1024Bytes said:On Sun, 17 Aug 2003 17:39:02 GMT, Marc Schwartz <[email hidden]>
wrote:
[snip]
Quoted message said:
Marc,
Thanks very much for your careful, thoughtful and well-informed
answer. Frankly it is far more than I hoped for. I have a full
blockage of the left cardiac artery and a 70% blockage of the right
artery. This condition has greatly changed my life, limiting activity
severely.
You are quite welcome.
Quoted message said:I have consulted a number of cardiologists and surgeons in the past
year about this and none feel that anything can be done to repair the
fully occluded artery because it is abnormally small. A balloon
angioplasty attempt was abandoned during the procedure.
Just to be clear, I am not a physician and so am not in a position to
offer any specific professional guidance relative to treatment options or
recommendations. As you have done, such a recommendation can only come
through detailed "in-person" communications with your physicians who know
you and your medical history closely.
Quoted message said:I have a recommendation from a well-known cardiologist that I undergo a
double bypass to the partially-occluded artery and a surgeon who agrees
and would perform the procedure, though he admits my risk is higher than
normal because that artery also is smaller than normal. Two surgeons at
the same coronary facility where the cardiologist practices have
declined to do the surgery except in an emergency. Both state that the
small size of the artery is a major reason for their decision. A balloon
angioplasty and a stent are not indicated in this artery due to the
position of the blockage near junctures in the artery, according to the
cardiologist I am seeing.
As you are finding, there will be a spectrum of opinion, some of which
will be based upon published data, some of which will be based upon
personal physician experience and comfort levels. As with any profession,
not every professional will have specific experience with particular
patient profiles. One physician's everyday experience may be another
physician's rare case.
Stenoses (the blockages) located at the bifurcations of the arteries
are historically problematic relative to catheter based treatment options,
since there is a risk of closing one branch, while you are attempting to
open the other. The risk of the procedure is increased when there are
already other blockages compromising blood flow. There are special
catheter techniques that are used by interventional cardiologists in such
situations, but not all are comfortable with them and the data still seems
to be somewhat inconclusive.
Quoted message said:You might conclude correctly that I am doing the math.... the overall
unadjusted mortality rate for CAB is reported at near 2.5% (according to
the study you pointed me to) conbined with my greater risk makes me
wonder if I should not look for a different option
I think that it is entirely reasonable to seek alternatives with the goal
being to ultimately make an informed decision. In the end, only you are in
a position to make the risk/benefit decision as to how to proceed, if at
all.
One other possibility, would be to seek the counsel of other physicians
at different institutions. This would include any larger private or
academic facilities (including those in other cities) that may be involved
in clinical research that might be applicable to your specific situation
and anatomy.
Part of the decision making process is likely to include an assessment of
your current ventricular function and how much, if any, improvement is
likely to be achieved by restoring increased blood flow to the affected
areas of your heart. In other words, if ideal technical outcomes were
achieved, to what extent and for how long, is your quality of life likely
to be improved if you take the risk of undergoing any particular treatment.
The risk based decision making needs to balance both short term and long
term risks and outcomes. As an example, the risk of short term mortality
in a routine stent placement is quite low when compared to the same risk
of surgery. That would lead one to have a stent without question in
almost every case. However, if one reviews the longer term outcomes over a
period of years, the cumulative risk of having multiple stent procedures
because of re-stenosis versus a single cab surgery over the same time
frame would likely lead to a different decision. This difference would
increase in the case of disease in multiple vessels.
One thing to keep in mind of course is that coronary disease is
progressive. None of these treatments are stopping the disease and
ultimately (at least with today's treatment options) the blockages will
return, either in the same locations or new ones. The combination of these
treatments, along with appropriate medications and behavioral
modifications, can certainly slow the progression to varied levels.
Quoted message said:I see two potential treatments on the horizon that I am wondering about.
The first is the use of "Human Fibroblast Growth Factor 1," a gene
therapy that is growing new cardiac vessels in patients in trials in the
U.S. and has done so in Germany. The second is laser angioplasty with a
new laser catheter, which I think has recently gained FDA approval.
Having attended a recent multi-day seminar, that included the opinions of
some of the most progressive folks in interventional cardiology, the
general opinion was that angio-neogenesis related therapies are promising,
but still "down the road". Similar opinions were expressed with respect to
the newer laser and cryo related procedures. The general sense was that
combinations of current therapies, near term, are likely to be the best
"mainstream" options. This includes by the way, some hybrid approaches
where both surgery and interventional cardiology techniques are used on
the same patient during the same admission.
Within the next 5 to 10 years give or take, you can also begin to expect
to see the next generations of the drug eluting stents emerge. These will
likely be made from bio-absorbable polymers. The advantage will be that
you will get the short term benefits of the mechanical support of the
stent and the localized delivery of the various drugs, but over time the
stent will essentially dissolve into the tissues, therefore not leaving
behind the so-called "railroad track" of metal. That makes the target site
more amenable to future repeat treatments (more stents or surgery) when
required.
Quoted message said:I see hope that either (or both) could be helpful in reopening (or
replacing) the fully-occluded artery and that laser angioplasty could
open up the partially-occluded artery. Are you familiar with either of
these new technologies? Have you found anything insightful about them
and their effectiveness and whether my hope is somewhat pie in the sky?
I think that in the end only you can determine your comfort level with the
guidance that has been provided by your current physicians. As I
mentioned above, seek the opinions of other physicians, to the extent that
you might find others who have greater experience treating patients with
your particular history and anatomy, where they can offer more definitive
projections of risks and outcomes.
If you are curious about some of the alternative emerging options touched
on above, some of which may be presently only available via entry into a
clinical trial, then you may wish to seek out the primary investigators in
those trials. You can communicate with them, seek their opinions and
determine if participating in a clinical trial is within your own level of
comfort, if you meet the required criteria.
I hope that offers some additional assistance.
Marc Schwartz
