Brief Answer:
Yes CABG should be done if PTCA is not a option

Detailed Answer:
Hi Dear ,

As you have written that your mother in law had blockage in all three arteries ,but it's a old concept now that CABG(bypass) is required if all three vessels are blocked, even in Triple vessel disease PTCA( stenting ) can be done now ,and is very successful.
however there are a few condition for e.g when blockage is present in Main left coronary artery bypass is preffered over PTCA .I would like to go through the reports of your mother in law which your cardiologist has provided you with, if possible you can mail me the videos of her angiogram on my email id - YYYY@YYYY , i would like to see the video and go through the reports of coronary angiogram of your mother once .

For your first question is it advisable to go for by pass surgery at a age of 70 years, My answer is yes if she has a blockage in three arteries ,she is symptomatic and the blockages are critical( more then 90%) and stents are not a option due to location of the blockages then yes she should go for a by pass surgery,its definitely going to improve her longevity and overall quality of life.

According to researches-
"Symptom relief occurs in most survivors post CABG and is accompanied by excellent rates of long‐term survival and a good quality of life overall.Therefore, an individualised risk–benefit profile must be carefully constructed by clinicians, taking into account several different factors and not just age of the patient alone."

In recent years the age group defined as “elderly” in the literature of cardiac sciences has gradually increased from ⩾65 years to ⩾80 years, your mother in law is still in 70's.
However , old age alone (ie, >70 years) is an independent risk factor for poor outcomes after CABG in comparison to PTCA .

Now lets come to risk factors and complication
Overall mortality rate in elderly post CABG is 3-4%,during the surgery itself heart attack can occur in 4 to 5% of patients which may cause immediate mortality,about 5% of the elderly patients requires re exploration post CABG due to Bleeding complications.
This mortality is increased ,if ejection fraction is low( 2d echo report) or the disease involve Left Main Coronary Artery or patient is a diabetic(as in your case).Mortality is slightly higher in women due to small coronary arteries.
A very small percentage of vein grafts may become blocked within the first two weeks after CABG surgery due to blood clotting.However with the advent of dual antiplatelets therapy graft blockage is now a rare thing.
Some arrythmias like Atrial fibrilation are common post CABG but can easily be managed.
She has to be in hospital for about 2 weeks post surgery.

Overall they are all bookish facts , practically speaking i have assisted more then 300 CABG'S in last three year with a mortality rate of less then 1% ,though some times complications do arise but with latest technology we can deal with most of them successfully.

But my suggestion is that as PTCA is a bit more safer in elderly ,CABG should be done only when Stenting is not at all possible.

The compelling indications for CABG( OPEN HEART SURGERY) are as follows:

-severe left main stem (LMS) disease, even if asymptomatic
-LMS equivalent—that is, >70% stenosis of the proximal left anterior descending (LAD) and circumflex arteries
-two‐vessel disease with severe proximal LAD stenosis and left ventricular ejection fraction (LVEF) <50% or demonstrable ischaemia on non‐invasive testing

Therefore i want to see her angiogram reports and videos with 2d echo report once before giving her a green signal for by pass suirgery

ACCORDING to NCBI-
"In case of elderly it may be better to consider percutaneous coronary intervention(stenting), as the risk of surgery may be higher,unless one of the lesion mentioned above is present."

So my answer to your first question yes surgery should be done as it is a triple vessel disease ,if PTCA is not a option.

Thank you
IF you have any more doubts you can ask me ,i would be happy to help you.
If possible do send me a copy of echo,angiogram report with video.

Thank you
Dr Rishu Saxena
Resident Cardiologist

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Brief Answer:
minimally invasive by pass surgery is definitely a much better option

Detailed Answer:
Hi,
Have gone through the reports of angiogram of your mom.LAD has 90% mid and distal blockage,LCX ,OM1 and RCA too is more then 90% occluded,PDA is also occluded.AS per the written reports your mother in law is a ideal candidate for CABG , she has critical blockage in all the three major coronaries and diffuse blockages in their branches.These many stents can't be deployed in a person at one time,so CABG is the only option left and you have to go for it.

Minimally Invasive Coronary Bypass Surgery-MICS CABG or MICAS stands for minimally invasive coronary artery surgery. It is a relatively new and advanced technique of performing coronary bypass for coronary artery disease.In this technique the heart is approached through the side of the left chest via a small 4cm incision. This cut is placed just under the nipple. The chest is entered between the ribs without cutting any bones and by splitting the muscle.

Conventional CABG or Coronary Bypass surgery is performed by splitting or cutting through the breastbone or sternum.MICAS is a latest advent in the field of cardiac surgeries and is very safe and useful especially in old patients with other chronic conditions like diabetes.


Advantage of MICS over conventional CABG in old age patients especially in patients with uncontrolled diabetes like your mother in law;

1)All infections are reduced whether it be wound infections or post surgical lung infection. This makes the procedure ideal in diabetics and older patients who have poor resistance to infection, infact this is the biggest advantage in your case.The risk of infection is close to zero. All infections are reduced dramatically in MICS CABG even in diabetics like your mother.As you are not opening the chest wall; hence chances of infection are very rare.

2)Blood loss is almost negligible eliminating blood transfusion in most and eliminating blood borne infection.Your mother is old and anaemic as this surgery offers minimal blood loss ,it would be easy for her to recover.

3)As no bones are cut, advantages in reducing pain, retaining function and having a positive effect on breathing. Unlike traditional CABG where bones are cut and patient has to suffer from lot of pain for atleast two weeks after operation.

4)Patient will be discharged on 4 days unlike the conventional heart surgery that takes 14 days.

As the heart function and left ventricle ejection fraction of your mother is almost normal,she is definitely a good candidate for MICAS.

But the biggest con with this surgery is that not all ctvs surgeons are trained in MICS.Its a latest advent in XXXXXXX ,even at my centre which is one of the best in XXXXXXX there are only a handful of surgeons that are capable of performing MICS safely.So choose your surgeon carefully.

This is a much safer option for your diabetic old mother with mutiple vessel critically blocked arteries ;diffuse in nature, but my sincere advice is to chose the surgeon very carefully.

Also the cost of the surgery is significantly higher then conventional CABG(just for your knowledge),as your mother in law will need atleast 4 grafts.

In case you have more queries or you want more details ,feel free to ask,i would be happy to help you.

If my answers were helpful to you then please do rate them.

Thank you,
and wish or mother in law a very safe recovery.

Dr Rishu Saxena
Resident Cardiologist
New XXXXXXX

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