For almost three months, I have had 100% blockage of my mid-LAD, and I am wondering about the feasibility of revascularization.

I’m 44 y/o male 5’ 8” / 190 lbs (20 lbs extra).  
On 2/7/11, I was at my retail store, I stood up & suddenly, collapsed of a cardiac arrest.  My bus. partner came over, felt no pulse, started CPR & called 911.  
About 40 mins earlier, I had finished (1 1/2 hrs) practicing salsa dancing in prep for a performance that had been scheduled for the following week.  
My general habit, in the last few yrs, was dancing fairly intensely 10–20 hrs per weekend & mostly deskwork during weekdays.  From 1980s to mid 2000s, I ran more than 20 half marathons & 6 full marathons.
On 2/7/11, I had no symptoms when I collapsed, & generally, I felt good.  My business partner was the only person present, & luckily, she had just had received a refresher in CPR. Since the retail store is at ground level on a main street, w/i about 4 mins of my collapse, paramedics shocked me twice & revived my pulse.  
In the ER, they gave me a vast quantity of sedatives b/c I had become combative, which I dont remember.  Soon thereafter, I went to the cath lab, & they found 100% blockage of my LAD & low cardiac output Ejection Fraction (EF) of 15-20%.  
I did not respond well to the 3mm bare metal stent implantation, or possibly, I did not respond well to sedatives.  For a couple of days, I was unconscious / semi-conscious, & after giving me diuretics to combat fluid retention, I recovered & was weaned from tubes.  

Due to my insurance carrier’s preference, I was transferred to a university Med Center.  After a couple of days of blood work, x-rays & an echocardiogram showing an EF of 35-40%, & adjusting my meds, the Med Center discharged me - on 2/15/11 (just a few hrs shy of 8 days after my collapse).  Upon news of my discharge, I protested that I did not feel up to release b/c my chest continued to hurt.  The cardiologist suggested that my chest pain was probably due to CPR compressions, stated that I could probably rest better at home, & provided me w 10 meds, including Vicodin, blood pressure lowering meds (an ACE inhibitor & a beta blocker), & Coumedin b/c they spotted that the anterior wall of my left ventricle was not moving (& a blood clot appeared w/i the left ventricle). The Med Center suggested I report to my GP on 2/17 (2 days after discharge).  Based on what was discovered later, I suspect that the Med Center had discharged me w/o knowing that my stented LAD had already reblocked (restenosis).  
Through Feb, on a daily basis, I continued feeling increasingly better w/o any major symptoms.  For about the next 2 weeks after discharge, I took Vicodin at night, when I slept (but not during the day), & on a daily basis, I walked for at least 20 min (little by little increasing the time – up to 90 min).  At about the 3rd week after discharge, I discontinued taking Vicodin.
My feeling of improving lasted about a month & on 3/12, I was 1.5 hrs into sleep, & I awoke feeling as if a balloon were inflating in mid-back of my head.  The inflating sensation was increasingly painful & lasted about 10 seconds.  Then the balloon-inflation feeling released.  Immediately, thereafter, about 40 seconds, I felt my heart palpitating very irregularly / strongly.  Palpitations were fast, slow, fast, very slow & then subsided. I felt dizzy, disoriented, & I wondered if this was how my life would end. I called 911. The ER did EKG, blood tests, chest X-ray, CT scan of my head, & released me w/o finding problems.
On a side note, the ER also gave me Vit K shot to neutralize the blood thinning effect of Coumedin, b/c at that time, my prothime had shown a Coumedin blood thinning of 3.93 (Therapeutic level is 2-3 & an aggressive therapeutic level is 3-4.5).  It seems doubtful the Coumedin contributed to my heart palpitations.  
The next week on 3/19, I called 911 again because w/i a 30-min period, I felt 3 sessions of palpitations & fluttering in my chest, along w dizziness (I was seated at a table when the palpitations began). The ER ran tests. I transfer to the university Med Center & Med Center repeated tests. Med Center staff was torn about whether my symptoms warranted cath, a nuclear stress test or just sending me home.  After some mulling on 3/24, I was taken to the cath lab & they discovered that my mid-LAD was 100% blocked in the same location of the 2/7 stent implant.
Upon discovering the 100% reblockage, my first questions to the cardiologist were, when did the reblockage occur & why am I not dead because this reblockage is in the same area that caused my 2/7 cardiac arrest? In essence, the cardiologist did not respond, & he said at the moment we have a question of viability before us.  He recommended that before further intervention, viability testing be done to determine whether the dependent blocked area remains viable.  It would not be a good to attempt to break through100% blockage or to restent if the dependent area is not viable.
We did a Cardiac MRI & nuclear stress test, & both showed non-viability of about 40% of my left ventricl, & my EF continued to be 35-40%.  
Through my 3/19-3/28 hospitalization, I continued to feel palpitations on at least a daily basis & from time to time chest pain (which I had not felt previously); however, the hospital staff told me that palpitations & chest pains were not appearing as detectable arrhythmias on their monitors.
On my 3/28 hospital discharge, we decided to begin cardio rehab, continue w meds, & consider implantation of a S-ICD (Subcutaneous Implantable Cardioverter Defibrillator).  
In early April, I continued regular-daily exercise while awaiting approval of cardio-rehab & the S-ICD.  During April, my palpitations decreased in intensity & frequency, & generally, my energy level increased.  Nonetheless, I continue to get short of breath fairly easily. For example, I can power walk for 2 hours or more, slow jog for 3-6 blocks spurts, & I can bring my heart rate up to nearly 120 bpm for 5 -10 minutes.  
In essence, based on my age and my otherwise pre-MI good health, I continue to wonder about the feasibility of forgoing revascularization of my left ventricle.  Since about March 28, my cardiologist has continued to assert that revascularization by either stent or bypass is a bad idea because the risks outweigh any potential benefit b/c the cardiac MRI & the Nuclear Stress tests show non-viability.  In essence, he asserts that heart tissue scars within about 12 hrs of no blood supply.  

I know that if I search around, I could find some cardiologist(s) ready, willing & able to perform revascularization of my left ventricle by either stent and/or bypass, yet a question remains whether attempts at revascularization would be to my benefit, even though some cardiologist would do it.

Additional ongoing concerns are:
1) The existence and continued development of Ischemic heart disease –involves increased risk for ventricular tachycardia, ventricular fibrillation & other cardio-electrical problems,
2) A considerable risk exists for hypertrophy of the left ventricle (aka remodeling), which also increases risk for ventricular tachycardia and ventricular fibrillation (I am taking 2 meds to attempt to lessen the likelihood of this hypertrophy, Carvedilol and Diovan, see below),
3) CHF which will likely develop soon,
4) Necessity for a heart transplant or an implantation of a ventricular assistance device (must have an EF < 25% & be otherwise healthy). Heart transplant does not seem very compelling since heart rejection & other complications remains a risk.    

My Current Meds are:
Plavix (Clopidogrel) 75 mg daily
Carvedilol (Coreg) 12.5 mg (twice a day)
Diovan (Valsartan) 160 mg (twice a day)
Asprin Buffered 325mg daily
Lipitor (Atorvastatin) 80 mg daily
Fish Oil 2.4g twice a day
Nitrostat (Nitroglycerin)  .4mg (Prn)  

Any feedback concerning revascularization or other raised issues would be welcomed.

J1george

[kenkeith]

QUOTE:Upon discovering the 100% reblockage, my first questions to the cardiologist were, when did the reblockage occur & why am I not dead because this reblockage is in the same area that caused my 2/7 cardiac arrest? In essence, the cardiologist did not respond, & he said at the moment we have a question of viability before us.  He recommended that before further intervention, viability testing be done to determine whether the dependent blocked area remains viable.  It would not be a good to attempt to break through100% blockage or to restent if the dependent area is not viable.

>>>>>If you have 100% blockage of the LAD, and you are still a viable cardiovascular system indictes you have collateral vessels that have developed to feed the deficit area that would have been supplied by the LAD.

For more than 7 years. it has been known that I have 100% blockage of the LAD.  The surgeon and cardiologist didn't  want to intervene with a bypass or drill through the blockade, and I do well with medication (ACE inhibitor, beta blocker) and before going to the Health Center for a workout I take a nitrate to prevent chest discomfort with intense workout.  I have 72% blockage of the ICX vessel, and the 98% RCA was stented would I was admitted to emergency due to heart failure.  A cath indicated my EF to be more than 15% and tests taken in emergency indicated EF 29%.  

If my LAD was reopened and stented, and hemodynamics considered to reopen could prevent good blood flow through the collateral vessels due to a change in gradient pressurer as the opened LAD vessel would have less resistance than the collateral vessel system.  Also, vessels down stream from the LAD may not be viable and dried up.  That may be the issues the doctor is evaluating.

You are correct you can find a doctor to mechanically intervene.  I have had two cardiologists.  The first cardio doc was an interventionalist and wanted to stent the 72% ICX blockage 7 years ago...he moved out-of-state and the present doc is a non-interventionalist. He has never mentioned an intervention.

At the time I was admitted, I had an enlarged left ventricle and a below 29% EF (considered by insurance underwriters to be heart failure range).  The enlarged LV was the underlying cause for the low EF.  The LV pumped against high resistence (high BP) and that overworked the heart and as a consequence the heart enlarged. Medication has been an ACE inhibitor to relax vessels and reduce resistence, and a beta blocker (coreg) to help with the blood pressure issue as well as provide stability of heart rate.  

I was on plavix for a year after the stent implant of the RCA, and subsequently I have stayed  with aspirin on a daily basis. Although I occluded vessels my cholesterol was never an issue so I don't have that medication.  My nitrate is isosorbide (slow acting) when I know I will be exerting myself.  I have a nitro pill that is fast acting but I never or very seldom have a need.  For a classification my angina is stable...meaning it takes exertion to effectuate chest pain and hasn't changed for all these years.  If one has unstable angina (chest pain with exertion or without) then there would be a consideration for intervention in my situation.  

Thanks for sharing and if you have any further questions or comments you are welcome to respond.  Take care,

Ken

[ed34]

Actually with 40% of the left ventricle being non-viable, as proved by mri and nuclear scans, I would say that your collateral formation was poor to non existent. To re-open the blockage would make no difference at all because the dead heart muscle will never use it, so the risk is pointless.
I can really understand your frustration and wanting to get back to normal again, but until research becomes every day treatment, this is sadly not going to occur. It was once believed that stem cells didn't exist in the heart, but these have now been located. It was believed it is impossible for heart tissue to re-generate, but now it has been discovered this is just due to a protein issue on the cells and can be altered in the future so hearts do fully recover. New hearts completely working have been grown in labs from stem cells taken from mice/rabbits/pigs and very soon humans. No rejection problems will occur. I think that you need to keep your hope alive and not give up because more money is pumped into heart research than anything else. New discoveries world wide are being printed weekly and knowledge of the heart is accelerating all the time.

[j1george]

Thanks Ken / Ed,

I appreciate your responses, and I have been studying into the specifics of my condition for only a few months and more intently in the last month.  I have read quite a few postings on this site and other sources, yet sometimes, it is not easy to figure out the advantages and disadvantages in various courses of action.  Even the science has mixed viewpoints within certain areas.


>>>>>If you have 100% blockage of the LAD, and you are still a viable cardiovascular system indictes you have collateral vessels that have developed to feed the deficit area that would have been supplied by the LAD.<<>>>If my LAD was reopened and stented, and hemodynamics considered to reopen could prevent good blood flow through the collateral vessels due to a change in gradient pressurer as the opened LAD vessel would have less resistance than the collateral vessel system.  Also, vessels down stream from the LAD may not be viable and dried up.  That may be the issues the doctor is evaluating.<<<<>>>You are correct you can find a doctor to mechanically intervene.  I have had two cardiologists.  The first cardio doc was an interventionalist and wanted to stent the 72% ICX blockage 7 years ago...he moved out-of-state and the present doc is a non-interventionalist. He has never mentioned an intervention.<<>>>>>At the time I was admitted, I had an enlarged left ventricle and a below 29% EF (considered by insurance underwriters to be heart failure range).  The enlarged LV was the underlying cause for the low EF.  The LV pumped against high resistence (high BP) and that overworked the heart and as a consequence the heart enlarged. Medication has been an ACE inhibitor to relax vessels and reduce resistence, and a beta blocker (coreg) to help with the blood pressure issue as well as provide stability of heart rate.  <<<<>>>I was on plavix for a year after the stent implant of the RCA, and subsequently I have stayed  with aspirin on a daily basis.<<<>>>>Although I occluded vessels my cholesterol was never an issue so I don't have that medication.<<<<<<<>>>> My nitrate is isosorbide (slow acting) when I know I will be exerting myself.  I have a nitro pill that is fast acting but I never or very seldom have a need.  For a classification my angina is stable...meaning it takes exertion to effectuate chest pain and hasn't changed for all these years.  If one has unstable angina (chest pain with exertion or without) then there would be a consideration for intervention in my situation.  <<<<

For about a month, I was taking Isosorbide, but my cardiologist was not too excited about my taking it (maybe because I was complaining about being tired all the time, and sometimes dizzy), and the cardiologist wanted to see how I would do if I did not take it for a while – because apparently one likely builds a tolerance to Isosorbide.  I have been off of it for about two weeks, and so far, I seem to be doing o.k. without it.  Also, I have nitroglycerin, that I take once in a while, maybe about once a week on average.  
Ken, overall from your description, it sounds as if you are fairly stable with your exercise tolerance etc.  Have your tolerance changed with the Isosorbide? I mean have you had to increase your dose over the years in order to keep it working?  I may have to continue taking it, but I would like to cut any medications that are not necessary and somehow keep my energy level up.

J1G

[kenkeith]

QUOTE:....Ken, overall from your description, it sounds as if you are fairly stable with your exercise tolerance etc.  Have your tolerance changed with the Isosorbide? I mean have you had to increase your dose over the years in order to keep it working?  I may have to continue taking it, but I would like to cut any medications that are not necessary and somehow keep my energy level up".

Yes, my cardiovascular system functions very well for daily activities, but there may be some angina with my exercise routine.  Isosorbide medication can create a tolerance for the nitrate therapy, but I don't believe it takes more than a day or two. I have never had an intolerance with the medication going on 8 years.