Rules: Limit of 2 questions per 6 month period

[Cindy]

Dear Friends,

Here is the rule describing how often people should post a question in the Heart Forum.  This information appears each time a person is about to post a question, but we thought it might be helpful to post this for all to see.

Please note:

As you can imagine, offering people access to world-class doctors and medical professionals in our free forums is extremely popular.  

Please limit your questions to no more than two questions within a 6 month period, so that others will have a chance at getting their questions answered.

Cindy Thompson
Med Help International

[CCF-M.D.-MJM]

Thanks Cindy.

[uptowngirl]

Thank you so much Cindy for the reminder.  Thanks to the MD's who research and answer our questions.
Uptown

[charlienashville]

Hi Doc,


I’m a 47 year old married father of four. Approximately 13 months ago, I drove myself to St Thomas here in Nashville after waking up the third or fourth time with pain under my left armpit which mimicked old chronic motorcycle wreck injury pain.  I noticed in the mirror that I was looking a might jaundiced and being only a few miles away drove off with my wife on the line at home in case I didn’t make it. I really did not feel awful and no typical angina or nausea etc.

I arrived and was given nitro which helped immediately and indicated something was amiss though my enzymes were fine. That was about 2AM. That morning my cardiologist came by and ordered immediate thallium stress test induced without exercise. When the nurse returned with the results, we knew it was bad. They ran me into the cath lab that afternoon and took one look at my LAD and declared the top third was completely occluded and that a single graft CABG was required. I was number two for triage the next morning. They noted at that time my collateral vascularization (God’s arteries) were “remarkable”.

I had suffered from arrhythmia all my adult life and had experienced acute cardio degeneration early on. Faintness from exertion in heat more than others, problems at altitude, sensitivity to stimulants. Hence I had been in the care of cardiologists off and on since age 22. I had even had a path study at Hopkins in 1985 by one of the famed Guarneri clan.

Anyhow, my surgeon at St Thomas, Will Coltharp who is in the top 10 volume wise for open heart procedures and who is something of an off pump pioneer did my surgery and utilized mostly my RIMA and a bit of Sapphous vein given that I am 6’5” and have quite a long heart.  St Thomas is I believe 3rd in volume nationwide as well. All went great and I went home in two days. When I came to in ICU, I already knew somehow what they had found…a genetic anomaly which had been pestering me my whole life. An acute intramyocardial bridging of the upper 1/3rd of my LAD. I had never heard of bridging even though I was fairly cardiac aware for a layman.  The surgeon told me I was lucky this had not killed me as a young man and that my collateral was truly incredible and that it appeared that this had been a deteriorating issue for me since birth. It was not a benign bridge. He did say that they really had yet to fully understand bridging effects.

Ok….well, the usual recovery….one month of loads of drugs and then all was fine and they took me off everything but Pravachol 40. I had a great summer and worked my hiney off in the sun ( I develop real estate and other investments) and other than sternum healing pain and some “coat hanger” neck pain, I felt better than I had since my teens. Incredible. …in every way although I did note my short term memory was compromised…pumphead I guess.

About 8 months after surgery (I had been walking 4-8 miles daily since one month post –op), I began to get strange vague pain and weakness an hour or so after walking and I started to notice vague chest pain if angered or stressed. I finally went to my cardiologist in November and he did an exercise thallium test. (I had done an echo in September and it showed regrowth in damaged or hibernated areas which he liked even though I had been told after surgery I had no damage(?))

The stress test was positive for insufficient blood flow to the upper left of my heart….on the skin as he put it. He gave me Toprol 50. I had had to wait 10 days for my test results which had caused some friction and I decided to go see another cardiologist at St Thomas but with another group. This fellow, Mark Robbins is a former fellow at your Clinic and a very attentive doctor and his staff is very supportive. I felt better with him asap. He wanted to do an arteriogram…which we did in late January. It showed that my upper LAD is of course dead as a door nail and that my graft is clean as new and that all my other arteries looked remarkably clean, but…..where my D1 comes off the LAD which is precisely where the old LAD blockage more or less ended is 95% blocked and is considered residual or preexisting to the graft and was missed. Apparently because the dye from my first arteriogram prior to my CABG could not get to the D1. The graft reconnects to my native LAD way downstream from the D1 and it was hoped it would recirculate back up but cannot for obvious reasons. There is some collateral to the D1 but they cannot get enough dye to it to see and of course it can’t be reached for a stent.

Dr Robbins feels that for sure that is the cause of my symptoms which have gotten somewhat worse. He believes I did not notice it till later simply due to the new blood surge I was experiencing which often masks things since folks feel better than they have for so long anyhow. I still when I am not symptomatic… (Weak, tired, vague chest pain, ankle pain, red face)…..feel better than prior to surgery.

I am scheduled to see Dr Coltharp 3-2-05 to get his opinion as to what can be done and the risks of surgery or doing nothing. They worry that the collateral is insufficient. Dr Robbins claims a D1 graft would be small and off pump and perhaps if I’m lucky, without sternum splitting again.

However, we don’t know yet. I would appreciate your views. I have considered coming to your clinic but as yet I don’t know if it is warranted. There may be a procedure there in Cleveland that could help me that they lack here.

Sorry for the long wind. I appreciate your time.

PS: saw Will Coltharp today. He advised LIMA graft to the D1...open sternum...off pump...best within next 2-3 weeks.

[charlienashville]

I'm sorry dear.

I thought i was posting a thread to the forum to be answered by the docs.

I apologize.

Feel free to yank my error.

New Here.

Charlie, Nashville

[Jeff67]

If only it was this easy to post a question ... some people have been trying for months unsuccessfully to get a question posted ... you need to actually post this question (not add it as a comment to another thread) if you want a doctor to answer it. I hope you are successful in doing so ... you have quite a story.

[charlienashville]

I understand that now Jeff.

Dang....sorry to waste their bandwidth.

I'm diving in next week. I am to see my surgeon Monday and probably admit me Monday or Tuesday.

Get it over with.

There is really no other option and he is currently number 6 in the world volume wise. He said I could try robotics but he would not advise it unless it were the only option. Too risky.

I have been plagued with this bridge mess for life and hope this fixes it. All of my other coronary arteries are quite nice as is my current LAD superwighway bypass.

Thank you so much for your encouragement Jeff.

I asked Coltharp and Robbins (a former CHC fellow) about heading up to Cleveland. They both said, well we now know your D1 is blocked. CHC would not want  you to leave w/o operating since you are from out of town. That is about the only difference you'll find there for someone with your condition.

[Carolina03]

Charlie,

Well, I'll be darn! You're the first person I've "met" with a myocardial bridge in the LAD. Not that that means much -- I was only diagnosed with one two weeks ago. Mine isn't occluded although I'm experiencing mild chest pain and SOB. I probably won't need surgery.  

While I doubt if this addresses your specific questions or concerns, I dug up this old reply on myocardial bridging from the forum doc.

I hope everything goes well for you, and that you recover quickly for the sake of your family and business.

Best,
Carolina


Reply by CCF-M.D.-RCJ on 06/03/2002
michL,
Myocardial bridging refers to a band of muscle that crosses over the coronary (heart) arteries. These bridges are present in somewhere between 1 and 25% of people.

During the time of the heart beat when the heart is "squeezing", this band of muscle may compress the artery, in your case the LAD, and cause symptoms such as shortness of breath or chest pain.

Fortunately, however, most of the blood gets to the heart not during the time when the heart is "squeezing", but when the heart is "relaxing". Therefore, most people are not troubled at all by the bridging. Whether or not symptoms are present during activity depends on (1) how much compression of the LAD occurs by the bridge and (2) how fast your heart rate gets.

SVT is rarely associated with bridging. The treatment for SVT caused by bridging is metoprolol or a drug like it.

A study done in 1978 in over 5000 patients showed that persons with less than 50% compression of an artery by a bridge were not found to have any "blockage" on functional testing.

[Emmaj]

Hey Charlie,

I think you need a second opinion...... at CCF or Mayo. A second ht surgery is a big deal, and your symptoms don't sound all that severe. I know, we all want to feel 100% at any cost, well almost any cost, but... maybe the risk does not actually justify the surgery?

I too had heart attacks & bypass surgery due to a very rare cause (benign tumor). The surgery was a very positive experience, although it did not entirely resolve my problem. I lived with the mild angina for a long time and got used to it.

HOWEVER, years later I had some new symptoms and ... some very negative experiences due to the "publish or perish" phenomenon... when some docs of fine reputation acted unwisely -- being just too tempted to publish their extraordinary
"solution" to my extraordinarily rare condition. (I know this sounds exaggerated, but hearing the whole story, drs I've told of my experience agree with my interpretation.) It backfired in a really bad way -- for me. I had not bothered getting a second opinion, thinking these docs were "the best"...

Unbelievably, later yet, I learned they had missed the diagnosis, and I had to have mitral valve replacement... and it was unrelated, evidently, to my other problem.

Anyway, I would get a 2nd or even 3rd opinion in a situation like yours... speaking from the "20-20 hindsight" stance...

Best of luck!

[charlienashville]

Thanks Hon for your reply.

I'm pretty up on bridges these days. Most occur in the LAD and most are benign.

Mine was not unfortunately and is now apparent, extended to my D1 which is quite occulded.

I have no other discernable ischemia anywhere else on my heart except around the "acute" or "significant" upper LAD bridge were my problem occured.

I wish they had seen the D1 earlier but on my original arteriogram before surgery, they simply saw the huge blockage at the top and a lifetime of God's arteries compensating and either did not or could not get enough dye past or around that to pic my D1 which comes adjacent below.

I probably should have been dead as a kid athlete so I'm not whining. I have faith in the surgeon. He worked with the report given him and did very well. The diagnostic team of cardiologists did not tell him to probe for the D1. He was too busy harvesting my RIMA and dealing with a rather large chest and a 6 and 1/2 inch superhighway bypass from the aorta (pulmonary I think) to the LAD to be connected below the D1

Thank You and I hope all continues well for you.

[charlienashville]

Thanks.

Well, I have a 95% occluded D1 at rest, that I can see on my arteriogram slides even as a layman. They wish they had seen it when they bypassed over it 13 months ago....but they did not nor did they know I had a severe bridging issue till my first surgery. Bridges are hard to spot with arteriograms unless indicated.

With a D1 like that and even with a fair amount of collateral since this has been more or less congenital for me, there is not much choice but to bypass. It can't be reached with a cath with total calcification upstream under the bridge.

My cardiologist who was a fellow at CCF for years flatly states that CCF would do the same thing....a single bypass LIMA aorta to D1 off pump....but they would do it now.....not letting me leave from out of town without remedy.

Robots are out except for last measure. My chest cavity is too large for Octopus or intra-rib surgery.

My surgeon is according to some arguably the best open heart CABG man alive and still practicing.

I don't think he views me as a case study for publishing....I'll ask him. We are a bit friendly and share friends...which helps no doubt.

I have been checked extensively over the years with vague cardio degenration symptoms from Mt Sinai to Hopkins and been deemed "acute cardiac awareness"....well I got vindicated last year.

Mayo. My dad had his astrocytoma *** megaglioma treated here. It was brutal. The doctors were brilliant, the staff not overly warm. Just my opinion.

I also have practical considerations. I have 4 children...two in diapers and cannot go off to spend weeks recovering that far away unless someone offered a technique that was less invasive and might help.

But a bypass is what it is and St Thomas and my surgeon do them as well as anyone. The hospital is 3rd volume wise in the US and hence the world and my doc is somewhere between 1 and 6 worldwide volume wise as well. I don't think I will get a better CABG elsewhere.

It is odd though to be feeling reasonably well 80% of the time and basically electing surgery now. My surgeon says that offers advantages to be in crisis (less risk) and that if I let it go that it would probably not kill me but will get worse and worse and cause more damage. My EF is already a bit low at 45-49 from a lifetime of the bridge compromise....they guess I had my first MI around age 19 from the bridge milking.

Anyhow...thanks for the advice. I'm scheduled a week from Monday now....you just walk in and get dope up and get in line.

Crazy. I can remember when you went in the hospital the nite before for any mundane procedure....not so today with Insurance companies.

Charlie

[Emmaj]

Hi Charlie,

Okay, you are sched for surgery... and I might not reply but for one thing I'll mention first... I did have the valve replacement at Mayo, # 2 cardiac-rated but, unlike Cleveland, a research institution... and my cardio and the surgeon there were fantastic. Okay maybe my surgeon could have been friendlier, but he was recommended by my cardio, and the trust was there. I look for integrity and cross my fingers... If someone is friendly too, that's great. I made two trips to MN for evaluation, and I don't think either time I was there for more than 3 days. I was out of the hospital from surg and home in NY in 9 days. These places are ORGANIZED. I actually find it hard to believe Cleveland wouldn't let you go home if you went for a 2nd opinion...

I wasn't really suggesting that what happened to me would be likely to happen to you... and I think the vast majority of docs probably have the purest of motives when it comes to recommending surgery to their patients... but... even docs with ultra pure motives differ. Also... my really negative experience happened at the hands of top-rated docs at a top-rated cardiac hospital, not Mayo or CCF, but not far behind either. So I have become a strong convert to the principal of second opinions.

Second heart surgeries are higher risk than first surgeries. Yes, you want to avoid chronic heart failure... but since there is no immediate risk in that dep't or risk of heart attack since D1 is aleady occluded (unless there's something I don't know -- always possible :), I don't think there is any real reason to rush into this and not get another opinion. Definitely, I can relate to your wanting to get it over with...

Anyway, take good care and best of wishes!

[charlienashville]

Thanks.