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











Follow Ups:


Re: Second CABG Risk? CCF CARDIO MD - DLB 8/02/1999
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Second CABG Risk? Don          From Florida 8/02/1999
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