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Deja Vu:

Eventually February 4th rolled around and it was time to have my second heart catheterization done at Stanford. But, this time it was going to be intravascular ultrasound + angiography.

IVUS Probe & Plaque.

Intravascular ultrasound (IVUS) allows direct "visualization" of the plaque as opposed to angiography which studies the flow of blood through the plaque. IVUS was key as it is the highest resolution test for plaques available. Much higher than CT scan or regular angiography (both of which had already been done and both producing different estimates of the plaque's obstruction - probably due to the effects of the severe bridge of the LAD.) So I was glad to be doing it as it would provide the final answer if I needed a unroofing + bypass or just unroofing. 

IVUS image of Plaque (green).

And, since they were already going to be in looking at the plaque I also consented to an experimental IVUS bridge study procedure. The goal of the procedure is to use IVUS to attempt to detect, measure, and quantify the effects of a bridge. Thereby helping not only differentiate severe bridges from benign ones but also help outline their effects on other complications surrounding the bridge. More data for the general bridge pool that, hopefully, would benefit me too. 

So at 6:45 am I found myself once again on butcher paper getting ready for a procedure. The ultrasonic transducer and sensor for the IVUS is tethered on the end of a long wire so that meant that this time they had to use the femoral artery in my leg for access rather than the wrist. So once again I had to get prepped for bikini season – but, this time they meant it. (I actually could probably even pull off a mini-skirt given how much they shaved.) 

Around 8:00 it was time to head into the main catheterization lab. They had redecorated since the last time I was in there; but, otherwise it was the same. This time, because I knew about it, I immediately asked for a "bear hugger" up front (the semi permeable air based warming mattress) and they managed to find one for me. Hurray for not freezing and being embarrassed at the same time. 

After they got me a good view of a monitor to watch the feed from the probe, ensured I was all "plugged in", and dimmed the lights – it was showtime. This round was much longer than the last due to lots of different explorations of arteries via detailed IVUS assisted mapping expeditions. From my vantage point it was interesting as I could see the arteries when they shot dye into them just like last time. But, unlike last time, there was this 2 cm long worm looking thing dancing around in there too. Of course, that was the IVUS sensor but I swear it really looked like a worm the way it "crawled' and "wiggled." (An impression I am sure was "assisted" by the much greater selection of drugs used this time. Drugs that included Acetylcholine to get the heart rate up and cause the bridge to be "unpleasant." And, some general sedative to back things off again.)

Also, of note, is that like last time I caught snippets of conversations happening outside of my field of vision and heard things like "another one" and "significant?" 

After, the procedure was over, but before being wheeled out, Dr. Schnittger came over to me on the table and reviewed what they had found so far. (The full report had to wait until recovery because they wanted to talk with Dr. Boyd (my surgeon) and some others about the findings.)

So next, from there it was off to the recovery room where I had to lie flat on my back not moving for four hours. It was not as boring as it could have been thanks to girlfriend's excellent company plus an iPad (definitely better than bleeding from my femoral artery) but still not a recommended way to spend an early afternoon.

Around 12:30 pm Dr. Schnittger dropped by with the skinny on the findings. 

Bridge B.O.G.O. …

Results from the Angiogram & IVUS:

• (Update) They did not do a full study of the bridge on the LAD because it is so severe as to actually be atypical enough that the results are not relevant and not really safe to explore either. Dr. Schnittger summed it up best by pointing out: "you can see that thing from across the room." But, to help with my surgery, they did precisely locate the entrance. They confirmed that it is 99%+ closed during systole and learned some useful other facts (see later on in this post).

So, according to Dr. Schnittger the priority for this surgery is:

1. Fix this bridge!
2. Fix this bridge!
3. Fix this bridge!

(It was also confirmed, that because of the length of the bridge on the LAD, it will not be possible to unroof the whole thing as the artery under the bridge becomes too small, <1 mm, at some point (maybe about ~6.5 cm down) to be safely unroofed. My hope is to clear about 6 cm.

• (Update) The IVUS study of the plaque in my LAD (the primary reason for doing this procedure) showed that the plaque, in both Dr. Schnittger's & Dr. Tremmel's opinions was not significant enough to warrant treatment. My surgeon Dr. Boyd disagreed and was going to continue to have "conversations" with Dr. Tremmel on the topic. But, regardless of who wins these "conversations" I feel better that this plaque is not as bad as originally thought. (Hurray!)

Of course right after she said this I started thinking "hey, since this plaque was the reason for considering the surgery then maybe I don't need the surgery…" (That ended quickly…)

• (New) They found a third, previously unknown, bridge on my Posterior Descending Artery (PDA). This bridge is basically like the one on the Left Circumflex (LCX) and interesting in that it exists but not really causing problems. It was just sort of "winking at them" on the scans.

• (New) The left main coronary artery usually divides into two branches, known as the left anterior descending (LAD) and the circumflex coronary arteries. In some patients, a third branch arises in between the LAD and the Circ. This is known as the ramus (pronounced ray-muss), intermediate, or optional diagonal coronary artery. Only about 15 - 30% of the population has this and, of course, with my "heart luck" I am a member of that group. 

The point where my ramus branches off happens to be under a section of a bridge which makes getting images or scans of that area using the other tests I have gone through difficult. But, not for the IVUS probe, so when they explored down the ramus with that probe they discovered, a previously unknown, second plaque. This plaque is in a section of artery that has a natural "hook" or "kink" and is obstructing 85% of the blood flow. A Bad Thing.™

That makes this a significant enough blockage to mandate treatment. So although the plaque on my LAD probably does not need bypass this one does. 

• (New) When trying to understand why this plaque was so severe Dr. Schnittger went back to the CT scans and consulted with some radiologists about them. When they looked more purposefully at the scans they found the culprit: there is a fourth, and previously unknown, bridge on my ramus. (I don't suggest reading the last part of that sentence aloud – at least not with anyone aged 12 - 16 around.) Creating a situation where you have the main, and most severe, bridge on the LAD back flowing blood into the blood that the bridge on the ramus is shooting "out the top." Basically, to borrow and build upon the analogy from a previous post, I have three (normal flow, LAD bridge, Ramus bridge) hoses squirting directly at one another. Thus creating a more damaging situation and thus bigger plaque. 

And, of course to treat this plaque, both of the bridges causing / contributing to it have to be fixed. So the bridge on the ramus must be unroofed as well. 

Bottom Line & Path Forward:

Summing up: An additional plaque, beyond the one that was already known, was discovered. This new plaque, in Ramus, is dangerous and requires intervention (bypass).

Also, during this procedure they discovered an additional two bridges beyond the two (LAD & LCX) that were already identified. One of these is likely not significant (PDA) and one of them is (Ramus). The one on the Ramus requires unroofing due to plaque if for no other reason. 

I was originally not supposed to require the heart & lung bypass machine during my surgery. However, due to the recently discovered additional surgical needs, this is no longer the case. So the surgery will be longer, slightly more risky, and the recovery a bit more involved than was originally anticipated. 

One last thing…the date of the surgery was moved up by two days too. So it is now scheduled for the 17th of February rather than the 19th. 

I know that I am, once again, super lucky. If Drs. Tremmel and Schnittger did not do this study, and it was not as thorough as it was, I never would have known about the second (and dangerous) plaque or the severe bridge that caused it until Very Bad Things™ had happened.

So don't get me wrong; I am happy and genuinely grateful. Especially to all the bridge patients at Stanford who came before me and from whom's experiences I am now directly benefiting…

…but…seriously four myocardial bridges…Four?!? Even Dr. Schnittger has never seen anyone with four bridges. (…uh…Yay…another "really don't want to win these things" record.)

If our next rainstorm is a thunderstorm: I am going to go out and stand in the middle of an open field while holding onto a flag pole…you can't get hit by lightening twice – right?  (Playing in the field will be more "successful" than buying lottery tickets. I tried that last month. Nada.)

Anyway, this was the best 16 mSv I ever spent.