CML, a 64 year old Indian gentleman, saw me some 16 years ago in ER, SJMC, at 2 am in the context of an acutely developing anterior wall myocardial infacrtion [ heart attack involving total,100 % blockage of the Left Anterior Descending Artery ].
He was duly admitted right straight to the Cath Lab, where the occluded artery was duly 'openned' with balloon angioplasty and drug eluting stent implanted.
At the same sitting the proximal Right Coronary Artery , that had 75 % stenosis [ significant, critical- flow blockage ] was also ballooned up and stented. He had 2 stents implanted that wee hours of the morning.
He was lost to my clinic follow up for years following Covid epidemic, until last week, he presented at my outpatient clinic with ? GERD pain., pain in the epigastric region moving up to the chest , like a heartburn type of discomfort.
A blood test for 'Trop T sensitive' was taken and I gingerly put him on the threadmill.
His resting ECG was normal looking but hardly 3 minutes when he started walking, the ECG showed evidence of myocardial ischemia. The Stress test was duly stopped.
Back in the clinic, his 'Trop T sensitive' result proved positive. He has ACUTE CORONARY SYNDROME.. He was duly admitted and planned for coronary angiogram the next day.
" Doc, whatever your finding, by hook or by crook, I don't want Bypass Surgery! ". When patients like CML, give this kind of 'preemptive' decision, interventional cardiologists like me have a wee bit of 'heart-burn' because doing an angiogram on people like CML, with chronic, badly controlled lipid level, with clinic f/u which at best are irregular, etc etc and etc, it is like going to have breakfast at Manhattan Fish Market : we dont know what is going to be the 'fish on the plate' for that morning.
If the lesions turn out to be complex, ad-hoc angioplasty and stenting, there and then, straight on the table without prior detailed discussion with or without his spouse or partner being present, can be wee bit stressful to the interventional cardiologist. We want to discuss further with patients and family but the " Doc, I dont want surgery, full-stop ", is usually a stiff order.
BUT AN ORDER IS AN ORDER.........he was very specific with what he wanted, and his wife was present, at the initial discussion.
I proceed.
Video 1
This was his Right Coronary angiogram. Alhamdullillah, the proximal stent in the Right Coronary Artery is still very patent despite 15 years plus, albeit with minimal 'in-stent restenosis' [ renarrowing ], about 20-25 % of diameter of stented part. In the distal RCA are two tandem lesions, about 90 to 95 % each. Critical. The RCA, at this point and the distal run-off, overall looks good for either angioplasty and stenting and also good for the surgeon.
Video 2
The Left Anterior Descending Artery cine showed a critical 90 % stenosis before the fully patent stent implanted 15 years ago, to the ostium of the Left Main Stem artery. They was no adequate landing zone for any stent implantation, if one is planning to stent this artery without encroachment in the Left Main Stem Artery. Infact the ostial LAD disease seems to spread into the distal LMS vessel, given a luminal narrowing of about 50 % at the distal LMS. This is a surgical option...
Video 3
A " spider cine view of the LMS lesion, 50 % narrowing here and subtending into the ostial LAD vessel with 90 % narrowing.
....
Video 4
A AP-Cranial cine view of the left arterial system highlighting the 90 % narrowing. At this juncture Ipointed to Mr CML:
" Sir, You have a very tight right coronary blockage, 2 narrowings in the distal Right, about 95% both of them, and a tight lesion in your proximal LAD before your old stent. Your left and right stents seemed to be holding very well despite 15 years with little, non significant re-narrowing....the left narrowing involved the Left Main Stem......the 1st option is CABG since , at present time, the available data seems to point to a better long term result. I will stop here and discuss the cine with you again tomorrow with your wife present, and give you time to consider a surgical option "
" Doc, is my disease dowable with angioplasty and stent.? What is the risk and how long will it take for me to get back to work. I have an oversea trip coming up a week's time. I dont want surgery."
" The ball-park figure for risk of mortality for chaps like you with this good looking lesions and distal vessels run-off, and normal left ventricular ejection fraction of normal 62 %, I think in my estimation around less than 1 %. You can begin work tomorrow evening. Your oversea trip next week , insyaallah, can proceed.... "
Video 5
I gingerly and carefully passed an 18/1000 inch BMW stainless steel guide-wire with a soft end into the Right Coronary Artery with Xray guidance. With the guide wire in place, I passed a small balloon,a semi compliant balloon, 2.5mm diameter and 15 in length over the guidewire going thru the artery gliding in the artery in a monorail fashion.
Video 6
The two tight lesions were dilated several times with the balloon in placed at that spot of constriction with pressures around 8 to 11 atmospheres.
Video 7
Having satisfactorily pre-dilated the lesion, I remove the 1st predilatation balloon , and with still the guide-wire in the right coronary, I passed and glided another balloon over the lesion. This time a 3.0mm x 26 mm in lenght balloon with a drug eluting stent of that lenght, factory-crimped on the balloon.
Deployed the balloon and stent twice at pressures 8 atm, & 12 atm respectively.
Video 8
Final result of the Right Coronary lesions after further high pressure dilatation, and removal of balloon and guide-wire. Looks satisfactory.
The distal narrowing in the small branch , I leave alone.
Video 9
Now it is on to the left system.
I passed another new BMW guide-into the un-diseased Left Circumflex Artery as an 'insurance policy' while we are to do work on the Left Anterior Descending Artery, as oftentimes, this vessel can close while we are doing work on it's partner branch of the Left Main.
I passed another guide-wire into the the culprit artery where we will be working ie. The Left Main Stem, and the Left Anterior Descending Artery., a Sonne Blue 18/1000 inch diameter wire also with soft ends.. Gingerly , I glided predilatation, semi-compliant balloon , 3.0mm diameter x 15 mm length,over the Sonne Blue guidewire, and placed the balloon just at the tight LAD lesion, and deploy at 8 to 10 atm, in sequential fashion, all along the lesion lenght.
Video 10
After satisfactorily predilated the LMS- Ostial LAD lesion with the predilatation balloon, I removed the balloon and re-introduce another balloon, the stent balloon ie 3.0mm in diameter and 26mm in lenght to satisfacttorily cover the whole lenght of the LMS and the ostial lesion in the LAD artery.
at this juncture it is important to get accurate placement of the stent to cover all the diseased portion of the artery, and cine from several views are usuaaly done.
In this video, it is showing the 'spider view' ' [ AP-caudal view ] of the LMS and the Left Anterior Descending Artery
Video 11
When it ws deemed the stent balloon had been accurtely positioned, only then was the balloon deployed at twice at pressures 10atm to 12 atm respectively.
As an interventional cardiologist for over 3 and a half decades onw, when I am in a Left Main Stem with balloon and stent fully deployed , I still have my adrenaline rush.
Mashallah, in this kind of work, things can always go southward in the best of cases, and this has benn my practice now for over decade that at the beginning of any angioplasty I asked my patient to say his favourite prayer or incantation continously while I say mine..
1 % mortality may not sound very much to you and me but if you happened to be that 1 %, it is 100 % for you !!!
Video 12
After satisfactorily deploying the stent across LMS- LAD, I take off the stent balloon and deploy a short high pressure 3.0mm x 8 mm high pressure non compliant balloon deploying it in the tent at 18 atm sequentiially.
Video 13
Then do a POT in the Left Main Stem with a high pressure , non compliant short balloon 4.0 mm x 8 mm lenght at 22 atm sequentially, and 25 atm at the ostium [ opening ] of the LMS with the aorta.
After this procedure I can sense the whole Cath lab staff, scrub nurses, technician and radiographer, there was a collective sense of relief and sigh.
Angioplasty and stenting, at whatever level of difficulty, is a total team effort. I am there acting just as conductor of the orchestra!
For me it is like music, occasionally just keroncong but oftentimes , like this case, it went on to Bach or Beethovan.
Video 14
This is the final result of the LMS-Ostial LAD stenting.
" CML, you are an excellent patient throughout the procedure, soo calm and composed...what yogic chant were you doing this 1 and hour hour?.....Is it OOOOOMM all the way? "
" Doc, who come you know ?......I was doing that, yes..!! "
" Well, CML, I was doing ..'Allaah ..Allaah..Allaah ' so I assume you must doing Oooooomm..Ooooomh..Ooooomm .......you looked so composed...you never once disturb our work.....you are a rare patient "
