Choosing Between CABG and Stenting: A Heart Patient's Dilemma

Q: Choosing Between CABG and Stenting: A Heart Patient's Dilemma

We recommend that you： 1. Discuss the above situation further with your attending physician. 2. Consider seeking a consultation at another cardiology medical facility. Wishing you good health. Thank you!

Choice between coronary artery bypass grafting and coronary stenting?

My father was sent to the emergency room on the afternoon of October 20th due to difficulty breathing.
He has a smoking habit and does not consistently take his hypertension medication.
His job is physically demanding.
On the morning of October 21st, he underwent a cardiac catheterization at the hospital and was later diagnosed with a myocardial infarction, with all three coronary arteries blocked.
Currently, my father is awake and able to care for himself, but he is anxious, agitated, and fearful in the ICU, insisting on being moved to a regular ward.
Now that he is in a regular ward, his lab results show NT-pro BNP at 1618, Troponin-I at 13768.8, and CK-MB at 13.50.
The cardiologist has presented two treatment options: the first is coronary artery bypass grafting (CABG), which is the preferred option, and the second is percutaneous coronary intervention (PCI) with stenting, which they believe is feasible.
One of the most severely blocked vessels has a bifurcation, and they plan to place a stent to open it while abandoning the other branch.
If they proceed with PCI, they may need to place three stents: two in the most severely blocked artery and one in the second most severely blocked artery.
However, if the procedure fails, they would revert to performing CABG.
The cardiologist mentioned that the risks are comparable for both procedures; just because PCI involves smaller incisions does not mean the risks are lower.

Initially, my father, mother, brother, and I all agreed on the surgery on October 21st, but my father suddenly changed his mind on October 22nd and wanted to opt for PCI, leading to the cancellation of the surgery.
Now, my brother has persuaded him again on October 24th, arguing that a drug-eluting stent costs around 70,000 to 80,000 NTD, and given my father's severe condition, he would likely need multiple stents, totaling around 500,000 to 600,000 NTD, which is not a small amount for our family, even though we can afford it.
So, he has chosen to go back for surgery.
Honestly, it seems that surgery would be better in the long run, but is PCI really not a viable option? My stance is wavering; I heard the doctor say that his heart function is around 20%, and it’s possible that in the end, his heart may still deteriorate.
In the worst-case scenario, he might need a heart transplant.
I don't know if the doctor has predicted the future based on the data and imaging or if he is being conservative, suggesting that if things are really dire, perhaps it would be better to place a stent to make him more comfortable for the time he has left.
It’s truly a difficult choice...
He was sent to the hospital in the middle of his work, and the worst-case scenario is that he may not have the chance to return home.

sam, 60~69 year old female. Ask Date: 2023/10/24

Dr. Cai Guiqin reply Cardiology

We recommend that you: 1.
Discuss the above situation further with your attending physician.
2.
Consider seeking a consultation at another cardiology medical facility.
Wishing you good health.
Thank you!

Reply Date: 2023/10/24

More Info

Choosing between coronary artery bypass grafting (CABG) and stenting can be a challenging decision for both patients and their families, especially in the context of acute coronary syndrome, such as a myocardial infarction. Your father's situation, with multiple coronary artery blockages and significant symptoms, requires careful consideration of the risks and benefits of both procedures.

Understanding the Options
1. Coronary Artery Bypass Grafting (CABG):
- Indications: CABG is typically recommended for patients with severe coronary artery disease, especially when there are multiple blockages or when the left main coronary artery is involved. It is often the preferred option for patients with complex coronary anatomy or those who have had a heart attack.

- Procedure: This involves taking a blood vessel from another part of the body (like the leg or chest) and using it to bypass the blocked arteries, improving blood flow to the heart muscle.

- Long-term Outcomes: CABG has been shown to improve survival rates and reduce the risk of future heart attacks in patients with significant coronary artery disease. It is particularly beneficial for patients with reduced left ventricular function.

2. Stenting (Percutaneous Coronary Intervention - PCI):
- Indications: Stenting is less invasive and can be a good option for patients with fewer blockages or less complex coronary artery disease. It is often used in cases where immediate relief of symptoms is needed.

- Procedure: A catheter is inserted into the blocked artery, and a stent (a small mesh tube) is placed to keep the artery open. Drug-eluting stents can help prevent re-narrowing of the artery.

- Long-term Outcomes: While stenting can relieve symptoms and improve quality of life, it may not provide the same long-term benefits as CABG, especially in patients with multiple blockages.

Factors to Consider
- Severity of Disease: Your father's case involves three blocked arteries, which may indicate a more severe form of coronary artery disease. The presence of a significant blockage at a bifurcation may complicate stenting and increase the risk of complications.

- Heart Function: With a reported left ventricular ejection fraction (LVEF) of around 20%, your father's heart function is compromised. CABG may provide a better chance of improving heart function compared to stenting.

- Patient Preference and Quality of Life: Your father's anxiety and desire for a less invasive procedure are understandable. However, it’s crucial to weigh these feelings against the potential long-term benefits of CABG. Discussing these concerns with his healthcare team can help clarify the best approach.

- Financial Considerations: The cost of stenting versus CABG can be significant, and it’s essential to consider the financial implications. However, the long-term health benefits and potential for reduced future healthcare costs should also be factored into the decision.

Conclusion
Ultimately, the decision between CABG and stenting should be made collaboratively with your father's healthcare team, taking into account his specific medical condition, preferences, and the potential risks and benefits of each option. Given the complexity of his case, CABG may offer a more definitive solution with better long-term outcomes, especially considering his reduced heart function. However, if he is leaning towards stenting for immediate relief, it is essential to ensure that he understands the potential risks and limitations of that choice.

Encourage open communication with his cardiologist to address all concerns and ensure that your father feels supported in making the best decision for his health.

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