Case Discussion

[PpfSuxTube]

I know several world class heart surgeons that would send this pt for TAVR if coronaries are normal (can you tell I believe that coronary workup is really important in this patient??).

I would do the same for my mother (I should add that I love my mother).

Hes a bit young tho eh?

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[vector2]

Hes a bit young tho eh?

FDA approved TAVR for low risk pts in 2019 after the Evolut low risk and PARTNER 3 trials came out. Me personally, I would still recommend SAVR given his age and condition because beyond 2-5 yrs out I think SAVR will be superior with regard to thrombus risk.

Low-Risk TAVR at 2 Years: Thrombosis Concerns Creep In

PARTNER 3 showing trends toward convergence of outcomes with surgery

www.medpagetoday.com

 

[dchz]

Hes a bit young tho eh?

Bit of a derail to the thread, but:

The thought is TAVR -> SAVR -> TAVR, which is better than SAVR -> TAVR -> TAVR which will give much better valve function with similar procedural m&m.... it's a bit on the fringe, but i see the logic of it.

I'm not sure what I'd personally do, I'd have to see how the evidence and data pans out.

 

[Shimmy8]

This is a joke, right? a cardiologist actually said that rather than just send him for a LHC/NM scan?

I don’t know what world you live in, but this is absolutely how this would go down.

Except I’m surprised he even got the echo in time prior to surgery.

 

[deleted875186]

I had a case in residency, did a preop on an elderly guy admitted for gastric outlet obstruction, kept having symptoms and couldn’t eat much, didn’t want a feeding tube so gen surg was going to try to fix it surgically.

Dude had a murmur, I tell them get an echo, severe AS, unable to evaluate METS, I pushed to have him get a TAVR first, ends up dying from his TAVR. For what it’s worth, probably wouldn’t have died from whatever laparoscopic surgical approach they were planning for his stomach.

 

[dchz]

I don’t know what world you live in, but this is absolutely how this would go down.

Except I’m surprised he even got the echo in time prior to surgery.

well, i guess i just don't understand this patient's condition...

 

[Shimmy8]

Oh I'm not saying your thinking is wrong. But this is exactly how this would go down in my world with regard to how cardiology would respond.

 

[Ronin786]

This is a joke, right? a cardiologist actually said that rather than just send him for a LHC/NM scan?

I don’t know what world you live in, but this is absolutely how this would go down.

Except I’m surprised he even got the echo in time prior to surgery.

No joke. This is exactly how things went down with minor changes to preserve anonymity.

Many cardiologists are terribly out of touch with the realities of surgery and are too geeked up on numbers to realize that things don't occur in absolutes. I had a CKD patient the other day present for a peritoneal dialysis catheter placement because her cardiologist wanted to cath her known LAD lesion and then dialyze her afterwards.

 

[GassYous]

I had a case in residency, did a preop on an elderly guy admitted for gastric outlet obstruction, kept having symptoms and couldn’t eat much, didn’t want a feeding tube so gen surg was going to try to fix it surgically.

Dude had a murmur, I tell them get an echo, severe AS, unable to evaluate METS, I pushed to have him get a TAVR first, ends up dying from his TAVR. For what it’s worth, probably wouldn’t have died from whatever laparoscopic surgical approach they were planning for his stomach.

But tavrs are done with mac and there's no insufflation

 

[Iso4ane]

Can we take a quick time out and focus on this great line this is here?

I have my moments. I’m surprised no one else thought of it.

 

[aafisahar]

Why the fixation on his coronaries? Fixing coronary disease with stents doesn't prevent MI nor reduce perioperative MI (see CARP 2008). Sure he needs a coronary eval but that's for his cardiomyopathy and possible SAVR. There's basically no indication for LHC prior to surgery other than we do it for surgical team palliation.

 

[greatnt249]

Great point. The patient is also the one that failed to follow-up with their cardiologist in a reasonable fashion.

With regards to the case, results came in day of surgery. I spoke with the surgeon and patient and explained that there's a real risk from proceeding and that patient needs to see their cardiologist first.

Of course, patient goes to see cardiologist and this is what cardiologist has to say


"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

Now what do you do?

I'm just going to go ahead and say that I wonder if that cardiologist, if asked to say what he/she wrote out loud, would realize how little sense his/her recommendation made.

 

[greatnt249]

To keep the discussion moving. This patient was seen in pre-op clinic and TTE was ordered. As per usual, TTE wasn't done until day before and read wasn't in until the morning of surgery.

EF 45-50%, DI 0.25, AVA 1.0 and gradient ~35mmhg

Are you proceeding with surgery?

There's enough discordance with the echo data whether it's severe or not that I would punt it to cardiology. Valve area is borderline severe, DI is straddling the line of severe, LVEF is now 45-50% but no mention of regional wall motion abnormality, but mean gradient is moderate. Someone needs to take a closer professional look at his imaging to determine what is going on (measurement discrepancies, Doppler underestimation) to steer in one direction or another, but I wouldn't expect that to be the anesthesiologist. Moreover, I can count on one hand the number of times I've seen true "low flow, low gradient severe aortic stenosis," and none of them have been in patients with mild LVEF reduction.

 

[GravelRider]

Great point. The patient is also the one that failed to follow-up with their cardiologist in a reasonable fashion.

With regards to the case, results came in day of surgery. I spoke with the surgeon and patient and explained that there's a real risk from proceeding and that patient needs to see their cardiologist first.

Of course, patient goes to see cardiologist and this is what cardiologist has to say


"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

Now what do you do?

Good discussion.

Sometimes I think the shotgun approach to clearances is actually detrimental. We all know colleagues who would have seen the above phrase highlighted or underlined by the pre-op clinic and proceeded with the case without a second thought. These kinds cases probably go without a hitch all the time even though the right answer is to postpone.

The surgeon will also read that line and stomp his foot wondering why you are postponing when cardiology is saying it’s ok to proceed. I get that the clearance has become a medicolegal cushion, but when we overly rely on them, we are essentially giving up turf to other specialists. I find “clearances” helpful as a data gathering tool, but I almost wish specialists would stop writing “clear for surgery.” I don’t understand why they would want to write that anyway for their own medicolegal protection.

 

[anaesthetic]

I find “clearances” helpful as a data gathering tool, but I almost wish specialists would stop writing “clear for surgery.” I don’t understand why they would want to write that anyway for their own medicolegal protection.

I’ve seen notes from PCPs on complicated patients that say, “Cleared for surgery. Would avoid nephrotoxic drugs, hypotension, and hypoxia.” Thanks, bro.

It’s the same as the surgeon scrubbing out and reminding you, “I want a smooth wakeup!” As if every other time, we want the patient bucking and coughing and coming off the table.

 

[Iso4ane]

I’ve seen notes from PCPs on complicated patients that say, “Cleared for surgery. Would avoid nephrotoxic drugs, hypotension, and hypoxia.” Thanks, bro.

It’s the same as the surgeon scrubbing out and reminding you, “I want a smooth wakeup!” As if every other time, we want the patient bucking and coughing and coming off the table.

IM Consult Note: Don’t do anything that might kill the patient.

 

[fakin' the funk]

Of course, patient goes to see cardiologist and this is what cardiologist has to say


"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

Now what do you do?

This is the realest post in this thread.

And this is where you say, sorry nope the patient isn't cleared.

 

[IMGASMD]

This is the realest post in this thread.

And this is where you say, sorry nope the patient isn't cleared.

I see so many different scenarios that can happen, I guess that’s where the “art” of medicine come in.

Is the note actually written by a cardiologist…? I’ve seen so many notes written by pa or np, I now make a habit of reading who the writer is.

Do I have a supportive department? I think most people so far has a tingling sense of, this isn’t a straight forward case nor a case that I want to come back to first thing on Monday morning. I’ve seen surgeons complain to the chair, and gets another anesthesiologist…. Your credibility goes to the toilet.

Lastly, as some have suggested…. Talk to the patient again. Dude you want to fix your back now risking of dying on the table or get your back fixed and come back fighting for another day?

Really good discussion!

 

[vector2]

.
Lastly, as some have suggested…. Talk to the patient again. Dude you want to fix your back now risking of dying on the table or get your back fixed and come back fighting for another day?

Really good discussion!

When these kind of scenarios come up and there's a conflicting "clearance," I tell the patient that his cardiologist knows a lot about his heart when they're sitting in the office, but the cardiologist knows very little about his heart when he's undergoing the specific stess of general anesthesia and surgery.

And you are absolutely right about departmental support. For all the chest puffing we do here about the anesthesiologist being the final clearance for surgery, that position doesn't mean jack if your colleagues and your chair/chief don't stand behind your decision making.

 

[kidthor]

And you are absolutely right about departmental support. For all the chest puffing we do here about the anesthesiologist being the final clearance for surgery, that position doesn't mean jack if your colleagues and your chair/chief don't stand behind your decision making.

I couldn’t agree more. There are some real weasels out there…. If you’re in a place where colleagues and leadership aren’t on your side, get out now.

 

[bcat85]

My opinion is that cardiac risk stratification should be performed by the anesthesiologist or anesthesia preop clinic. We are in the best position to evaluate the hemodynamic risks of the anesthetic and surgical procedure, not the cardiologist. The concept of clearance often obscures important information and makes it appear that the patient will either be just fine or will die imminently, which just isn't true.

In this case, the question is really whether there is a huge meaningful risk reduction from doing an aortic valve replacement prior to elective low-intermediate risk surgery. It's not like patients transition from just a little risk to massively increased risk the second their AVA reaches 1.0 (which is probably the poorest echocardiographic indicator of AS severity, IMO-DI is the most useful), and also remember that they will need to rehabilitate after their AVR which is going to be more difficult with chronic back pain that is functionally limiting.

My approach in this case would be to repeat the initial TTE to evaluate valve function, refer to cardiology for discussion of potential valve replacement since he actually does meet criteria for AVR (severe AS with decreasing EF), but that if he would prefer to proceed with his spine surgery prior to addressing his valve I would agree that's a reasonable thing to do. Despite the dogma, aortic stenosis really isn't that dangerous in the perioperative period and it would be fine to just do the case.

 

[vector2]

. It's not like patients transition from just a little risk to massively increased risk the second their AVA reaches 1.0 (which is probably the poorest echocardiographic indicator of AS severity, IMO-DI is the most useful),

In this patient's case I think the fact that his LV function has started to decrease is the most specific sign that he is of a significantly higher risk category. It's telling you in about the clearest terms possible that his AS is hemodynamically significant and that he is "symptomatic."

 

[dchz]

In this patient's case I think the fact that his LV function has started to decrease is the most specific sign that he is of a significantly higher risk category. It's telling you in about the clearest terms possible that his AS is hemodynamically significant and that he is "symptomatic."

Just imagine if his decrease in EF is 2/2 to ischemia.

 

[PpfSuxTube]

IM Consult Note: Don’t do anything that might kill the patient.

Its funny because we get quite a few IM Icu fellows rolling thru our csicu for their electives. Presumably these are better at the whole GA type scenario than most IM docs doing consults. Well they would probably kill every single patient...

No idea of dosages, cant read the room, cant react to even the slightest deviation from Normal, no idea where anything is or how to obtain it, cant dilute any medication, better at central lines than pivs... its bananas