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Dilemma in the strategy of treatment: revascularization or medical treatment?/Tedavi stratejisinde ikilem: revaskularizasyon mu, tibbi tedavi mi?

A 43 years old woman presented with chest pain. Because she had no angina and she was in the subacute phase of myocardial infarction neither thrombolytic nor percutaneous coronary intervention (PCI) was done. On the coronary angiography, it was seen that left anterior descending artery (LAD) was totally occluded proximally, there were critically discrete stenoses at the midportion of right coronary artery (RCA). Circumflex artery (Cx) was normal and there was Rentrop 2 collateral flow to LAD from Cx artery and RCA (Fig. 1-4). On the ventriculography the left ventricular sizes were normal, akinesis at the anterior and apical portion of the left ventricle, mild mitral regurgitation were seen. The ejection fraction was measured as 38%.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

What must be our treatment strategy in this patient?

1. PCI to LAD and to RCA

2. Coronary artery bypass surgery (CABG) to LAD and RCA

3. PCI to RCA to maintain collateral blood flow to LAD from RCA

4. Medical follow-up

Recently, in the study of Hochman et al. (1) 2166 patients with acute myocardial infarction with proximal total occlusion and EF<50% were studied, medical therapy versus PCI to the infarct-related artery plus medical therapy was compared. Reinfarction, the NYHA functional status and heart failure and mortality rates were not different between these groups. This study was controversial to the previous studies results, but it must not be forgotten that most of the previous studies were retrospective and nonrandomized contrary to the study by Hochman et al. (1). If we act according to these studies results, it will be wise to choose medical treatment without PCI.

[FIGURE 3 OMITTED]

It's known that the presence of collateral blood flow preserves left ventricular function and patients with collateral flow have better survival rates than those without collateral flow. Overall, 23 cases of totally occluded left main coronary artery with good collateral flow from RCA were reported. Twenty-one of these patients have CABG operation and two of them denied the operation. After mean follow-up of 60 months, all of the patients were alive (2).

Our had collateral blood flow from RCA to LAD and critical stenoses in midportion of RCA. If the critical stenoses occluded totally the RCA, the collateral flow to LAD will be lost. To prevent this we can think of PCI to RCA, but the possibility of total occlusion of RCA during the procedure makes us stay backward. Also there is no any data supporting this thought's accuracy. Then can we increase the existing collaterals? It was shown that exercise and high dose statin usage increases collateral vessel development (3, 4).

Our case is a suitable candidate for CABG. Considering the results of the study by Hochman et al. (1) we must think of CABG operation once more. To my knowledge, there is no any prospective randomized study comparing these kinds of patients.

We are sure that, every clinics decision of treatment approach will change according to its own experience and vision. According to us, in the light of the literatures it will be wise to recommend medical therapy including beta-blocker therapy with high-dose statin.

Ersan Tatli, Meryem Aktoz, Gokhan Aydin, Mustafa Yilmaztepe, Armagan Altun Department of Cardiology, Trakya University School of Medicine, Edirne, Turkey

References

(1.) Hochman JS, Lamas GA, Buller CE, DzavikV, Reynolds HR, Abramsky SJ, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006; 355: 2395-407.

(2.) Charitos CE, Nanas JN, Tsoukas A, Anastasiou-Nana M, Lolas CT. Total occlusion of the left main coronary artery with preserved left ventricular function. Int J Cardiol 1997; 61:193-6.

(3.) Dincer I, Ongun A, Turhan S, Ozdol C, Kumbasar D, Erol C. Association between the dosage and duration of statin treatment with coronary collateral development. Coron Artery Dis 2006;17: 561-5.

(4.) Boluyt MO, Cirrincione GM, Loyd AM, Korzick DH, Parker JL, Laughlin MH. Effects of gradual coronary artery occlusion and exercise training on gene expression in swine heart. Mol Cell Biochem 2007; 294: 87-96.

Address for Correspondence/Yazisma Adresi: Dr. Ersan Tatli Department of Cardiology, Trakya University School of Medicine, Edirne, Turkey Phone: +90 284 235 76 41/2100 Fax: +90 284 235 23 05 E-mail: ersantatli@yahoo.com
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Title Annotation:Letters to the Editor/Editore Mektuplar
Author:Tatli, Ersan; Aktoz, Meryem; Aydin, Gokhan; Yilmaztepe, Mustafa; Altun, Armagan
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Geographic Code:7TURK
Date:Oct 1, 2008
Words:700
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