[HSF] Coronary Case

[A]

I think you have to look somewhere else for her symptoms. Looking at the
last cath findings I don't think she requires surgery for them unless you
think the LAD bridge is significant then I would take to the OR for that. By
the way what is (ISR)? I strongly believe that she will right back in your
lap with the same problem 

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Ani Anyanwu
Sent: Monday, January 29, 2007 8:14 PM
To: OpenHeart-L at lists.hsforum.com
Subject: [HSF] Coronary Case

I would be grateful for opinions on this case.

Female 50 years, hypertensive, smoker presented with ACS in 2004. Cath
showed 75% mid LAD stenosis just before a myocardial bridge. Left dominant
system, circumflex okay. 2.5 cm DES placed in mid LAD. Continued to have
exertional angina so in 2005 another 2.5 cm stent placed in mid LAD to cross
myocardial bridge. Same time IVUS shows 30% ramus lesion. Cx okay. 

Still gets exertional angina despite both PCIs. Had 12 cardiac caths in
intervening period till this year all show essentially normal vessels with
stent in LAD (which remained patent) and mild disease in ramus. Isotope
study did not show inducible ischaemia. Symptoms are crippling and alternate
between CCS 2 to 4. Assumption is coronary spasm. On high dose vasodilators
but still very symptomatic. Still smokes.

Most recent catheter shows about 40% tubular stenosis (ISR) within 5cm of
stented LAD. Unobstructed large Cx which gives rise to PDA, 30% ramus
lesion. On this instance there was 80% proximal narrowing of the
non-dominant RCA which resolved with nitroglycerin confirming spasm in this
vessel. Normal LV function. Angiographically can bypass distal LAD, ramus,
any number of 3 major circumflex branches (OM, PDA and PLV) and a
non-dominant RCA. 

Accepted for surgery. Assuming you have accepted to operate, what operation
would you do? What vessels would you bypass and with what conduits? Are
there any concurrent options (e.g. TMR, nerve ablative therapy)? I am not
willing to discontinue clopidogrel in this setting (or indeed these days in
any elective case with DES) so please assume procedure you choose will be
done on aspirin and clopidogrel.

Thanks for any opinions

Ani Anyanwu
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