Re: Second CABG Risk?

Posted By Don          From Florida on August 01, 1999 at 10:29:18
History:
CABG (X-6) 1988..........After new testing 06/22/99, results are:
There were four saphenous vein graphs that are occluded at their ostia.
There was a LIMA to the mid LAD that is widely patent. The LIMA itself had a very large branch coming off of it, and supplying the diaphram. It is free of disease. The LIMA at its origin and its anastomosis into the LAD is free of disease.
The right coronary artery is occluded at its most proximal portion. It gives faint collaterals to the right side of the ventricle.
The left main is long, large caliber vessle, bifurcating into the LAD and circumflex vessles. It has a long 50-60% lesion in it. There is mild calcification.
The LAD is occluded in the mid vessle after a 2nd small heavily diseased 1st diagonal. There is a very large 1st septal followed by a small to moderate-sized 2nd septal that are compromised by the left main disease and an LAD diseased segment between the 1st & 2nd septal. Both septals give collaterals to the PDA and PLV branches of the right coronary artery. The distal LAD that is seen via the patent LIMA has mild diffuse noted taking off from the LAD that is free of disease.
The circumflex is a moderate-sized vessle giving rise to a very diseased small 1st obtuse marginal, however there is 99% stenosis at the mid trunk supplying a trifurcated three obtuse marginals. The distal circumflex is compromised by a moderate proximal segment disease.
Selective Right Renal Angiography:
Selective bilateral renal angiography showed a patent left renal artery without any angiographically visable disease.
There is 60% stenosis at the ostium of the single right renal artery with a 22 mm gradiant.
Left Ventriculography:
The LV gram done in the RAO projection shows that there is an ejection fraction of 30%. There is mild anterior hypokinesis.
There is akinesis. There is severely hypokinetic inferior inferobasal and inferoapical wall. There is +1 mitral regurgitation.
Selective Right Femoral Artery Angiography:
This shows a widely patent right common femoral artery and right external iliac system as well as the profunda.
Discussion:
This is a 47 year old high risk gentelmen who has had previous CABG with all saphenous vein graphs occluded. Only a LIMA is patent to the LAD. The LIMA also is probably compromising flow to the LAD due to a very large branch coming off of it going to the diaphram. It may not be such a bad idea to coil the branch that is coming off the LIMA, if the pet scan shows that there is steal syndrome and ischemia to the anterior wall (pet scan was possitive). However, we can consider coronary artery bypass surgery to the PDA and PLV branch of the right coronary artery, and to the three moderate-sized obtuse marginals of the circumflex. Aslo considering putting another saphenous vein graph to the proximal LAD. Since the flow to the 1st septal and 2nd septal which appear to collateralize to the circumflex and RCA supply heavily the septum of the myocardium, it may be compromised from the left main lesion.
Would like to know if this surgery seems to be the way to go (trying to consider the risk of any complications during the CABG). The angina at this time is daily, and appears without much exersion whatsoever.
The surgery would be done by one of Cleveland Heart Clinics previous surgeons (I believe) which is Dr. Mark Mostovych who now resides here in Jacksonville, FL. Assisting him would be another previous Cleveland Clinic associate (Dr. Merky or Murcky) who also resides in Jacksonville, FL. at St Vincent's Medical Center.
I realize without all the records from the testing (Cath films) it isn't possible to diagnose anyone. However i was hoping that Dr. Lytle or someone could read this summery, and give me an off the wall idea of weather this "re-do" would be recommended, or would PTMR/TMR be a better way.
Thank you in advance,
Don From Florida,
***@****

PS: Surgery date is scheduled for 08/10/99

[CCF CARDIO MD DLB]

Posted By CCF CARDIO MD - DLB on August 02, 1999 at 10:29:42
Dear Don
I would not rush to use the PMR/TMR option just yet, as it sounds like repeat bypass surgery could treat the blockages. If there was in fact anterior ischemia, tying off the branch of the LIMA supplying the diaphragm may help.
I hope this has been useful. I wish you the best of luck. Feel free to write back.
Information provided here is for general purposes only. Specific questions should be addressed to your own doctor. If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

[anonymous-user__0]

Posted By Don          From Florida on August 02, 1999 at 10:54:09
CCF CARDIO MD - DLB,
Thank you for your quick response to my surgery concerns & questions. I am mostly wondering about the risk factor in this "redo" CABG, as for the 4 different surgeons here that are aware of my situation, all seem to have different opinions on the approach of treatment options.
One stating that another CABG would not be possible at all with the danger of injury to the existing graphs.
One stating the surgery could be done, but only would advise if the "angina" was to severe to procede with normal daily activities. Stating also that the vessles need to be bypassed were rather small, and could cause a great degree of difficulty.
One (the one who is doing the surgery) stating that the risk envolved in this surgery would be slightly higher than normal (rated at 8-12%)verses the first time CABG at a 2-4% risk factor.
These different opinions leave me in a confused state of mind, on exactly what would be the best route to take with these occlusions. I know that something needs to be done, but living with the "LIMA" artery only, versing a chance of not making it through the surgery at all, makes for a very hard decision. The surgeon who is scheduled to preform the CABG is very confident that things should go well, giving my age. I sure hope he's right!
Thanks again for the response, and hopefuly i will post the outcome on here sometime after the 10th of August.
Best Wishes To Everyone,
Don........RANGERDOOD

[CCF CARDIO MD DLB]

Posted By CCF CARDIO MD - DLB on August 02, 1999 at 14:13:47
Dear Don
Damaging the LIMA is a concern with redo CABG. However, if there is anterior ischemia that is felt to be due to the branch on the LIMA, the LIMA is already in need of repair. Damaging the other grafts is not a concern, since they are all occluded.
If the vessels are small and there are no good targets for the new grafts, you could still have angina after the surgery. A multivessel angioplasty would be an alternative option. Without actually reviewing your films, I cannot intelligently comment further.
I hope this has been useful. I wish you the best of luck. Feel free to write back.
Information provided here is for general purposes only. Specific questions should be addressed to your own doctor. If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

[Don-From-Florida]

Posted By Don        From Florida on August 02, 1999 at 18:48:05
<>
Thanks again for the replies to my surgery concerns.
They are going to attempt about 4 bypasses on the 10th of this month. This is my concern (the risk factor on redo cabg)with the condition my previous grahs are in, and the low ejection fraction (now at 30%). I am told (by the surgeon) he will try to use the right internal mammary, 1 radial from the left arm, 1 saphenous from the right leg, and i think i graph from somewhere from the back of the leg.
I'm just hoping the CABG is the right choice in this matter.
All of your replies have been greatly appreciated, and with a lot of luck, i'll be posting the outcome of the surgery sometime after the 10th of this month.
Best Wishes To Everyone,
Don.......RANGERDOOD

[CCF CARDIO MD DLB]

Posted By CCF CARDIO MD - DLB on August 03, 1999 at 09:12:43
Dear Don
If you are having lots of symptoms, CABG sounds very reasonable.
I hope this has been useful. I wish you the best of luck. Feel free to write back.
Information provided here is for general purposes only. Specific questions should be addressed to your own doctor. If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

[Don-From-Florida]

Posted By Don        From Florida on August 04, 1999 at 08:47:12
Thank you for the information, and incouragment concerning a "redo" CABG. I realize that "redo" surgeries are getting to be quite common these days, with the rapid percentage of CAD patients on the rise in this country.
I guess i'm just a little worried about my own situation (especially the EF at 30%) when a year ago it was at 58%. That was the reason for posting the cath results (up top) in order to give you an idea of where it all stands at this point.
The different opinions of the surgeons down here made for some original fears to arise, and i still can't figure out why 1 of them said the surgery would not benifit me, and would be a very high risk (he is an assistant).
At any rate i'm going to have the surgery, as for the decline in the heart function (EF) has me concerned about the outcome if i don't attempt to correct this problem as soon as possible.
As i stated at the top (first post) it is my belief that both of these surgeons were at one time affiliated with Cleveland Clinic, and that in itself gives me a little more comfort.
I don't guess there is any chance of the Cleveland Clinic moving down here to North Florida by next Tuesday is there?.....LOL!!
Once again thanks for the information, and best wishes to the staff at Cleveland Clinic, and all the patients on this board on their continuing efforts to improve their health.
Sincerely,
Don.......RANGERDOOD










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