Cancel or not??

[TrustMe]

This was a case presented to me by a colleague who wanted an opinion. I don't have every detail, but I will give all the info I have. 50 something male presenting for craniotomy for tumor resection. It is thought that this is metastatic from laryngeal squamous cell CA. Pt. not previously cared for in our hospital system so all of his info. is from outside physicians. Hx. of HTN, former smoker, newly diagnosed laryngeal squamous cell CA and found to have a intracranial lesion thought to be metastatic disease. In talking with the pt. and looking through the provided info. it is discovered that he has severe aortic stenosis with an AVA of 0.8 by last TTE. Reportedly asymptomatic. He says he walks his dog everyday and has no problem with 2 flights of stairs. Colleague cancels case and has cardiology evaluate the pt. Repeat TTE shows an AVA of 0.7 (don't know gradients). What do you tell the pt. and the neurosurgeon regarding what needs to be done?

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[proman]

I'd do the case. He's not a candidate for cardiac surgery. Pre-induction a line, etc.

 

[rsgillmd]

Agree with proman. Based on the information I have been given, I'd do the case also.

Out of curiosity, why the crani for a metastatic tumor? For symptomatic relief?

Obviously you need more info about the laryngeal tumor/airway before inducing GA, but that's a different topic.

 

[Idiopathic]

id like a complete picture of cardiac function, make sure there isnt dilated cardiomyopathy or mitral disease, get an idea of the LV systolic and diastolic function, etc. but otherwise we do patients with aortic stenosis for non-cardiac surgery all the time

 

[Bertelman]

Agree with proman. Based on the information I have been given, I'd do the case also.

Out of curiosity, why the crani for a metastatic tumor? For symptomatic relief?

Obviously you need more info about the laryngeal tumor/airway before inducing GA, but that's a different topic.

That. And why did he ever get the echo in the first place? Systolic murmur?

Otherwise, I wouldn't have any reservations about the case, just be aware. The way I see it, if you can do a crani for tumor resection with an awake patient, you can do a crani for tumor with severe "asymptomatic" AS.

 

[MTGas2B]

Tight valve, but agree if he's asymptomatic you can do it.

I assume surgeons want to establish met vs two primaries? Its cancer, if they want to treat probably don't want to wait through and AVR and then fight through anticoagulation for subsequent onc surgery.

 

[ssmallz]

Even if he's symptomatic you still have to do the case. Like others have said, he's not getting a new valve and you're doing this for palliative puposes. As long as you know what the echo shows there's no reason to delay

 

[seinfeld]

Even if he's symptomatic you still have to do the case. Like others have said, he's not getting a new valve and you're doing this for palliative puposes. As long as you know what the echo shows there's no reason to delay

I second that

 

[proman]

If he's symptomatic he gets an aortic balloon valvuloplasty then his crani.

 

[Surfer]

Interestingly, I think we do 0.7 valves all the time without realizing it. Lots of people walking around with undiagnosed disease.

I agree with the others... Do the case, this is a patient that already has lots of risks and they need or want this sooner rather than later. Discuss risks and proceed.