Non Surgercal Alternatives To Cornoray Bypass

[Russell Park]

Wondering if there are non surgical or minimally invasive alternatives to bypass surgery for an otherwise healthy 80 year old.

My Dad (80yr) recently suffered 4 simultaneous strokes and diagnosed with endocarditis. Strokes were caused by debris breaking off vegetation on mitral valve.

He had elevated triponin, maybe indicating a slight heart attack, but no other indicators of heart attack; EKG & echocardiagram were normal

He suffered 2nd minor stroke in hospital, 5 days after the 1st. Cardiac cath was performed shortly before this 2nd stroke. It was a minor stroke that went undetected by physicians until we requested a 2nd MRI/MRA.

A 4 week (2 in hosp,2 at home) antibiotic regime (gentomycin, penicillin/rocefin, lovonox) cleared up Endocarditis. He has not had any additional strokes, and is up an about.

Cardiac cath revealed estimated 70 to 90% blockage in 4 main arteries, with estimated 90% blockage of left main. Current recommendation is quadruple by-pass surgery. Before the endocarditis he was under the care of a Cardiologist,had regular echocardiograms & stress tests. Tests indicated nothing out of the ordinary for an 80yr old

He does not have now, nor ever had, chest pain, shortness of breath. Since Endocarditas he is very tired and sleeps alot. Were it not for endocarditis-induced stroke he would still be riding his bike everyday and not know about the blockage.

Echocardiogram is pretty good for an 80 year old. Ejection Fraction 65% and his mitral regurgitation 2+
Current meds:
Norvasc:
Asprin:
Lopressor:
Lipitor:
Synthyroid:

[CCF-M.D.-RCJ]

Russell Park,

Thanks for the post.

Unfortunately, persons with left main disease have a much higher incidence of death if they do not undergo bypass.  In fact, it is one of the few types of blockage that is clearly best served by bypass even in someone without symptoms.  Making any medical recommendation other than bypass would be counter to the available medical evidence.  There is no good minimally invasive alternative.

However, the decision to proceed or not is your father's (with your help of course).  He may not want the surgery due to being tired of being in the hospital, not liking doctors, thinking that he is too debilitated from the strokes, or some other reason. As long as he understands that not having the bypass could lead to an earlier demise, then choosing to forego the surgery may make him happier than actually having it.

Good luck.

[Russell Park]

Appreciate your prompt rely and candid response. Want to be sure my father has all the the latest & best information available on non invasive techniques before he makes a decsion on surgery. Answers to a few more questions would be greatly appreciated.

How subjective is the reading of a heart Cath exam?

Is it possible to get a second opinion from the Cleveland Clinic without doing another heart cath, as its my understanding that heart caths are somewhat risky, or would you need to do another Heart Cath?

Does Cleveland Clinic have a less invasive/risky procedure to determine the extent of blockage?

What is the best procedure for choosing a cardiologist at the Cleveland Clinic?

Thanks so much for the informative service you provide

[CCF-M.D.-RCJ]

Q1:"How subjective is the reading of a heart Cath exam?"

It is a subjective thing, but most cath interpreters will recognize a 90% stenosis as severe, even if a new interpreter said the stenosis was only 70% (for example).

Q2:"Is it possible to get a second opinion from the Cleveland Clinic without doing another heart cath?

Yes.  Check out http://www.eclevelandclinic.org/home.jsp for guidance.

Q3:"Does Cleveland Clinic have a less invasive/risky procedure to determine the extent of blockage?"

The existing cath film should be fine.

Q4:"What is the best procedure for choosing a cardiologist at the Cleveland Clinic?"

How about I make some recommendations based on the info you provided (in no particular order)?  Dr Donald Hammer, Dr Roger Mills, Dr Wael Jaber, Dr Rick Grimm, Dr Marin Thamilarasan would all be good choices (as would many others).

[Russell Park]

Thanks you so much. I am giving all this info to my Dad so he can make an informed decision. Hope he decides to come to Cleveland Clinic

[Momto3]

Just thought I'd let you know that I have been to Dr. Thalmilarasan and he is absolutely wonderful.  He is very patient and very attentive.  I'm sure all of the doctors mentioned are great, but I can personally attest to Dr. T!! Best of luck to your dad.

[3rdMajor]

I'm just a 5x bypass guy with an uneducated opinion.
My (post)understanding of bypass surgery is that it has no statistical benefit in precluding future cardiac events. The primary benefit of bypass revascularization would be greater physical activity in someone constrained by angina.
Bypass not precluding future cardiac events may sound counterintuitive, but I believe it can be explained by the fact that it is the relatively new/soft (20-40%) blockages that tend to rupture and cause coronary thrombosis, while the larger/stable (70-90%) blockages tend to cause (disabling) angina.

[Russell Park]

3rdMajor thanks for the feedback, Can I assume that looking back you would choose a bypass again. Also where did you have your bypass surgery, and who was the cardiologist and cardiac surgeon