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LAD occluded after proximal part in ANGIOGRAM. SURGERY needed?

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Last week I had angiogram test because of some chest pain that happened 2 months back and here the report findings - (Doctor said ECG shows Myocardial infarction and so to undergo angio test)

Here the angiogram report findings:
LMCA : Normal
LAD : Occluded after proximal part. Mid and distal LAD fills via collaterals.
LCX : Large Vessel. OM1 - Large vessel with mid 70% lesion.
RCA: Mild mid RCA atherosclerosis. Supplying collaterals to LAD.
LIMA : Normal

Doctor has given 2 months time for surgery. Is my condition really serious and do I need a surgery or I can improve with medications?
Following medicines have been prescribed - deplatt, tonact, ranolazine

Category: Cardiologist

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Category: Cardiologist
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It is usual practice to do coronary angiography after a myocardial infarction. In your case the finding of ecg is confirmed in angiography i.e the lad is 100 percent occluded. And another OM Artery is 70 percent occluded. So it merits revascularisation.
Ideal would be to subject ypu to a pet scan for viability of myocardium in the infarct area. If more than 10 percent of the are in the lad territory is alive or viable then the lad merits revascularisation. If it is not viable more than 10 percent it could be left alone. However the 70 percent blockage in other artery definitely should be tackled. However practically speaking most doctors do not follow this protocol and assuming that more than 10 percent of the are is viable in the infarct area the revascularisation of the 100 percent occluded artery is advised. It is not a totally wrong approach. So you could either directly go for angioplasty for the 100 percent and 70 percent lesion or a bypass surgery if angioplasty is difficult or otherwise you could find whether the area of lad is alive more than 10 percent of total area of lad supply. If not alive then only 70 percent lesion may be treated. Both the approaches are correct.

As far as the timing is concerned it could be done after 7 to 10 days if you prove that lad is alive. A bypass coild also be done after 3 weeks. Medications seem appropriate. However if your bp and heart rate are appropriate then a beta blocker and ace inhibitor along with eplerenone may be useful.
Dr Vivek Mahajan
DM Cardiology

Patient replied :

Is it possible to avoid angioplasty or bypass surgery and stay on just medications, with proper diet? Is there possibility of any sudden heart attack while on mediciations and controlled diet? Also, does EECP therapy help in avoiding surgery and improving heart health.
My ejection fraction is 60%,

With 100 percent occlusion of LAD, LCX 70 percent occlusion, it merits revascularisation.
Diet and medications are preventive but definitely not curative in this stage. Angioplasty will be required. With diet alone, and without angioplasty/ bypass, chances of heart attack will always be there. Can be minimised by the surgery to a large extent.
Since one artery is totally occluded and only rca is disease free that means the om artery also needs treatment if for financial reasons you do not wish to undergo revascularisation then medical management can be a option. But if possible get it done. Of course diet and lifestyle have to be followed. With your anterior myocardial infarction and closed down lad, I doubt your ejection fraction woll be 60 percent. Kindly get it rechecked must be lower
Regarding ECCP therapy, it is only advised when the candiate is not suitable for bypass surgery. It is a relatively newer method and not much literature is available regarding how effective it actually is.


Patient replied :

Am I in a urgent need of surgery or Can I wait for a couple of months and see my status.
I re-chected my EF and it is 60%. It was taken two months back post MI. Will it have gone drastically in last 2 months? I dont have the data of LVEF.
Some cardiologists say that if collaterals are well developed they can act as a natural bypass and supply enough oxygen rich blood. Is that true? In my case can you tell me how good are my collaterals.

In my opinion you should get it done as soon as possible.
Though EF 60 percent is not bad for the time being, but things can change a lot in 2 months.
Don't panic please, discuss with your cardiologist and proceed.
Yes if collaterals are well developed, they can act as a natural bypass.
There are some collaterals which have developed around your LAD, and that is doing the bulk of the supply now. It is because of this well developed collaterals that you're not having as many symptoms as you should have with such blocks.
In my opinion, you should get the surgery done. Don't delay it beyond a month. The more you delay the more chances of a heart attack.

Patient replied :

May I know how are you able to say that my collaterals are well developed? I have a problem locating where is the actual block in my heart. It is mentioned as block after proximal part.
"LAD : Occluded after proximal part. Mid and distal LAD fills via collaterals."- from report. With any image can you tell the block location.
After angiogram test, the cardiologist said I can wait for 2 months. I consulted with few more cardioligsts and they said the block is not that serious and I can stay on medications. I get mixed answers.
Does occluded lad means 100% block?
A doubt regarding symptom. Every morning after sleep i have pain at the left side about 3inches under my armpit area? Is that any worrying symptom?

I did not mean to imply that your collaterals are well developed. Kindly read my last answer. Since you aksed a question whether collaterals ( if well developed ) can act as a natural bypass, my response was ' yes, if they are well developed ' they can act as natural bypass. In your case you have collaterals supplying to LAD, which has the maximum block.
The cardiologists who are able to examine you physically will be the best judge. I won't say your condition is very serious, but I will advise you to get a PET SCAN, to confirm if 10 % of the area is viable in the infarct area, if it is then revacularisation is necessary. More than the 100 % block in LAD, 70 % block in OM should be tackled soon. But as i said, your cardiologist who examines you physically is the best judge.
Regarding your symptom, it could be due to the recent infarct, there will be some amount of referred pain. You have been put on Deplatt, Tonact, Ranolazine, the pain will gradually go away.
Dr. Vivek Mahajan.

Dr. Vivek Mahajan
Category: Cardiologist
Fellowship: DM, Cardiology, PGIMER, 2013
Residency: MD, Internal Medicine, AIIMS, 2007
Internship: King Edward Memorial (KEM) Hospital, 2003 
Medical School: MBBS, Seth G.S. Medical College, 2002
Dr. Vivek Mahajan and 4 other Medical Specialists are ready to help you

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