Coronary arteries supply blood to the heart muscle. Like all other tissues in the body, the heart muscle needs oxygen-rich blood to function. When the coronaries are blocked you may suffer a heart attack and even die suddenly. Normally, we conceptualise the blood supply of the heart as a system of three vessels (hence the terms “single-vessel”, “double-vessel” or “triple-vessel disease”). 1) The “left anterior descending artery” (LAD) supplies blood to the front of the heart. 2) The “left circumflex artery” (LCX) supplies blood to the side and back of the heart. 3) The “right coronary artery” (RCA), supplies blood to the right ventricle, right atrium, and sinoatrial node. But few pause to think of the vital “Left Main Coronary Artery” (LMCA). It is a “short stem” which typically runs for 20 mm and then bifurcates giving origin to LAD and LCX, two of the above three important arteries. Blockage of the “Left Main Stem” is therefore the most serious thing that can happen. If untackled, its affection will be followed by a massive heart attack or instantaneous death.
When coronary angiography was developed in the early 1960s, the very high risk associated with obstructive “left main coronary artery disease” came to light. To overcome its critical blockage, until now, the only option was “open-heart surgery.” However, specific revascularization techniques with stents have undergone considerable evolution and with regard to treatment of “Left Main Coronary”, we can say like Bob Dylan… “Times are a-changing.”
Permit me to narrate here the story (I hope she won’t mind!) of my journalist-friend “Mme Butterfly”, a foodie in the real sense of the word. Tara Narayan is her real name. She is someone keenly interested in rich food and eating well. Like George Bernard Shaw, she believes that “there’s no sincerer love than the love of food”. To read her superb articles in the Goan Observer is sheer delight. I have never seen a better food columnist than Tara. Writing about gourmet food she also offers rare recipes. Her pen just flows. I devour her writings but do my best to keep away from “Doctor Tara’s” prescription because it’s injurious to health.
It so happened that tasting food in the best restaurants out of sheer fun, Tara ended up putting on a lot of weight. Then, one day, a casual “stress ECG test” turned out to be positive and a coronary angiogram done in quick succession revealed “blockage” in the “Left Main Coronary” (ouch!), with other coronaries clear. Every doctor advised her open heart surgery. Tara was furious, “How come I have to undergo “open heart surgery” for one vessel disease?” Of course, that was the trend four years ago when our “poor Butterfly” took ill. She kept disparaging all doctors for not being able to solve her problem with just a “stenting” procedure. Today, I am happy to say that Tara after a successful “open Bypass” is in the pink of health. Yet, her love for “gourmet” food remains undiminished. What indicts the medical profession v/s Tara’s case is that latest painstaking research vindicates Tara’s position all along.
A major international study has now found that “drug-eluting stents” — a less-invasive alternative to surgery — are as effective as “bypass surgery” for patients with blockage in the “Left Main Coronary Artery.” Findings from the EXCEL trial were published recently online in the New England Journal of Medicine and brought immense relief to doctors and patients.
“Coronary artery bypass graft” (CABG) surgery has historically been considered the definitive and only treatment for patients with “left main coronary artery disease” (LMCAD), in which the crucial artery that supplies oxygen-rich blood to most of the heart muscle is clogged with atherosclerotic plaque.
The study under consideration has now convinced doctors that patients with “LMCAD” who prefer a “minimally invasive approach” can rest assured that a stent is as effective as bypass surgery and safer. But, it is not something for the novice! The cardiac interventionist must be extremely skilled with many successful procedures under his belt. Therefore, should you have the misfortune of being hit with LMCAD, go to the best Centre never mind the expense.
The researchers also analyzed what happened to the patients in the first 30 days after treatment. Within that period, stent patients had a significantly lower incidence of death, stroke, heart attack, or revascularization than those who had bypass surgery. In addition, fewer stent patients had major bleeding, infections, kidney failure, or abnormal heart rhythms compared to those treated with surgery.
Mme Butterfly may want to sue the medical community for having put her unnecessarily through an open heart procedure. But doctors are just frail human beings who advise their patients what is best as per the evidence available at that particular time.
But cheers to her for looking ahead and seeing what others could not anticipate. Please, Tara, keep writing your beautiful columns but pray, do not tempt us too much, as in Goa this is the fine season for weddings, parties and… rich food. However, continue to be the “adorable Butterfly” you have always been. John Keats wrote, “I almost wish we were butterflies and lived but three summer days — three such days in life could fill us with more delight than fifty common years could ever contain.”
(Dr Francisco Colaço is a seniormost consulting physician, pioneer of Echocardiography in Goa, column writer)
