Question

Answer the questions based on the following Medical Record: History of present Illness: This 77 year old gentleman was hospitalized with chest pain, and a diagnosis of myocardial infarction was made. The patient had CPK elevation to 800 with 10% MB fraction. He subsequently developed heart failure and cardiac arrhythmia. He underwent cardiac catheterization and coronary angiography. His ejection fraction was 30%. He has severe left main coronary artery stenosis and right coronary artery occlusion. The patient has had carcinoid tumor of bowel resected 4-5 years ago and in a recent laparotomy he was found to have diffuse carcinoid involvement of the liver and mesentery. The patient did have small bowel resection and currently has a colostomy. He is expected to live 2-3 years.

Past Medical History: Long standing hypertension, colostomy secondary to bowel carcinoma, transurethral resection of the prostate, previous transient ischemic attacks, and bilateral carotid disease with 60-70% stenosis.

Impression: Severe coronary artery disease with recent with recent myocardial infarction, high grade left main coronary artery stenosis and occlusion of right coronary artery, ischemic cardiomyopathy, ventricular and supraventricular arrhythmias History of carcinomatosis, status post recent bowel obstruction, previous colostomy Carotid occlusive disease with history of transient ischemic attacks.

Recommendation: The patient and his family are fully aware of recent cardiac catheterization findings. The patient is in agreement with proceeding with coronary artery bypass graft surgery, knowing that he is expected to live 2-3 years. Informed consent has been obtained.

1) What medical problems does the patient have? Explain these in lay terms, as if you were talking with the patient and his family.

2) What does it mean to have a "30% ejection fraction?" Is this good or bad?

3) Describe the coronary artery bypass graft surgical procedure in lay terms.

4) What is carotid endartarectomy, and is this patient a good risk for it? Why or why not?

Answer 1

1.The patient is having a severe heart problem. This is because of block present in two major blood vessels which supply to heart.This has lead to irreversible muscle damage.There is a need to supply blood to the heart muscle which is possible by a surgery called CABG (Coronary Artery Bypass Graft)It is a procedure where patients blood vessels from other body parts (e.g.,saphenous vein from leg) is removed and it is attached to the heart blood vessel bypassing the block on two ends.This will enable blood circulation in heart.This can help the patient to survive for next 2 to 3 years,.

2.Ejection fraction simply means the amount of blood pumped out from the heart during each cycle or when the heart contracts.

The normal range is 55%_70% of blood should be pumped our during each contraction.

An EF of 30% is a clear sign of hearts inability to pump blood and the patie t is at very high risk of getting cardiac arrest,severe dysarrythmia at any time.

3.CABG is called as coronary artery bypass graft

• It is done to supply blood to the heart muscles overriding the blocked area
• For instance if there is a block in the middle of a blood vessel
  • Vein is taken from other parts of the body (usually saphenous vein in the lower leg)
  • This blood vessel is connected on both the ends of the blocked blood vessel to ensure circulation called as bypassing

4.Carotid endarterectomy is a procedure to relieve or remove blocks in the blood vessels and narrowing the pathway The patient is at a risk category due to his advanced cardiac disease, age,other medical conditions.All this has to be addressed and with a stenosis of 70% and TIA the patient has to undergo this procedure on the best interest of patient.