Submitted by Dr T on October 30, 2010 – 7:34am
Your dad has a number of complicated issues to deal with:
- Advanced Atherosclerosis
- Advanced Coronary Artery Disease (CAD)
- A damaged heart muscle with poor heart function
- Risk of Ventricular Fibrillation (VF) & Sudden Cardiac Death (SCD)
- Atrial fibrillation
- Cholesterol problems (I am sure)
I. Let’s start with his CAD. Fifteen stents! When is enough, enough? Patients with Diabetes and diminished heart function and especially with Left Main disease do MUCH better with Coronary Artery Bypass Surgery than with stenting, as his constantly recurring disease has already shown. Was he ever sent to a Cardiac surgeon for consultation? If so, was he told he was not a candidate for surgery? I bet not! I once saw a patient who had undergone 31 angioplasties before he was finally sent for surgical consultation, had his bypass operation and finally stopped having to see his doctors every 3-6 months. Many physicians think cardiac surgery is a horrible thing to go through – it isn’t, certainly not when stents keep failing.
II. While true that bypass surgery becomes more risky in patients with poor heart function, if successful, the outcomes are often excellent. Among other things, there is something called “hibernating myocardium”, where some of the heart muscle is malfunctioning because of insufficient blood supply. After bypass surgery, it is not unusual to see those areas of the heart begin to function better. However, this is always a complicated situation that requires a team approach, including cardiologists & surgeons to come up with the best recommendation. Having said that, I have operated successfully on many a patient like your dad with just that (improved heart function) happening.
III. In some patients with poor heart function there is indeed a greater risk of VF and SCD. An Implantable Cardiac Defibrillator (ICD) can detect VF and shock the heart back to a normal rhythm before SCD occurs. In addition, the newer devices also have special pacing capabilities that may reorganize the heart rhythm (“resynchronize”) and thus improve heart function somewhat. Thus, an ICD may indeed help patients survive longer. However, since your dad also has atrial fibrillation, I would suggest he gets evaluated for an ablation procedure, to see if it is possible to get him back to a normal rhythm first. All these considerations require he gets an EP study.
IV. Patients with end stage heart disease become candidates for a heart transplant. I doubt your dad is there yet, but it points out that he needs treatment in a center with experience in all aspects. Major medical centers around the country specialize in the treatment of heart failure, and not every patient needs an operation. Certainly there must be ways to optimize his medical therapy with medications, diet & lifestyle modifications.
V. Finally, this brings me to the last part, diabetes, diet etc. Patients are usually quite willing to subject themselves to whatever pills & treatments their doctors come up with, but are often totally unwilling or incapable to improve their diet, exercise, lose weight and stop smoking. Nothing is going to change, unless your dad does takes charge in his own care. All the rest, the surgery, more stents, an ICD or even a heart transplant is just a stop-gap measure!
If you go to my website, browse around and you’ll find lots more information you will find useful. One thing you might want to do, is take this test to see from what treatment your dad might benefit the most:
I think I know the answer.
Hope this helps,