Re: Post Bypass Stenosis

Posted By CCF CARDIO MD - MTR on May 03, 1998 at 20:43:26:

In Reply to: Post Bypass Stenosis  posted by Don Henderson on May 03, 1998 at 15:02:45:






In 1982 I experienced angina and as the result of a heart cath was
diagnosed with a unique stenosis of  95% in the LAD just prior to the
first major diagonal, and difuse deposits 50-60% in the right coronary
artery.  A triple bypass was performed utilizing the LIMA to the LAD
diagonal and veinous grafts to the LAD and to the right coronary artery.
Recovery was uneventful. Started on an aspirn a day and no other
medication.  In 1987 started with Lovastatin as total cholesterol was
approximately 250-260 even with prudent diet.  About 1992 replaced
Lovastatin with Zocar.  Presently taking 30 mg Zocar and 50 mg Atenonol.  
Latest total cholesterol =179,  HDL=60, LDL=96, VLDL=23,
TRIGLYCERIDES=115.
Presently in good health, non-smoker, age 68, retired.  I exercise
regularly in local cardiac rehab (for the last 10 years) unit 3 x weekly.
4/26/96 - Stress thallium at 10.8 METS , no chest discomfort showed
"subtle diminished perfusion in the upper septum on the post exercise
images which normalizes on the delayed images."
1/21/98 - Stress thallium at 11.0 METS, slight chest discomfort showed
"moderate diminished perfusion to the  LV septum which normaliizes on
redistribution images.  The scintigraphic findings overall appear more
prominent than 4/26/96 study"
4/03/98 - Left heart catherization.  Summary of findings:
"left main - 80% stenosis at the bifurcation,  LAD- long 80% stenosis at
origin followed by 100% occlusion at junction of proximal and midsegments;
left circumflex - 75% stenosis just distal to to the origin of the first
obtuse marginal branch + 50% at the junction of the proximal and
midsegments in the first obtuse marginal branch + a 90% stenosis in the
proximal segment of ther second obtuse marginal;  Right - dominant -
70% and 90% stenosis in proximal segment followed by total occlusion at
the junction of the proximal and midsegments.
Bypass graft angiogram:  saphenous vein graft to LAD totally occluded at
origin; saphenous vein graft to the right coronary artery is patent with
good antegrade flow to main vessel;  LIMA to diagonal branch of LAD is
widely patent, good antegrade and retrograde flow into native vessel
with retrograde flow extending into the native LAD.  Retrograde flow
demonstrates a 90% stenosis in the proximal diagonal branch.
Recommendations: Patient not a candidate for coronary angioplasty: Should
patient fail a medical regimen, consideration should be given to repeat
bypass graft surgery"

Questions:
1.  Given the amount and number of stenosises particularly in the LAD,
should not something be done in the near future rather than "wait and
see"?
2.  What is the risk of second time bypass surgery compared with first
time?
3.  What is risk of  second bypass surgery with increasing age?  
(i.e. is better to do it now or wait and see?).
4.  Are there other possible alternatives that Cleveland Clinic might
recommend ? (following an exam, of course)



  _____
Dear Don, thank you for your detailed question.  I first would like to
congratulate you on your lifestyle habits, exercise, and excellent control
of your cholesterol.  Even with these commendable activities, you have
progression of athersclerosis in your own native coronary arteries and in
your bypass grafts.  I can't give you a good explanation why this happened
with everything you have done but we do see some people who have progression
of their coronary disease even with low cholesterols and regular exercise.
First, I have to ask why the stress test was done in January.  Were you having
chest pain or other related symptoms?  That information is critical in
deciding how to approach your current problem.  You certainly have advanced
coronary disease and with the LAD vein graft being occluded and the left
circumflex not being bypassed, you have areas of the heart muscle that
are not getting enough blood.  However, the results of your stress test
do not correlate with the severity of disease found on your cath.  To
address your questions individually, I'll first elaborate on what the options
are now.  Increased medical therapy could alleviate symptoms of chest pain
(if you are having symptoms now) but would not redirect blood to the areas
that are not being perfused well.  I think many cardiologists would recommend
a redo bypass surgery for you since you sound healthy and you are not really
that old (68).  The risks of a redo CABG are higher than a first time CABG
(stands for bypass surgery) with the mortality being close to 5% but those
figures are averages and a surgeon would have to see you to give you a
more accurate risk assessment for you individually.  At Cleveland Clinic,
our surgeons specialize in redo CABG surgery and have excellent results so
you should consider an evaluation here.  There may be other alternatives in
your case, such as transmyocardial laser revascularization (using a laser to
drill tiny channels into the heart muscle to bring more blood in) or an
experimental drug called VEGF which promotes the growth of new blood vessels.
However, both of those treatment are only available via clinical trials and
you would need to be evaluated here for consideration as a starting point.
I think your best bet would be a redo CABG and if you would like to be
seen here, call 1-800-CCF-CARE and ask for an appointment with a cardiologist
at Desk F-25.  If you come for an appointment, please bring detailed copies
of your records including a report from your stress test, a copy of your
cath films, and copies of your doctors' notes.  I hope you find this
information useful.  Good luck and please write back with further questions.
Information provided in the heart forum is for general purposes only.  
Specific diagnoses and therapies can only be provided by your physician.