Comparison as last procedure findings were not explained we'll

[mamaw2ps]

Wondering if u can tell me if the heart is worse comparing heart cath and bypass to last cath and stent

Left ventriculography:  revealed an ejection fraction of 50% with moderate inferior apical hypo kinesics.

Selective coronary angiography:  revealed a 60% proximal LAD stenosis, a 70% circled trunk stenosis, a 90% posterior descending stenosis if the circumflex, and 95% obtuse marginal-2 stenosis.  There was moderate plaque within the LAD.  The right coronary artery was totally occluded with the distal portion seen filling via collaterals.

To prepare  graft:  the first graft performed was a saphenous vein graft to the PDA  I could not find the right coronary artery distal to it, it was 100% totally occluded.  I grafted the PDA. In between the area of the PDA on the obtuse marginal and distal obtuse marginal, there was an area of infarction  the saphenous vein graft to the PDA was anastomoses using running 7-0 Prolene technique.  The next vein graft that was done was sequential with the same graft, brought the graft through the left side of the heart through the obtuse marginal second one which was also occluded on the cardiac catheterization.  This was also performed using running 7-0 Prolene technique.

The next graft anastomosed was an obtuse marginal 1, this was anastomosed using running 7-0Prolene technique with left radial to the obtuse marginal.

Next, I proceeded to anastomose the piece of saphenous vein graft, after measuring the graft, going through inferior wall.  I cut it and the other piece was employed to perform diagonal to the saphenous vein graft with running 7-0 Prolene technique.

The last graft was LIMA to the left anterior descending.  The left anterior descending was difficult to find, it was intramyocardial and I actually performed the anastomoses on the distal portion of the left anterior descending. This vessel was maybe 1.5 to 1.7 millimeter in size.  The anastomosis was performed with running 7-0 Prolene technique.  It was a good anastomosis.  The IMA had excellent flow.

We then performed proximal anastomosis on the ascending aorta.  This was performed using running 5-0 Prolene for the saphenous vein graft to the ascending aorta and 6-0 Prolebe for the radial anastomosis.  At that point I deaired the graft.    I gave hotshot through antegrade root and retrograde  root as well.  At that point, with the patient on Trendelenburg and the vent going, the aortic cross clamp was released.  What happened after was basically that the patient did not recover sinus rhythm immediately, we has to pace him.  We attempted to come off but was unsuccessful on two occasions. We loaded him with inotropes, eventually the patient recovered.  I reviewed all the grafts, basically with Doppler, they all has excellent flows.

With that in mind and patient loaded with inotropes, I wanted to say the problem that we has was on the left heart because right heart was actually functioning very appropriately.  With that in mind I thought with the severe disease that he had, it would be better to put an intra-aortic balloon pump which we did.

The following was Last cath and stent:

The left coronary system was selectively engaged.  One shot was taken and showed the left main has some luminal irregularities.  It bifurcates into left circumflex which proximal and mid segments have 80-90% native disease and gives multiple OMs.  It continues in the AV groove as moderate size with some moderate disease.  The second branch of the left main seen in that view is the LAD which has proximal disease of 70-80%.  It continues with diffuse disease in the mid segment and distally competitive flow noted.  There are multiple small diagonals with some diffuse moderate disease noted as well and a large septal perforator.

The right coronary system was selectively engaged.  Angiogram showed a completely totaled RCA in the proximal segment.  

Graft study was attempted.  First graft was a stump.  Then a second graft was noted that looks like an arterial graft that goes to a distal OM branch.  After that LIMA graft study was done and La is widely patent all the way down to the distal LAD.  

Conclusion:  
1.  Severe native vessel disease with 90% left circumflex, 70-80% proximal LAD and totaled RCA
2.  Patent arterial graft to distal OM.  Patent La to LAD.  Other grafts not seen in these views could not be engaged as well.
3. Successful PCI with Xience Xpesition 3/28mm stent to the proximal native circumflex artery.

[ed34]

Yes Thallium is a radioactive isotope. Collaterals are tiny arteries on the heart which can open to form natural bypasses. If you read the first part of your post it states "The right coronary artery was totally occluded with the distal portion seen filling via collaterals." which means some collaterals were already open at that time, filling the right artery. This is why some people don't have heart attacks, the body opens bypasses on its own.

[mamaw2ps]

Thank you for your response.  This is on my husband.  We never saw the dr that performed the cath/stent, only an assistant it whatever.  He just came in spoke to us for about 2 minutes top. I did not understand anything he said other than they used the least amount of dye possible to the cath as my husband's kidneys are not on the best shape. His levels were up also so that was a
concern.  What do u mean when u say a high collateral networking on the right side.  I'm sorry to bother u with these questions.  I assume the thallium nuclear scan would require dye?   He sees the cardiologist on Friday. Hopefully he will explain more to us.  Again thatnks

[mamaw2ps]

Thank you for your response.  This is on my husband.  We never saw the dr that performed the cath/stent, only an assistant it whatever.  He just came in spoke to us for about 2 minutes top. I did not understand anything he said other than they used the least amount of dye possible to the cath as my husband's kidneys are not on the best shape. His levels were up also so that was a
concern.  What do u mean when u say a high collateral networking on the right side.  I'm sorry to bother u with these questions.  I assume the thallium nuclear scan would require dye?   He sees the cardiologist on Friday. Hopefully he will explain more to us.  Again thatnks

[ed34]

From what I can gather, because it is rather a lot to take in, is that the vein grafts have probably failed. The radial artery used from your arm is still working and is connected to Obtuse Marginal 1, and the Lima is still feeding into the bottom of the Left anterior descending. The right side is of concern because the right artery is blocked. So is the PDA I assume due to closure of the vein grafts. The only way to be certain if the veins have closed is to have a ct-angio where a different isotope is used and the images can be clearer if it's a good scanner. So they stented your circumflex at the top and in the mid section there is another tight blockage. However, you have a radial artery graft going in below that blockage, into the OM1. I think this is why they likely didn't bother stenting that restriction. Now your question is whether your heart is worse now than after the bypass. The problem is, this is too difficult to tell. You must have one huge collateral network going on the right side, or the right side wouldn't be working at all. To obtain your answer, you really need a thallium nuclear scan and this would be very useful to your cardiologist too. It would show which areas of the heart muscle are affected and any dead areas. It would also be a great historical record for any future treatments.