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Is Bipass neccessary when RCA is blocked, LCA stented?


Posted by T. J.

46 Yr old male.  Family history of heart disease and High Cholesterol/ Trig, etc... I've not had a heart attack.  2 years ago while undergoing an angiogram, the doc found a long section of the RCA blocked 95 percent.  The LCA was 75 percent blocked and stented with the drug coated stent.  At first the doc thought another doctor might be able to roto router the RCA open.  He said it was to risky, brittle, etc...and that the LCA was feeding the right side retrograde.  Last EF was 64 I think.  I am still trying to get my numbers right...recently upped the Lipitor to 40 and added Niaspam.  At some point should I have another angiogram to check the stented artery?  The doc says any test other than that would be a waste of time.  Also, is it true that with a stent I would definitely have symptoms (early warning) if the LCA was clogging up again vs. the fall over dead scenario.  Any thoughts appreciated.
 
Answers (2)
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You need to talk to a non-invasive cardiologist, as it sounds like you've only talked to an invasive cardiologist.

There's no clear clinical benefit of routine heart catheterizations, especially in someone such as yourself with known coronary artery disease.  Importantly, routine catheterization exposes you to unnecessary risk (e.g. radiation, bleeding, kidney damage, etc.) and doesn't define the physiological importance of blockages.  Almost all of us have blockages to some degree, but not all of them matter.  There's a paradox between stenosis degree (e.g. blocked 95%) and chance of heart attacks, as the smaller blockages are more likely to lead to acute heart attacks.  One way to think of it is that if a blockage has developed slowly enough to reach 95%, it's probably very stable and is less likely to suddenly close.  The blockages that are more likely to acutely "break" and lead to an acute heart attack are those that are less than 70% in severity, as they're less mature and less stable.

If you want to determine if your blockages matter, you should exercise and determine if you get symptoms.  If you can run/swim/bike/etc 30+ minutes, working hard, without getting chest pain and/or shortness of breath, then you're likely doing fine and don't have to have tests done.  The test of choice to follow-up with symptoms with exercise would be a perfusion study (e.g. exercise stress test with nuclear imaging).  This is far better than just doing a heart catheterization, as it provides physiological information.

Unfortunately, it is possible to suddenly die without symptoms from your stent having problems, just like it is possible to die suddenly without symptoms from blockages in native arteries.

With a normal EF and collaterals ("left side feeding right side"), it sounds like you don't necessarily need a bypass.  Take great care of your heart with healthy diet and exercise and you can stay out of the operating room.

Thanks for taking the time to answer. 
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