PCI vs. CABG in two vessel ? multivessel disease with proximal LAD stenosis in 81 yr old

[clayidus]

Hi,
    My father (a Radiologist's father)  is  a 81 year old ,retired,ex-smoker,with systolic hypertension,slightly elevated blood sugar a month ago ( now normal ),has DOE since 9 months- can walk for about 6-7 min,after which he feels
breathless. No chest pain.H/O mucoid expectoration since 15 years.
Spirometry -Normal.
Coronary angiogram : Left Main : Normal.
LAD : Type II vessel. Harbours a true bifurcation 90 % stenosis involving the ostium of D1. Rest of LAD is  normal. D1 is moderate sized and harbors 90 % ostial stenosis
CIRC: Non-dominant vessel.Harbors non-obstructive plaque in proximal segment.OM1 & OM 2 harbor non-obstructive plaque  proximally.
RCA : Dominant.Harbours subtotal occlusion in mid segment and harbors intracoronary collaterals.Distal segment harbors 70 % stenosis and subtotal occlusion at crux.
2D Echo : LVEF 60 % .
Total Cholesterol : 125, HDL : 29,LDL : 69,Triglycerides : 137.
His Cardiologist ( in Bombay,India) advised CABG in the angiogram report,but on the day following the angiogram when my father expressed concerns about the efficacy/morbidity/mortality of CABG at his age to the same Cardiologist,the Cardiologist (who performed the angiogram)informed us verbally that he agreed with my father,and advised against a CABG at age 81.Also,he said that PCI was not a viable option,and advised medical Rx verbally.
A second Cardiologist,however advised PCI with 3 medicated stents - one in LAD,and 2 in RCA
A third,senior Cardiologist advised PCI with one unmedicated stent in the LAD and ? leaving the RCA alone right now.
With a LAD stenosis of 90 % and 2 vessel ? multivessel disease,is CABG the preferred modality of treatment ?
My father has  is unwilling for CABG at the moment.
Long term results of PCI with stents (medicated/unmedicated) vs. CABG in my father's case?
Is LAD bifurcation lesion difficult to stent?
He is on Ecosprin,Atorvastatin,Glyceryl Trinatrate,Metoprolol 25  1/4 -0-0  and
Clopidogrel 75  1-0-1

[Cleveland Clinic]

Generall, there is no mortality advantage in this situation going with CABG vs PCI (medicated or not).  In the PCI group, pt's however tend to need repeat procedures months or years later.  In the CABG group there is a higher risk of stroke and peri-operative mortality, especially in your dad's case because of his age.  Finally, keep in mind, that most of these studies were done by experienced operators, so if no surgeon is willing to perform open heart surgery and no cardiologist is willing to perform PCI, then all you have left is medical therapy.  Without LM disease and with no LV dysfunction, patient who are medically treated do as well as those that have either intervention.  Usually, maximal medical therapy involves a high dose beta blocker, a high dose statin, ace, aspririn, plavix and a nitrate.  Those are typically uptitrated based on vital signs, such as pulse rate and blood pressure.  In your dad's case, I would push for aggressive medical therapy at first, especially, that he himself is not willing to undergo aggressive procedures at this point.  Again, there is no mortality benefit.  If that dosen't work, consider stenting of the LAD only and see if that helps.  Bifurcating lesions are more difficult to stent and they have higher complication risk during the procedure in terms of dissection or jailing another branch.    

[clayidus]

Hi,
  I didn't explain my situation in my previous reply properly.
The second and third Cardiologists ( referred to in my first post)
are willing to perform PCI-
The second Cardiologist has adviced PCI with 3 medicated stents-
one in LAD,and two in RCA. ( but this Cardiologist has far less experience than the first and third Cardiologist)
The third Cardiologist has advised PCI with one unmedicated stent in the LAD and ? leaving the RCA alone right now.( The third Cardiologist
is well experieneced with PCI,and is Head Of Interventional Cardiology at
a major Hospital in India)
My Dad was not willing for Angioplasty till now,and refused the procedure to both the Cardiologists.He is now willing for PCI with stenting.(But he is unwilling for CABG at present)
A fourth US cardiologist has adviced CABG very strongly.( informed us
over the telephone,after seeing the Angiogram sent to him on CD by Fedex),and has expressed  doubts about the feasibility of stenting the RCA lesion. ( ? diffusely diseased vessel ,with high risk of restenosis).
All these multiple opinions have left me and my father confused.
You have said " Consider stenting of the LAD only,and see if that works,if medical treatment does not work",in your previous reply.
Thank you very much for your reply,
My father is on Aspririn 150 mg 1-0-1, Atorvastatin 20 mg 1-0-1,
Glyceryl Trinitrate 6.4 mg 1-0-1, Clopidogrel 75 mg 1-0-1,and a
low dose beta blocker Metoprolol 25 mg 1/4-0-0. The reason for the low dose for the beta blocker is that my father has Bradycardia.
Once again,thanks very much for your reply

[clayidus]

Hi,
Thanks very much for your reply.I know that it is extremely difficult to give a reply regarding further treatment without seeing the Coronary Angiogram.Neverthlesss,you have given me an extremely useful reply.
I wanted to clarify a few points/ask for further advice.
My father is unwilling for a CABG a the moment.He is willing to undergo PCI with stenting now. ( He was unwilling for PCI a few days back).He may change his
mind about CABG also ? after some time.
Because of his unwillingness towards CABG,I have not consulted a CardioThoracic surgeon yet.There are a few experienced CardioThoracic surgeons in Bombay,who have experience with  OPCAB also. ( OPCAB is safer than conventional CABG ?)
Also,the Cardiologists who have seen my father are all experienced Interventional
Cardiologists ( The Cardiologist who adviced medical Rx  has performed 3500 angioplasties and the third,senior Cardiologist has probably performed more).
Both Cardiologists are Heads of Interventional Cardiology at large Hospitals in Bombay.
I have sent the Angiogram on CD to a Cardiologist in USA,for consultation,(by Fedex)
and have been informed by him (today) that he recommends  CABG for my father,ideally. The US Cardiologist has also expressed  doubts about the feasibility of stenting the RCA lesion -( ? diffusely diseased vessel ,with high risk of restenosis).He has also said that RCA would require 3 stents probably,if PCI with stenting was performed on the RCA.
To my untrained eye,the RCA lesion seems to be a long lesion ( involving midsegment and distal segment ) and causing subtotal occlusion ( 99 % stenosis in midsegment) and also 70 % stenosis in distal segment,although it harbors intracoronary collaterals.
PDV,PLV show TIMI I flow.
Would this long RCA lesion be very difficult to treat by angioplasty with stenting?
Also,would bypass be the best choice for this diseased RCA?
Once again,I know that it is difficult to give a reply without seeing the Coronary   Angiogram.
Is it possible for me to send the Angiogram ( and other reports)on CD  ( and other reports) to a Cardiologist in Cleveland Clinic,and get an opinion ?,without the patient travelling to Cleveland.I don't think that the latter is possible,but I am still asking.
Also,my father is on low dose beta blocker because of Bradycardia.
The EKG obtained recently shows Inferior and Lateral wall Ischaemia with Unifocal,multiple Ventricular premature beats,comapred to the EKG obtained a month ago which only showed occasional Ventricular Ectopics.
Lastly,my father has complaints of expectoration of mucoid sputum since  ? 15 years.
That,combined with his dyspnoea and smoking history was attributed to be due to COPD
by a Chest Physician,until another Chest Physician ruled out COPD by performing
spirometry,and recommended a consultation with a Cardiologist.
With normal Spirometry results,his complication rate with CABG should be the same as
other patients of his age ?
What is the  mortality rate for CABG at age 81 yrs. at major centers in the US?
Once again,thank you very much for your previous reply and future replies.
Any help would be highly appreciated.