I must count myself 'lucky' or unlucky, depending from which perspective I look at it, this last two weeks. I have the opportunity to manage directly four 'left main cases' ! Coronary artery disease is my bread and butter as an interventional cardiologist but even after more than 20 years in practice as one, 'left main' remains a rarity. If I get to see and manage directly one case in 6 months, that is already being on the 'cutting edge'. Until this two weeks when I am faced with four cases...It is like a sledgehammer. [ http://drnikisahak.blogspot.com/2012/05/procedures-in-medicine-coronary.html ] Man has two coronary arteries. Both branch out straight from the Aorta, as the great blood vessel emerge from the stem of the heart.One on the right side known as the Right Coronary Artery, supplying blood on the right side of the heart namely the right atrium and the right ventricle. The Left Coronary Artery, comes out on the left of the aorta and is known as 'The Left Main Stem' as it runs for a few centimetres, [ 1 to 4 cm ], before branching off into two main branch, the Left Anterior Descending artery which runs forward supplying blood to to the left ventricle. The other branch of the left main is known as the Circumflex Artery and it curve backward supplying blood to the back part of the left ventricle and the left atrium. Of the two branches, losing the LAD would be more 'major' or catastrophic than losing the Circumflex, since it covers more territory. Suffice to say, in any one branch, be it on the right or the left, having a 100 % blockage or occlusion at the more proximal part of the vessel confers more damage than having an occlusion more distally. Common sense. [ A traffic jam at PJ Hilton of the Federal Highway would cause more problem than one also on the Federal Highway near Port Kelang !] Along the same reasoning, an acute occlusion of the Left Main would invariably cause almost 100 % death in a patient since 60 % of the beating heart is deprived suddenly of it's blood supply. I had 4 of these over the last forthnight! The first one was a young 45 year old Chinese male who came in the context of a major anterior myocardial infarction seen at ER. We push him straight to OT from ER to do Primary Infarct Angioplasty. It turn out to be a Left Main! We could not cross the blockade and open up his artery in time . He died on the table despite 'heroic' cardiac resuscitation. No way that he could have survived, looking back , more wise, after the benefit of a 'retroscope'. We appear always wise 'looking back'. More wiser, looking and commenting from an 'armchair' over coffee or in court of law ! Case 2, involve a young Malay man , 38, five feet six , obese plus plus at 99 kg. Familial hypercholestrolamia of 9.5 mmol !! Routine coronary angiogram following a positive stress test done after he complains of slight chest discomfort on waliking up staircases at his office. At angio, noted 70 % diameter narrowing in the distal Left Main. I have scheduled him to see my cardiothoracic colleague in a week's time. He need bypass surgery. A low risk straight forward case for my surgical colleague. A tough decision for me though to send young chaps like him to go under the surgeon's knife, but a left main is a left main. It would have been just a half hour job for me if I were to proceed from the angiogram and do an ad hoc angioplsty and stenting procedure. Just need to cross his narrowing with my guidewire at angioplasty and ballooning and subsequently putting a drug eluting stent across it.
Easy. But I am not going to expose this young man to that 0.5 to 1 % chance of possibility of 'sudden cardiac death' [ SCD as a euphemism] due to 'subacute stent thrombosis' [ SST], post-procedure for the next one year or so, despite optimal dual anti thrombotic therapy with plavix and aspirin. On any other patient cohort, a 0.5 to 1 % risk of SST would be OK by any standard as the result would just be a small infarct or an unstable situation we cardiologists term as 'Acute Coronary Syndrome'. We could as easily bring them back to the cath lab as they present themselves to us in the clinic or Er as a case of sudden onset 'angina' and cross the clot build-up with a guidewire then balloon and stent. But in the 'left main' cohort of patients , the possibility of instant death at presentation is real. This is not acceptable Case 3, a 50 year old young lady, 20 years diabetic, HRM manger some GLC company, recently insulin dependent,with a wee bit of heart failure. At angio, a tight Left Main Stem narrowing with severe triple vessel disease in the Left Anterior descending artery, Circumflex a s well as her Right Coronary artery. Good surgical candidate but my Cardiothoracic colleague will curse me while operating. Diffuse disease, small vessels, many lesions, these are typical hallmarks of neglected, long-term diabetes. I pity the surgeon. We are giving them difficult cases to do nowadays ! Case 4, the chap is still in CCU, second day post infacrt. 68 year old Malay chap, looking his age. Already had two stents to his coronaries done at IJN in 2000. Bad neglected diabetic mainly on self medication, buying his drugs from pharmacies mainly. Chronic renal failure on haemodialysis over 10 years as well. Sudden onset low grade chest pain after hemodialysis at the hospital in the evening. Called to see patient in the ward at one in the morning as pain persist. Angiogram at 2 am showed, OMG!, a very tight Left Main lesion [ the culprit aretery causing the chest pain ] and diffuse three vessel disease worse than Case 3. He survived the infacrt because there was partial spontaneous recanalization. Not a staraight forward case otherwise I would have ballooned and staented him. Todate, still hanging on in CCU. Left Ventricular function on echo assessment, moderately poor which make mortality risk during intervention higher. Other option? Leave him alone on medical therapy....not quite acceptable in 2012. I have to find himone very brave Cardiothoracic surgeon and a superb anaesthetist... still searching.
[ ....this week, reminded me of the fleeting and transientness of this earthly existence, it brought me back to the three ,central and pivotal elements in each individual muslim's life : ILM , IMAN & AMAL ] Part 1
Ali Johar, [ not his real name of course ],27 year old junior technician working with a port authority in Pasir Gudang , Johore, walked into my clinic two days ago complaining of 'progressive shortness of breath' over two months duration. He told me he needed to stop twice for breath walking from the underground car park to the hospital lobby. Coming from a 'vital' 26 year old , I was immediately all 'ears'. Examination was remarkably normal apart from a 'pursed' lip while breathing. He appeared fairly breathless just sitting there on the couch. This is not good. Not good at all. No overt evidence of heart failure. ECG and Echocardiogram done at the same visit 'shocked' me. Routine chest x-ray was normal except for an over-prominent pulmonary arterial shadow. That clinched the instant diagnosis of Primary Pulmonary Hypertension, a very rare ailment. CT of the chest and doppler echo studies of the leg veins done in the same evening, more or less confirmed the diagnosis and exclude the possibility of another cause for his 'breathing difficuly, a relatively common diagnosis in camparision with PPH ie ' chronic pulmonary embolism... a condition where you get continued, chronic, 'plugging of the lung circulation by minute blood clots ,over time, coming from the deep veins in the legs and pelvic region.' His ECG showed obvious 'right heart strain' and in the echo, the right heart [ right ventrical and right atrium ] are both enlarged! His PA systolic pressure [ pressure in the lung circulation, normally less than 20 mmHg ]on echo assessment is 115 mmHg , as high as his systemic pressure on the left. This is bad, prognostically- speaking. PPH video:-
What is my specific plan for this unfortunate young man? I am referring him to my former student and junior colleague in IJN who 'subspecialise' on this disease and is currently the director of their 'heart and lung' transplantation programme. Six months to two years down the lane, my gut-feeling is that, this young man would need a heart and lung transplant, judging by his markedly raised PA systolic pressure now. Whether he would get one is another matter I would not want to ponder about. Waiting list is long 'plus plus', and hearts and lung from 'donors' very in very short supply. Only 'accident cases' in 'brain dead' circumstances qualifies. Even then, family consent is difficult to get by. This is the real world... Even if he gets one, one year down the 'lane', there is the incessant problem of host versus graft disease; graft versus host disease; and myriads of other issues; and last but by no mean the least, is cost. In the interim period, IV prostacycline infusion initially, and the new oral ones recently introduced may tide him over. Very expensive treatment , a couple thousand RM a month! Oral viagra or cialis , which help lower the pulmonary circulation pressure have been helpful in some, giving a new hope of better symptom control in many at less cost. How do one tell all these to a previously bubbly 26 year old, younger even than even my sons and daughter;recently married young chap; with a young innocent wife and a six month baby in tow?! Just three months ago he was still playing 'futsal' with his work colleagues in JB...... That in practical terms, his life will be drastically 'truncated'. . I am reminded of an old professor of medicine at Massachusett General, Prof Sir William Osler, doyen of American medical fraternity at the turn of the previous century, who used to say: " The science of medicine is long and arduous, the art is even longer.." How very true. I am still learning...... Inna lillah hiwainna ilaihirojiun. From Him we come , to Him we return.
What a day today. I am on call for the hospital covering all cardiological admissions 'after office hours' till 8 am tomorrow., meaning all cardiological emergencies and referrals..... Still very high on adrenaline at 2 am especially after the last ' primary infarct angioplasty case which I had just now, I could not sleep...... Started the day very well at 6am after 'fajar' prayer, did a short surf on the internet just lurking around and reading my mails etc and etc. Came across a wonderful already 'dated' utube 'article' from Down Under. Very happy to note that my fellow endurance competitor Meg Wade, four time Tom Quilty champion, and several consistent top ten's at world level, recovering very well from her near-fatal equestrian brain-injury sustained after a fall in mid 2009 in a local 160 km ride in Australia. [ http://www.abc.net.au/news/2011-11-20/back-in-the-saddle/3682640?section=sa ]. Indeed Meg Wade up to the time of the 'spurious fall', [ that can happen to anyone actually competing at any level in that 'crazy' but self enduring sport ], the top rider in the world, following and replacing the footstep of the legendary,aging Ms Valary Kanavy of USA, the undisputed endurance queen of the early and mid 2000's. They share the same common denominators: They 'eat, sleep and breath equine'. Kanavy is born into 'old money' in Vermont, USA with acres and acres of farmland ideal for endurance. Meg Wade used to fly her own helicopter to keep track of her farmland herds in northern Victoria, Down Under. We went a long way together even though we do not know each other personally.I first competed with her in the World Equestrian 160 km Championship in Dubai in 1998, myself riding and ex-race Thoroughbred, Boss, very much a 'rookie' at that time. Then, at Canberra Open FEI 120 km in 2002, where she was a very fast 1st and myself just completed at 9th position. Another event locally in Putrajaya over 80 km in 2012, a small event for her presumably. Again in the World Equestrian Games at Jerez, Spain in 2003. I think she was top ten at that Game. I was around number 40 in a field of two hundred horses, when my mount , Floyd , a leased horse from France, collapsed at the penultimate round of a total of seven rounds/phases of riding . Exhaustion plus plus, camouflaged by massive herbal antidote given by my French handlers. I had on board a heart rate monitor on Floyd and he was looking good all the time 'cardiovascular-wise'. I was too polite to tell the FEI people about the 'herbal thing' given to Floyd at every rest stop, and thus was made to be a 'pariah' in the international endurance scene, for prusumably 'pushing the horse to far'. Horse death in the sport, especially at this level of competition, is taboo despite everyone wanting to do their best. A paradox. I was exonerated a year later by the Secretary General of FEI himself, Mr Michael Stone. The French Equestrian people, of course went ballastic and their 'press' had a field day on me for weeks after the event. Lucky I don't read French! But looking back, it is all worth it. I lost face for a year, at the most two. The lady owner and her husband lost her horse for her own 'naivity' and mistaken belief that 'things herbal are OK and cause no harm! . My disclosure at that time would have cost her more 'pain'. I can handle my 'pain' but was not sure it is fair that she should have a share of it, at that point in time. Time is a great healer anyway. By morning outpatient clinic I was into the 'thicks of things'. Saw a young Malay chap, just 34, obese plus plus, who came in with classic 'angina', with a total cholesterol of 9.3 mmol !! Stress test is positive. He need admission rightaway for a coronary angiogram, to get a road map of his coronaries, plus minus angioplasty plus minus ad-hoc 'stenting' http://drnikisahak.blogspot.com/2012/05/procedures-in-medicine-coronary.html At angiogram, was found to have a 'left main stem' lesion. We , plumbers' , whenever, we see a LMS lesion on the screen would say a little prayer of: " My God, let me finish this study without mishap ". If a LMS blocked 100 % acutely, it would mean instant death for any individual. And an occasional LMS do get disrupted occasionally during even an angiogram study. http://www.medicalnewstoday.com/releases/81412.php
This young man, in my book, will be scheduled for 'bypass surgery' soon. It is not often now that we sent our patients for CABG [ 'bypass surgery'] given that stents and equipments for angioplasty are becoming better and better with time and techniques have improved by leaps and bound, making cardiac surgery in most cases almost unnecessary. Cardiac surgery , from the standpoint of bypass surgery, is fast becoming a 'sunset profession' the world over. Only valves operation remain their last bastion and even that is going the 'endoluminal' way as cardiologists are invading into their turf with new valves. I emphaties with my surgical colleagues but the problem facing cardiac surgeons all over the world is monumental and fundamental at the same time: While in cardiac surgery especially, they basically have only their pairs of excellent hands and skills to depend on, we cardiologists have a myriad of people and new 'tools ' to play with: bioengineers, geneticists, new science, the whole gamut of the fast moving pharmaceutical industries and free enterprise , are all behind us. It is not a level playing field certainly. Having said that, LMS is still in 2012 , at least in my book, a 'surgical animal' in most countries except Japan and Korea. I will refer patients for surgery , even at 34, without having to think long and hard about it. I belong to the 'conservative' very 'British school of thinking'. My patients oftentimes ask me why we Malaysian cardiologists do not follow the Japanese or the Korean way and do more 'Left Main Stem' cases, apart from the occasional ones during dire emergencies. I always have to tell them my favorite story: In Japan, if a patient dies on 'the 'table' after a difficult procedure, The 'professor' can be assured that the next day the late patient's son of daughter would be queueing dutifully in the professor's outpatient clinic or office with a bouquet of flower for him and some form of 'profuse' apology to the effect, ' Sir, I am sorry my late dad gave you a lot of trouble etc etc and etc..'. Elsewhere in the world , including ours, we may be lucky to escape with a very 'hot' lawyers letter fishing for details and what not! Time has change. At 10.30 pm I get called to see a 43 year old Chinese gentleman with sudden onset central chest pain and profuse sweating plus plus. He was drenched in sweat when I saw him. EKG showing an acute phase of an oncoming 'massive anterior infarct' [ heart attack affecting the front part of the heart due to 100 % blockade arising from a plaque rupture]. An ST-T EKG changes of 5 mm depression in all anterior leads....very 'angry looking and threatening EKG' indeed! No time to waste. His lungs were getting 'wet' by the minutes. Every minute and second counts. He was brought straight to the cath lab and our emergency team alerted for a 'salvage, emergency procedure. We must get a 'road-map of his blocked arteries and 'start from there. Surgery is out of question, there are 'slow animals' as far as we are concerned. At angio, I nearly 'died'.I found out he had an acute LMS total occlusion.. My God!!...seconds count now. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3029447/ I could not cross his acute occlusion with my 'guide wire'. Pulmonary oedema sets in very fast, breathing difficulty,then slow heart rythmn [ 'bradycardia' ], followed very fast by no rythmn, then, ventricular fibrillation [ cardiac arrest ]. When things like these happen , they happen very fast. No time to stand and stare. Patient succumbed on the table at around 1 am, despite more than one hour of resuscitation.. 'Innalillah hiwainna ilaihirojiun' From Him we come to Him we return.
Post Script :................
Now in 2021, Left Main Stem with Multivessel angioplasty and stenting are very common place.
The Park brothers of Korea have for the past 3 decades, shown the world that it is safely "dowable", with conparable results. The West, Americans, French, Europeans and British, were initially slow to catch , up but now, Left Main Stem stenting and angioplasty are acceptable everywhere.........
From my personal perspective, more than 50 % of the cases that I send for bypass surgery in the past, by present " dowability ' and good results status, I would angioplasty and put in stents.........
Such is progress in stents and stent delivery.
That 34 year in 2012 that I sent to bypass surgery in 2021, I would have in 2021, easily stented , with equally good long term result.
........................................................ A Current Article from " For Those Who Think ":- 1. Key To The Garden : In Pursuit Of Happiness http://tafseerkoran.blogspot.com/2012/11/key-to-garden-in-pursuit-of-happiness.html
