Failed Bypass Surgery

[bobert]

An abnormal nuc. stress test showed a 100% intact heart muscle (ejection fraction 51%) but poor blood flow to the back of my heart, then an angiogram showed I had 100% blockage of the right coronary artery, 85% blockage of the main LAD and 100% blockage of the Circumflex.  Essentially I was living on collaterals.  I did not have resting angina but did have angina upon exertion.
I was advised that I needed immediate bypass surgery.
I agreed to have it done.  After 6 weeks I experienced pericarditis and had to have my heart drained.  A month or so after that I complained of chest discomfort.  Repeated the nuclear stress test (ejec. frac. 66%), result abnormal.  Showed that I had suffered a small heart attack in back of heart.  Another angiogram showed that I have improved collateral circulation and the main LAD is fine but all my other grafts have closed down.  I feel worse than I did before I had the operation and I’m often tired.  Also I have great anxiety, my heart is now damaged.  I'm on cardiac rehab.
I don't think patients are fully informed of the many risks assoc. with bypass surgery, e.g., the fact that on the average venous grafts close within 7 years, risk of stroke, heart attack, infection, etc. If I had to do it again I would seriously consider taking my chances with intensive medical therapy.  As I now understand it bypass/angiogram/stents aren’t proven to be any more effective than med. therapy at prolonging patient’s life except in extreme cases (maybe mine).
Do you think the bypass was my only alternative considering the poor condition of my arteries?

[CCF-M.D.-MJM]

Hi Bobert,

That is a tough question. If you are a diabetic or if you have impaired left ventricular function, I would lean toward surgery, although stenting is always an option.  The data for the groups I listed above suggests that surgery is better, but those studies were done before drug eluting stents and other platelet medications that we have now.

In your situation now, if your graft to the LAD is open ( I assume this is an arterial or LIMA graft), the other vessels could potentially be fixed by stents.  You are correct, the motivation to fix these lesions is not to extend your life but to improve your symptoms.

At the Cleveland Clinic we are blessed with very gift interventional cardiologist and full time surgical back up.  Many other centers do not have this.  At some centers, people may go to surgery because the interventionalist don't feel comfortable or think the risk is too high. It all depends on the experience and confidence of the person doing the procedure.

You should also be on maximal medical management now including an appropriately dosed statin like atorvastatin, beta blocker and possibly an ACE inhibitor as well.

If you want a second opinion, please feel free to schedule one here.

I hope this helps.

[Healthyself2]

Sorry to hear about your problems with CABG surery.

I had a heart attack 6 years ago.  Angio showed 100% occluded RCA and a 70-90% ostial occlusion of the circumflex.  They couldn't open the RCA lesion and thought that a circumflex stent at that position was a risky proposition.

A year later I agreed to an experimental angioplasty procedure to open the RCA.  This was aborted because a "cratered" plaque was discovered in my left main which was actually an extension of the circumflex plaque.

Anyway, I was really given a hard sales pitch for CABG surgery, especially the second time.  I was given a 40% chance of death within 5 years, if I didn't have it, which is coming up right about now.  Funny thing is that I still feel good, have good physical abilility, only feel angina under extreme circumstances, and generally feel normal.  

Early on, I read a lot of research on the newer drugs and pressed my cardiologist for a very agressive lipid and bp pharma control regimen.  I take a triple cocktail of lipid meds which have raised my HDL from around 30 to the 50's and my TC under 160 consistently, which ain't bad for a large animal.  I walk three miles on a hilly course religiously - rain or shine - and do more on the weekends.

I really believe that my "cratered" left main plaque was the result of successful lipid therapy - when all of the junk came out of it the hydraulic action ripped the cap off.  My belief is, that, if there was anything in there, it would have killed me at that time, not that it was in eminent danger of killing me as the cardiologist suggested.  By the way, I busted it climbing Mt. Adams and it didn't kill me that day, but I did feel it on Mt. Rainier the next day and couldn't do much more than an 80 year old woman for a week or so.

I had a pretty well developed collateral system around the RCA blockage the second time that they were in there and decided that I would take no further action to open it.  At this point I really don't think it matters and they are rarely re-opened successfully long term anyway.

Of course, unlike you, my LDA was in pretty good shape.  I probably would take a stent there, if it was limiting me greatly.

Early on, I was a lot more careful with my diet, but this winter I ate like a pig and drank like a fish, so perhaps I don't really want to live that bad.  Anyway I walked up a couple of thousand feet a few times in the last month and found it quite a lot harder than last year, but think it's just the extra weight.

I really wonder if you need coronary arteries, once you build a good collateral system and condition your heart for ischemia like I have.  I really don't want to find out, but believe that I could live ok with all of my coronary arteries blocked.  

Anyway, if I got to a point where I couldn't do anything, had chronic angina, or felt I was at extreme risk for a cardiac event, I probably would reconsider the CABG surgery.  Hopefully I won't have to face that decision.

Best Wishes.

[bobert]

Thank you for your comment.  It is very kind and helpful of you to share your experience with me.  Would you share your age with me?  I'm 55.

You may have picked up that I think I was given a hard sell and I do.  It upsets me immensely (to put it mildly).  I think I had a good surgeon but I still have this big ugly scar on my chest and I feel worse than I did before I submitted to the knife.  I feel that CABG, despite requiring great skill on the surgeon’s part, is a barbaric procedure that will be replaced in the future with kinder/gentler approaches.

I didn’t mention in my e-mail that I’ve had a 2nd opinion.  This cardiologist says that despite the well functioning LAD graft, I should still have a stent put where the 85% LAD blockage is because I have a 70% blockage on a major offshoot of the LDA just above where the arterial graft is (being fed by blood from the graft moving uphill) and (1) if the 85% LDA blockage closes up, he will be unable to stent the 70% blockage, (2) if the 70% blockage closes up I’ll lose the blood supply to a lot of my collaterals, the bottom of my heart and I’ll have a massive heart attack.  Interestingly enough, he’s okay with a med approach for now.

Your regimen sounds similar to the one I am now undertaking.  I take aspirin, a calcium channel blocker, a beta blocker, an ACE II inhibitor, a diuretic and I walk about a mile every day.  My total cholesterol has never been a problem (137) but my ratio of HDL (34) to LDL (81) is low and my trigylcerides (112) are higher than they should be, so I take Lipitor.  I am also attempting to become a vegetarian.  I haven’t eaten beef in years but I love chicken.

I do experience some angina when I walk uphill extensively so I try to keep it level for now but I don’t have any trouble with day to day activities.  I try to steer away from heavy lifting for now.

I have read, as you’ve mentioned, that  once you build a good collateral system you can live with all your of my coronary arteries blocked.  I would prefer not to be the test case.

I hope you continue to do well.

bobert

P.S.  It didn't help that I was diagnosed with Parkinson's Disease the same week I was told I had CAD.  My recovery was long and very very painful.  I've lost my job, I will lose my group insurance soon, I'm going to have to sell my house, I have 2 young children to raise and I fear I won't live long enough to see them grow up.

[Healthyself2]

Yes, I am 55 also.  Had my first documented heart attack 6 years ago, but was told the RCA block was longstanding and had been told twice prior that my EKG showed a prior heart attack.

You do seem to be one of the lucky ones who builds collaterals as I am.  I think that it's a natural function if you survive the original blockages.  I believe that it's also a response to ischemia, that's why I physically push up to the edge of ischemia daily, but not through it.    

Bobert, I believe in the comeback.  When I was 49, I had lost a business 2 years before and had just slightly recovered from being flat broke, and then had a heart attack.  I now consider myself pretty healthy, I feel that the CAD is at least arrested, if not in remission, and I have come back career wise and financially over the last 7 years.

When these things happen to you, it's depressing, and you really wonder about your future, but you can get back to leading a healthy and prosperous life.  I know so many people that have had a severe health crises in their 50's, have survived, and are doing well.

I know that it sounds like BS, but a positive optimistic attitude and joy of life is very important for health.  I wasted a big part of my life chasing things that I now don't think are very important, but after the heart attack all I was thinking about was survival.  Since then I have come to appreciate the gift of life and want to get something out of my remaining years.  I walk in the woods every morning before work and take time to listen to the birds.  

The other day, I was on a mountain peak where I had a full view of the North Cascades and thought how lucky I was to be able to enjoy this and still be capable of getting up there.  After my heart attack, it was hard, but I just kept working at it every day.  That's the only way that I can keep it also, so I really can't slack off and go back to my old ways.

On the positive side, you have a real good EF and not much heart damage, so, if you protect what you have, there is no reason that you shouldn't be able to have a normal life.  And believe me life is not over at 55 - it really can be the prime years for many things like career.

Best Wishes

[bobert]

You are a wise man.

Thank you for sharing your philosophy with me.