Should I Decline a 50% Blocked LAD Bypass While Having AVR Surgery?

[itsme2]

I have a 50% blocked LAD and must have AVR surgery. My surgeon wants to do a LAD bypass while he is doing the AVR but he also states that doing the bypass may not be successful because the LAD is only 50% blocked. He says the usual standard is 60%+ before doing a bypass. I have since learned that AHA recommends not doing a simultaneous LAD bypass and AVR procedure unless the LAD is more than 70% blocked.

Because my cholesterol has been under control for the last i5 years I suspect that the LAD blockage may not be advancing during that time either. If I don't do the bypass I can have a minimally invasive AVR procedure. I don't yet know if my surgeon will allow me to decline the LAD bypass and still do the AVR surgery.

Is it foolish to be pursuing minimally invasive AVR surgery? From what I'm reading lately some places are also doing minimally invasive bypass surgery without stopping the heart. I need to find out if this can apply to my case if I need a future LAD bypass?

Does it make sense to waive the bypass for now and if needed do a stent instead of the bypass on the LAD in the future?

I am a young 74 yr. old weighing 180 pounds, 6' 1" tall, non smoker. Have no other health issues except for early stage Parkinsons diagnosed this year - only symptom so far is resting tremor in right foot.

What would others here do with regard to not doing the LAD bypass now under the same circumstances?



Thank you.

 

[almost_hectic]

I could not and would not give you advice on this issue. But I see it like this. When I found my surgeon he came highly recommended. I did my research and I was very impressed with his reputation, background and credentials. I met him and was very comfortable with him and his entire staff. Ultimately I decided, I was going to put my complete trust in this man to save my life. From there forward I asked questions, but never questioned his judgement, skill or expertise. Whatever he decided I was 100% behind him all the way? I found great comfort in absolute trust. Otherwise I would have been scared to death.

 

[honeybunny]

What is the alternative to not doing the bypass during AVR surgery? Would you have a stent inserted in the future? One of my arteries was 70% blocked and a bypass scheduled for my AVR surgery. I could have had a stent but that would have delayed AVR surgery for at least six months I was told. So I'm wondering if, in your case, you could have surgery now without the bypass with a stent at a later date.

 

[itsme2]

Deleted inaccurate post.

 

[epstns]

I don't know. . . I think your surgeon's advice carries some weight, but I was in a similar position. When I went in for my pre-op angiogram, my surgeon instructed the angio team not to stent anything that they found, because he would simply perform a bypass "while he was in there." I remember discussing minimally invasive procedures with my surgeon, too. His response was that he prefers full access so that he can deal with whatever he finds once surgery is underway. His opinion was that recovery wasn't really going to be any different, and he could minimize scarring. In my angiogram, they found a 50% blockage in my LAD, and in surgery combined with my valve replacement, they did a bypass from my left interior mammary artery to the LAD.

I think a lot has to do with your surgeon's opinion after seeing your angio results. I'd go along with my surgeon unless I had really major misgivings. In your case, though, since you say that your blockage cannot be relieved by stenting, I would certainly discuss erring on the side of caution with my surgeon. There is no guarantee that your cholesterol being under control will keep that blockage from getting worse.

 

[Jkm7]

Have you asked your cardiologist for his/her opinion? Your surgeon and cardiologist both have an important role in your care and condition.

 

[W. Carter]

I would get everything fixed at the same time with OHS. Why put it off when you have a surgeon wanting to fix it?

 

[Northernlights]

The 2014 AHA / ACC guidelines only recommend concomitant CABG with valve replacement when the blockage is significant, which they define as 70% or greater, or 50% in the left main coronary ( not the same as the LAD) . The rationale is that a lesser blockage will not be limiting flow or causing angina, and therefore a bypass is unnecessary ( and increases operative mortality). The graft is also more likely to fail, due to the fact that less blood will be going through it, as the original artery is still patent. Therefore if you decided against bypass , you would be following the guidelines, so it seems perfectly reasonable. Perhaps a second opinion would be useful. The important thing is to avoid progression and risk factors, but since you have been keeping your LDL cholesterol low it seems you are doing that.

 

[Agian]

Did someone say 'stent'? I recently had one of those and suffered a 'trivial heart attack', as a consequence. This is a rare event, but I'm just putting it out there.
If it was me knowing I might need another OHS in future to fix a 50% that 'might' progress would haunt me, even if it never got worse.
I agree with Steve on this one. If your surgeon uses the mammary artery, they tend to be a lifelong fix (yeah, I researched this after my little episode).
Northern makes some very valid points as well: "The graft is also more likely to fail, due to the fact that less blood will be going through it, as the original artery is still patent."
Get a second opinion. Itsme, how old are you?

 

[itsme2]

Did someone say 'stent'? I recently had one of those and suffered a 'trivial heart attack', as a consequence. This is a rare event, but I'm just putting it out there.
If it was me knowing I might need another OHS in future to fix a 50% that 'might' progress would haunt me, even if it never got worse.
I agree with Steve on this one. If your surgeon uses the mammary artery, they tend to be a lifelong fix (yeah, I researched this after my little episode).
Northern makes some very valid points as well: "The graft is also more likely to fail, due to the fact that less blood will be going through it, as the original artery is still patent."
Get a second opinion. Itsme, how old are you?

I'm a young 74. Would an opinion from my cardiologist qualify as a second, I have a meeting with him in 5 days? Surgery is scheduled for December 7th.

Thanks...

 

[itsme2]

The 2014 AHA / ACC guidelines only recommend concomitant CABG with valve replacement when the blockage is significant, which they define as 70% or greater, or 50% in the left main coronary ( not the same as the LAD) . The rationale is that a lesser blockage will not be limiting flow or causing angina, and therefore a bypass is unnecessary ( and increases operative mortality). The graft is also more likely to fail, due to the fact that less blood will be going through it, as the original artery is still patent. Therefore if you decided against bypass , you would be following the guidelines, so it seems perfectly reasonable. Perhaps a second opinion would be useful. The important thing is to avoid progression and risk factors, but since you have been keeping your LDL cholesterol low it seems you are doing that.

Northernlights:

I found the AHA Document you refer too but I can't figure out how to find and print the section on Concomitant CABG with valve replacement. I see a Chapter 14.2/151 that seems to be the correct content but nothing in the document seems to numbered page wise and so I can't find the information: http://content.onlinejacc.org/article.aspx?articleid=1838843

Can you or someone else here help me out with this, THANKS!

 

[Northernlights]

Itsme2:

It is a very non-user-friendly document. I just scrolled through till I found it, I'm afraid, but I think the easiest way is to open the pdf version ( there's a link on the same page) where the numbered sections are highlighted in green . It's section 14.2 and is on page 95 of a 129 page document, which may give you some idea of where to start looking. Sorry I can't be more helpful.
Interestingly the 2011 ACC/AHA guidelines for stents and CABG alone have the same 70% cut off point, though they also use reduced FFR ( fractional flow reserve) as a guide.

I can see it is tempting psychologically to 'get everything done at once' but I think there is also a reasonable argument for following the guidelines, meticulously controlling your CAD and keeping your left mammary artery in reserve for if it's really needed ( hopefully never!) rather than using it early and having an increased chance of it failing earlier too. But really it's something to talk over the pros and cons with your cardiologist.

 

[itsme2]

Itsme2:

It is a very non-user-friendly document. I just scrolled through till I found it, I'm afraid, but I think the easiest way is to open the pdf version ( there's a link on the same page) where the numbered sections are highlighted in green . It's section 14.2 and is on page 95 of a 129 page document, which may give you some idea of where to start looking. Sorry I can't be more helpful.
Interestingly the 2011 ACC/AHA guidelines for stents and CABG alone have the same 70% cut off point, though they also use reduced FFR ( fractional flow reserve) as a guide.

I can see it is tempting psychologically to 'get everything done at once' but I think there is also a reasonable argument for following the guidelines, meticulously controlling your CAD and keeping your left mammary artery in reserve for if it's really needed ( hopefully never!) rather than using it early and having an increased chance of it failing earlier too. But really it's something to talk over the pros and cons with your cardiologist.

Thank you Northernlights!

 

[Agian]

I'm a young 74. Would an opinion from my cardiologist qualify as a second, I have a meeting with him in 5 days? Surgery is scheduled for December 7th.

Thanks...

Itsme, if it was me I'd want to talk to another surgeon.

 

[Agian]

I'm a young 74. Would an opinion from my cardiologist qualify as a second, I have a meeting with him in 5 days? Surgery is scheduled for December 7th.

Thanks...

Itsme, if it was me I'd want to talk to another surgeon.

 

[ALLBETTERNOW!]

My surgeon is a while we are in there guy but at 60% he left one of my left arteries alone! I guess AVR, Aneurysm repair and maze procedure was enough to do at one time

 

[itsme2]

Itsme, if it was me I'd want to talk to another surgeon.

Thanks, I now have a second opinion consult scheduled with Vanderbilt University Medical for Dec.11th.