Friday, November 23, 2012

Case History : Left Main Stem...



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.


                                                                         Part 1




Part 2:-  

                                         

                                                                         Part 3 :





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Fresh Catch from "Tafseerkoran.blogspot.com"/For Those Who Think:-
http://tafseerkoran.blogspot.com/2012/11/surah-al-hijr-5prologue.html

















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