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Dr. Phil, MD
Dr. Phil, MD, Medical Doctor
Category: Cardiology
Satisfied Customers: 57249
Experience:  Cardiology Expert
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Hi Im in UK. Have been listed for urgent PCI. Angiogram

Resolved Question:

Hi

I'm in UK. Have been listed for urgent PCI. Angiogram has shown:

RCA: mild proximal disease, severe mid vessel lesion, mild to moderate distal disease.

LMS: unobstructed.

LAD: mild proximal disease and moderate mid-vessel lesion.

LCx: severe proximal disease of small proximal OM branch, otherwise mild atheroma.

LVgram: preserved LV function.

LV: EDP 5mmHg.

Estimate is 80% stenosis RCA and 85% small proximal OM branch of LCx.

Recent cardiac MRI shows a basal septal perfusion defect. This is apparently a single defect where I would have expected two defects reported if ischaemia caused by both OM branch of LCx and RCA.

My questions:

Would RCA cause a perfusion defect elsewhere rather than basal septal? Is PCI of LCx small OM branch a more likely cause of basal septal perfusion defect? Is PCI of LCx small OM branch possible or is risk burden too great?

Thanks

Harry
Submitted: 3 years ago.
Category: Cardiology
Expert:  Dr. Phil, MD replied 3 years ago.
Hello. I'm Dr. Phil, licensed and practicing internist. Excellent service is my goal.


Would RCA cause a perfusion defect elsewhere rather than basal septal?

Yes, it could. But an 80% blockage doesn't necessarily mean there will be a perfusion defect. Many 90% or more blockages don't have a perfusion defect. So the answer is possibly yes but not necessarily



Is PCI of LCx small OM branch a more likely cause of basal septal perfusion defect?


It could be either. The basal septal is in an area where both the RCA and the LCx could be causing it. You will likely needs stents in both

Is PCI of LCx small OM branch possible or is risk burden too great?

No, this is possible. It is a riskier vessel but it should be amenable to intervention


Customer: replied 3 years ago.

Hi Dr Phil


 


I was told after angiogram that they felt PCI of LCx small OM branch wasn't possible due to it being a small vessel. The centre is an acknowledged centre of excellence in UK. A consultant cardiologist has classed this procedure as urgent.


 


My worry is that they do PCI to RCA alone and nothing improves as LCx small proximal vessel is culprit for perfusion defect. Should they be able to tell from cardiac MRI which vessel is the culprit?


 


When you say PCI of LCx small proximal vessel is riskier by what magnitude or scale?


 


Finally, wouldn't medication like amplodipine or Isosorbide mononitrate be a better first try to see if one of those relieves what are fairly mild symptoms at present.


 


Many thanks.


 


Regards.


 


Harry

Expert:  Dr. Phil, MD replied 3 years ago.
1)Hi Harry. The MRI may be able to give a clue which vessel is the culprit but if they can't do the LCx then I'm not sure how the MRI will help. If the MRI shows the LCx is the cause, then are they going to do it anyways despite risk? I would think not.

2)If it is very hard to get into then it is drastically riskier. I cannot give you an exact amount

3)medical management works wonders in some cases. Ranolazine or isosorbide are good options but it might be too late for those to do the job fully
Customer: replied 3 years ago.

Hi Dr Phil


 


Sorry I may have misled you. The cardiac MRI was a CMR cardiac stress perfusion scan. It was the earlier coronary angiogram that visualised the LCx small OM branch occlusion and scale of vessel. Previous coronary angiogram in 2010 had only shown mild disease in LCx small OM branch and RCA at pretty much today’s level of stenosis. A cardiac MRI a few months later showed no ischaemia. This would indicate to a layman that perhaps the LCx small OM branch has become the culprit over the last four years and they wouldn’t have listed me for PCI unless they definitely thought they could relieve the cause of ischaemia now seen. Otherwise they would be doing just the RCA on the chance this was the culprit. An unlikely scenario I would have thought? Do you agree?


 


A cardiologist in the team also told me that a total blockage in LCx small OM branch would only cause a mild heart attack. Is that right?


 


Many thanks. This conversation with you has given me a much better focus on things.


 


Regards.


 


Harry

Expert:  Dr. Phil, MD replied 3 years ago.
Yes, I agree Harry. That is unlikely

Yes, that is correct. So if the vessel goes out you will still be ok
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Expert:  Dr. Phil, MD replied 3 years ago.
I appreciate the good rating.

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