Normal blood flow from the RCA is being fed by other vessels.

It is much easier to make a choice (intervention or meds) if medication successfully treats chest pain (angina) from ischemia...that would be a high probability the medication is effective and no need for intervention at that time.  However, there is a risk for ischemia and no symptoms so it would not be clear if the medication is effective. Did the angiogram indicate any areas short of blood supply; Your post doesn't indicate? Was father on heart medication at that time? If there are no symptoms, what was the reason for the angiogram?

Is you father taking medication to dilate coronary arteries (nitrate)?  High blood pressure successfully treated (ACE inhibitor, beta blocker)?  What is your father's EF?  Are the heart chambers and walls of normal or near normal size.  Any concomitant health issues?  

[PY3]

Hi,
My father is aged 80 years and had recently done Angiogram. The report says that:
LAD- Type III vessel, proximal LAD shows 70% stenosis, mid LAD shows tandem 90% stenosis, Daignols- normal
LCA- Normal
RCA-Dominant, totally occluded in the middle, distal RCA fills retrogradely from left side, PSA/PLV- fill by collaterals from left side

He does not have any chest pain, he lives a healthy lifestyle with low cholestrol diet, he has alo now quit smoking

Should we go for CABG or only medication can help?

PY

[kenkeith]

.  
QUOTE: "To: kenkeith,
so By Pass surgery is the right option?????"

>>>>>Somey, more than 6 years of reading and answering medical problems, and my own personal experience, it is clear to me if you ask an interventional cardiologist almost always you are apt to hear stent implants are the best option.  A non-interventional cardiologist will favor medication. The doctors are biased based on their training and possibly financial gain.

Bypass surgery is not necessary as related to your father's condition according to your posted information.  Technically surgery can be a stent implant, but in this context it would apply to a bypass and somewhat misleading.

I had a heart attack 6 years ago, and my partially blocked coronary vessel was immediately stented to supply blood to a specific location.  The LAD is/was completely blocked and I have 72% blockage of the vessel that bifurgates from the main vessel.  A few months later, the interventional cardiologist wanted to stent the 72% blockage, a week or so later the cardiologist moved away.

My current cardiologist has been treating me with mediation for the past time since.  No mention of a stent implant, and I have not had a single sick day since my heart attack and no progression of the condition.  If medication does not remedy symptoms such as chest pain, etc. . I will then have a stent implant.

What I am saying find a doctor that can and will discuss options...especially if medication can remedy symptoms.  There are many variables regarding the configuration of the vessels, your father's general health, health history, etc. Your father's health welfare is an important consideration, and if there is no emergency start with least invasive procedure if appropriate and consult with a doctor keeping in mind there may be a bias opinion. Take care and the best regards to your father.

[ed34]

I think this has become very confusing for you. Some people, not all, develop small natural bypass vessels on the heart commonly called collaterals. When an area of the heart is low in oxygen feeds, these vessels in some people come into action and get extra blood to that area. This helps a lot of people survive heart attacks, but not everyones heart seems to form these. Medication has far more effect on people with collaterals also.
If you imagine a pipe which is blocked at one end 100%, then nothing will pass through. Now if you feed the pipe from the other end, you have fluid at both sides of the blockage. Yes they still say it has a 100% blockage, but in reality it isn't blocked because collaterals are feeding it at the other end. Medication will help in this case much more effectively because the drugs have a way of getting into the vessel blocked at one end. Now imagine a case like mine where I had 100% blockage at on end, and just a 5% feed at the other. The actual vessel was very thin indeed. To get medication to affect that vessel was impossible because the feed was too small. Nitrates (Used to open up vessels) was tried even in small doses, but nothing reached that vessel. Every other artery in my body was affected, but the LAD was not, giving me chronic headaches as a side effect. So, you have to ask your cardiologist what the vascularisation is like. It would actually be wise to first have a nuclear perfusion scan which shows how much blood is reaching all  the areas of the heart, highlighting problem areas. This will give far more accuracy for determining a treatment. IF collaterals have formed, then medication may be suitable. IF not, then I would certainly look at the option of stenting first. If the cardiologist feels stenting is too difficult, but I cant see why from the report, then bypass is the last option. There are no guarantees with any option, even bypass. Some people have surgery and it lasts 15-20 years, others bypass lasts just a few years, others it only lasts months and others just weeks. Mine lasted just 3 months and going through all that discomfort for nothing was just slightly annoying.
You know it's kind of ironic that I requested stenting but cardiologists said it was not possible. So I had a bypass which failed after 3 months. My only other options were transplant or stenting. Stenting was then done which was supposed to be impossible. If they had made the right decision in the first place, it would have saved so many problems, resources and money. Unfortunately a decision is made on the experience and confidence of your cardiologist. Rather than admit it could be done, but they don't feel comfortable with it, they say it's too risky or impossible. What they should do is refer you to someone with more experience.
Looking at your Fathers case, I would ask why they haven't done a nuclear scan yet. This is standard procedure to establish problem areas of the heart before intervention.

[somey11]

so By Pass surgery is the right option?????

[kenkeith]

Everyone has a different configuration of vessels and nobody but a surgeon can provide a reliable evaluation as to stent if medication is not an option.  Correction, surgeon as in interventional cardiologist.  

[kenkeith]

I have total blockage of the LAD and 72% of the circumflex (LAD and circumflex bifurgate off the main). and I do very well with medication for the past 6 years.  I mention this as there may be an option to forgo any intervention with angioplasty.  Everyone has a different configuration of vessels and nobody but a surgeon can provide a reliable evaluation as to stent if medication is not an option.  

Also, atherectomy (procedure to remove plaque) my be the best approach with or without stents is another option.  The size of the lesion, the exact location, would be determining factors.

[ed34]

I think if I was in your Fathers shoes, being as young as he is, and taking into account "Fair LV systolic function", I would be asking cardiologists the possibility of a couple of stents. Looking at the report, there are a couple of tricky spots which cardiologists feel uneasy about stenting. The first is the ostial section of LAD. Due to this being so close to the circumflex branch, it puts most cardiologists off stenting. However, this is a moderate blockage. The other is the ostial section of the second diagonal. Branching off the LAD below the first diagonal, this vessel is at quite a large angle and is not easy to balloon/stent. The disease is virtually up against the LAD. This is a tight blockage but you need to establish the percentage. The two areas I would be most eager to treat if it was my heart are the middle of the LAD because this is tight and the middle of the circumflex because this is a total blockage. It doesn't mention the obtuse marginal branch which is about mid way down the circumflex, so I assume the total blockage is below this. So, if this was my heart, I would have those two areas treated with stents if cardiologists are willing. Then medication can be used to treat any remaining symptoms if any, but the medication should be able to be much weaker. I was on medication for 2 years and it ruined 2 years of my life, I couldn't find the energy to do anything.
At the end of the day, we all have different opinions, as do most cardiologists. Your Father has to decide what he wants from life. I hope your Father has been lectured on lifestyle changes by his cardiologist, regarding diet etc.

[kenkeith]

Thanks for sharing the information,

Normal EF (ejection fraction) is 50 to 70%, and your father has acceptable amount of blood pumped into circulation with each heartbeat so the heart is functioning properly.

There are some blockages that is said to be "tight".  Usually there is a percentage of plaque buildup (stenosis) given. Mild iregularities, etc. is not very specific The choice your father has is whether to treat "tight" stenosis medically or a stent implant.  

Generally, if medication dilates vessel sufficiency to provide blood/oxygen to heart cells, indication would be relief of chest pain caused by "tight" vessels, then medication would be appropriate.

Regards,