Post-CABG Heart Issues: Clarifying Concerns and Treatment Options - Cardiology

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Post-CABG heart issues can be complex and require careful consideration of various factors. Let's address your questions one by one.

1. ECG Changes and Myocardial Ischemia: When we say that the ECG shows no significant changes before and after CABG, it can imply two scenarios. First, it could mean that the CABG surgery did not address all the obstructed vessels, leading to persistent areas of myocardial ischemia. This is common in patients with multiple coronary artery blockages, where the surgery may bypass the major arteries but not all smaller branches. Second, it could indicate that prolonged ischemia prior to surgery has resulted in myocardial necrosis, meaning that even if blood flow is restored, the affected heart muscle may not fully recover. This is particularly relevant if the ischemia was chronic, leading to irreversible damage.

2. Complete LBBB and CRT: In patients with heart failure and complete left bundle branch block (LBBB), Cardiac Resynchronization Therapy (CRT) is often recommended. CRT can improve heart function and potentially alleviate functional mitral regurgitation (MR) and tricuspid regurgitation (TR) as well as pulmonary hypertension. However, it is important to note that about one-third of patients may not respond well to CRT. Therefore, a thorough discussion with a cardiologist specializing in electrophysiology is essential to evaluate the potential benefits and risks of CRT in your father's case.

3. Myocardial Perfusion Imaging vs. Catheterization: Given your father's chronic kidney disease (stage 3), it is understandable to seek alternatives to invasive procedures like catheterization. Myocardial perfusion imaging can provide valuable information about blood flow to the heart muscle and can be a non-invasive way to assess coronary artery status. However, if there is a strong suspicion of significant coronary artery disease or if symptoms persist, catheterization may still be necessary for a definitive diagnosis and potential intervention.

4. Prioritizing CRT and Mitral Valve Repair: The decision to prioritize CRT or mitral valve repair (transcatheter mitral valve repair, TMVr) often depends on the specific clinical scenario. Generally, CRT is aimed at improving heart function and synchrony, while TMVr addresses the mechanical issue of mitral regurgitation. There is no strict guideline on which procedure should be performed first, as both aim to improve heart failure symptoms and outcomes. Studies, such as the COAPT trial, have shown that TMVr can be beneficial regardless of prior CRT placement. However, if TMVr is performed first, it may complicate future CRT placement due to changes in heart anatomy or function. Conversely, if CRT is placed first and MR persists, TMVr can still be performed later, but the overall heart condition should be carefully monitored.

In conclusion, your father's case involves multiple considerations, including the potential for residual ischemia post-CABG, the appropriateness of CRT, and the timing of mitral valve interventions. It is crucial to maintain open communication with his healthcare team, including cardiologists and cardiac surgeons, to develop a tailored treatment plan that addresses his unique needs and circumstances. Regular follow-ups and monitoring will be key in managing his heart health effectively.