36 year old man with an occluded Left Anterior Descending Artery........

36 year old planter with a big GLC.
Hypertensive for 5 years, on irregular treatment and clinic follow up.
Borderline cholesterol.
No family history of ischaemic heart disease.

Presented to me at the outpatient centre, SJMC, with a history of recent onset central chest discomfort related to mild exertion  and occasionally , even at rest, with radiation of discomfort in between the scapulae bones in the upper back, and " classical " radiation to neck and jaws".

 

"Dokto, saya rasa "senok di dada" dan "bebal"  saja di tulae gerehae saya ". He is Kelantanese..,"bebal", means dull ache.." Gerehae means jaws!!.." senok" or "sekok" to me is angina , unless proven otherwise.

The Kelantanese vocab is one of the richest in the world, their wording very precise!!

To old "kakis" like me, " senok" or "sekok" , with pt pointing their closed palm centering around the chest is sine qua non to ANGINA, unless proven otherwise!!

This chap does not need an ECG or Stress test.....He is having ANGINA, fullstop......It is academic.

His Resting ECG, done earlier by his GP is normal anyway.

I now seldom do resting ECG in such a classical case of chest discomfort presenting at my outpatient...go straight for the jugular...i do Stress ECG...if stress ecg at rest show abnormalities, we stop there..if normal, I process with the exercise.

Stress ECG very abnormal with ST-T depression on mild work load , and this ECG changes took long to recover in the recovery phase.

No play, play with calcium score or ct angio.
This young man needed an urgent coronary angiogram YESTERDAY!!!, and his blocked arteries opened!!.......YESTERDAY!!

He needs coronary angiogram to show me the exact " road map " for me to be able to triage him into one of possible 4 classes :

1. Normal coros, which is pretty unlikely in him but still possible......in which case, he has no coronary problem but the chest pain being "non cardiac" in nature, and he has a False Positive Stress ECG..

Very very unlikely, the way he present and the degree of positivity of his stress test, but nonetheless still possible.

2. Has coronary lesion/plaque or multiple plaques, but non-critical...also unlikely, the way he presents.
In this situation, if that is what the angio shows, he would need long term low dose aspirin and optimization of medical therapy and regular follow Stress ECG and high dose statin 

3. Plaques, single or multiple and critical.
If amenable to angioplasty and stenting, it would be done either ad hoc, or staged, depending on complexities and number of lesions..

If complex and nature of lesions borderline, in between BYpass CABG surgery and endoluminal techniques seemed to be of equal standing, I would stop the procedure right there, and discuss the angio the next day for pt to deliberate and discuss.......or even get a 2nd opinion, if he wish.

4. Multiple lesions and diffusely diseased, involving both the medium size middle portion as well as the small tributaries and branches....in which case, both CABG and endoluminal technique are not optimum modalities of treatment strategy.
He is only for " optimization of medical therapy ".
A euphemism actually. 

Not a nice scenario to be in , at any age.

We see this often in pt with long standing diabetics

I personally would not wish to be in this group.

The 'coros' that follow that same evening........

A coronary angiogram view of the left coronary artery. Here the Left Anterior Descending Artery is missing. It is 99 % totally occluded and one can only see a small blot in the centre of the cine picture, just a 'ghost' view of rthe remnant of the LAD, supposed to be biggest artery supplying the front portion of the most important 'piston' in the heart, the left ventricle.

With a wee bit of 'persuasion' and difficulty, i successfully passed a 14th thousand of an inch diameter guide wire,

sonne blue wire, passed across the occlusion...when this is done, 80 % of the " battle" is won...

since opening the occluded artery and subsequent placement of stent is contingent on having a metallic wire passed the site of occlusion...it act as a " railway line for balloon and stent delivery in the artery.

An appropriate balloon is then slided over the wire and expanded up to appropriate atmospheric pressure to open up the occlusion...when this step is deemed adequate, the balloon is taken out, and the artery is then ready for stent placement.

This is the final cine after stent deployment at high pressures between 16 to 20 atm pressure...the occluded Left Anterior Descending Artery is a really big dominant artery in this young man!!!

The whole procedure took about an hour an a quarter.

I was quite"lucky" with him actually, since the wiring into the occluded artery just took me less than 5 minutes.

It could well be much much longer.

I remember chatting away with pt about his recent trip to a Musang King durian plantation and the nice time he had there!....Oftentimes a necessary diversion, to keep what actually is a quite considerable tense an hour or two for pts like him, lying flat on the radiological table, fully draped and strerilised from the neck down to his feet, with myself and my scrub nurse, working thru a small needle size hole via his femoral artery......" playing video game of sort", with help of

an overhead radiological image intensifier

As you can see, these procedures are all done under only light sedation, to keep risk lower , as doing under GA would entails another additional risk, apart from an additional unwarranted cost.

My game plan most time is to ask my pt to concentrate on his favourite zikr while we work, if he or she is Muslim, but this time the young man was a 'bundle of nerves', so the 'Musang King' or "nasi Beriani" diversion was a necessary adjunct.

Pt was discharged well the next day on low dose aspirin and plavix and a statin to bring down his ldl cholesterol to below 1.4 mmol.

................................................

PS :

I am reminded of a car mechanic and a top American cardiologist in Idaho

The mechanic, after repairing the cardiologist sleek looking Mustang, handed him a rather hefty, atypical bill, definitely double the usual  Idaho 'going rate'.

" Why sooo much? ", quipped the cardio

" Doc, my bill is just peanuts compared to yours! "

" Well young man......your bill will not be peanuts, if you can repair my burst gaskets while the engine is still on! ", replied the cardiologist.

Interventional Cardiology 101.......Coronaries of Diabetics

 

https://youtu.be/FkT5-ZTEVoc

Normal Left Coronary Artery. 

The central big long vessel, the Left Anterior Descending artery [ LAD ] supply the main "piston" of the heart, the ''main driver or pump" of blood moving out of the heart chambers to all part of body, via the major blood vessel , the Aorta.

The LAD supplies mainly the  anterior segment of the left ventricle. The Left Circumflex branch supply the back portion of the left ventricle. This cine shows normal circulation of both arteries with rich healthy branches.

You imagine your heart as big as your fist, these arteries sit on your heart, astride on the heart, like a 'mat rempik' on his 'motor bike'.

The LAD and the L Circumflex  branch join together to form the Left Main , which got itself inserted to the root of the big vessel the Aorta, receiving highly oxygenated blood just gushing out from the pumping left ventricle. This flow into the LAD and LCirx , which then move on on into the small arterioles and vessel which ramifies into the ventricular muscle wall, to supply oxygen and energy , ATP's, required by the hard working , non stopping muscle fibres of the heart.

When your heart stop pumping , you also STOP!!!

https://youtu.be/rlnfnX91jBQ

Compare that left coronary system with this one angio I did on an obese diabetic pt of mine, who just celebrated his 40th birthday, married, with 4 young children in toe. ..in his Left Anterior Descending artery itself I can see 4 significant lesions to be ballooned and stented. 

The Left Circumflex branch has one narrowing  which need ballooning plus DEB ballooning [ drug eluting balloon ] or small stenting. The view in the extreme left appears crowded because there is late appearance of distal circulation of the right system. It should not be there. The fact it can be seen from this left shots means the Right Coronary Artery is totally occluded....

This young man has severe triple vessel disease, at an early age.

He has had maturity onset diabetes since age 30.

Currently he is in deep 'shit'...he needs revascularization...1st choice would be bypass surgery. Given his relative young age, I have great  reservation about sending a young man for bypass, but it still remain 1st choice from the viewpoint of extent and severity of the blockages in the both the left and the right coronaries.

To me the left side is easily dowable even though I may end up implanting 3 stent there, but his right total occulsion as seen from the left coronary shots poses special difficulty for us 'plumbers'.

1stly, we may not be able to the cross the occlusion with our guidewire, a necessary pre requirement before we can balloon or stent the lesion. The guidewire acts as a 'railway  sleeper and line for the balloon and stent deployment.

Nonteheless, if this young man refuse surgery , I will do him in 2 stages.

1stly the left system. If I am happy, with the result, I may not even attempt to open the right, since it is already well covered by the retrograde flow from the left.

Of course some 'purists' amongst the plumbers would insist on doing the right, whatever the cost, even though there is a high risk of wire perforation of the artery, since the occluded portion in the right appears too long for comfort.

To me the right coronary is already a 'lost cause'.

The young man has had a 'silent' heart attack in the past on the right side...something common in a diabetic...damage to that side has been done...and now he has some blood supply to the right side from the diseased left. If I correct the left, the right side will get better supply., full stop!

Bypass surgery in this young man , though the 1st option, is not even ideal. The LAD would need sequential graft with a LIMA graft, since there are multiple blockages in the LAD.

Like everything, even bypass surgery has  a 'shelf life'.

By 10 to 12 years, some graft may reblock.

Stents and ballooning also have its  problems....restenosis...though it is easily repeatable.

We are looking at shelf life and shelf life.....whatever we do!

This is not an ideal world...the world of a diabetic with coronary problem.

I approach coronaries like playing 'gin rummy'.

To me, CABG is the all important 'JOKER'.

If I can delay using my 'JOKER', I will delay playing it, and by time 1st with balloons and stents.

'Gedebuk gedebak gedebuk gedebak' young diabetic with coronaries problem give special headache to both us 'plumbers as well as to surgeons!

Diabetes with obesity are causing major problem in the young people this millennium further compounded by a relative lifestyle of physical inactivity.

There will be an epidemic of diabetes amongst the younger generation now since the IT, the handphones, and the video games have produce a whole generation of obese, 'couch potatoes' amongst our children.