Perioperative Atrial Fibrillation

[DrOwnage]

Hey guys, I had a case I would like your opinion on/what to do for the future.

88 year old, robust, found to have incidental infrarenal aortic ulceration after CT imaging done in ED for hematuria 3 weeks prior. Findings include: aneurysmal dilation of the infrarenal abdominal aorta measuring up to 4.0 cm in greatest transverse dimension with associated saccular outpouching measuring up to 2.6 cm.

He was on eliquis for PE's found in February (segmental in the left lower lobe with further propagation) and history of atrial fibrillation (for which he's not sure if he was on anticoagulation for). History of CHF, on diuretics. No recent echo. RHC/LHC done in 2016, clean coronaries, normal PA pressures, normal EF, CO 5.5.

Patient here for an EVAR. Has been off of anticoagulation for 3 weeks since episode of hematuria. Hematuria lasted only a couple of days, likely a stone. Hgb normal and other labs unremarkable. CHADSVASC2 calculated is 5.

Discussed with patient and daughter who seemed to not know anything about a fib and stroke risk. Told them he was at increased risk perioperatively, especially because he had been off anticoagulation for 3 weeks and given his high CHADSVASC score. Told surgeon who really didn't care.

Procedure is mostly elective since hes old af and incidental finding. Would you guys not bother with this detail or does it concern you?

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[deleted171991]

You informed the patient. You informed the surgeon. They want to proceed, end of story (unfortunately). I would have recommended a TEE to look for clots, before incision (e.g. your cardiac colleagues could do one, after induction). No good surgeon would do that surgery when they SEE a clot in the left atrial appendage.

I assume this patient had some kind of cardiac clearance which washes your hands. If not, ask for one preop, just for liability purposes.

Next time, try to discover patients like this ahead of time (e.g. pre-anesthesia clinic), and have them get a TEE before surgery.

 

[vector2]

Hey guys, I had a case I would like your opinion on/what to do for the future.

88 year old, robust, found to have incidental infrarenal aortic ulceration after CT imaging done in ED for hematuria 3 weeks prior. Findings include: aneurysmal dilation of the infrarenal abdominal aorta measuring up to 4.0 cm in greatest transverse dimension with associated saccular outpouching measuring up to 2.6 cm.

He was on eliquis for PE's found in February (segmental in the left lower lobe with further propagation) and history of atrial fibrillation (for which he's not sure if he was on anticoagulation for). History of CHF, on diuretics. No recent echo. RHC/LHC done in 2016, clean coronaries, normal PA pressures, normal EF, CO 5.5.

Patient here for an EVAR. Has been off of anticoagulation for 3 weeks since episode of hematuria. Hematuria lasted only a couple of days, likely a stone. Hgb normal and other labs unremarkable. CHADSVASC2 calculated is 5.

Discussed with patient and daughter who seemed to not know anything about a fib and stroke risk. Told them he was at increased risk perioperatively, especially because he had been off anticoagulation for 3 weeks and given his high CHADSVASC score. Told surgeon who really didn't care.

Procedure is mostly elective since hes old af and incidental finding. Would you guys not bother with this detail or does it concern you?

Look at the femoral veins preop since he has a hx of PE. Then you or your colleague drop a probe after you go to sleep and look at the appendage (and do a comprehensive exam since you said he doesn’t have a recent one in the chart). Have cards in conjunction with vascular restart eliquis or Asa+eliquis whenever appropriate after the stentgraft is deployed.

E: even if he does have a clot I think you have to proceed anyway given the saccular aneurysm and aortic ulceration and thus high risk of rupture. But if you do have a clot then you can discuss IVC filters and heparinizing for their procedure and just keeping heparin going until you’ve bridged, etc

 

[DrOwnage]

Unfortunately I don't have the prowess to do a TEE examination. I could get a 2 chamber view to possibly see a clot myself but then again I'm not TEE trained. Another one of my cardiac colleagues would usually be busy in a case. In other words its either I say they accept the risk, or I tell cards to come down and write a note. Is there any timeframe you would be comfortable proceeding without doing anything? Say he had been off for a week?

 

[deleted171991]

Unfortunately I don't have the prowess to do a TEE examination. I could get a 2 chamber view to possibly see a clot myself but then again I'm not TEE trained. Another one of my cardiac colleagues would usually be busy in a case. In other words its either I say they accept the risk, or I tell cards to come down and write a note. Is there any timeframe you would be comfortable proceeding without doing anything? Say he had been off for a week?

The amount of time blessed by a cardiologist.

 

[GassYous]

I would get some bull**** test or consult so that someone else can inherit this trainwreck since it is a bull**** surgery anyway.

 

[vector2]

Unfortunately I don't have the prowess to do a TEE examination. I could get a 2 chamber view to possibly see a clot myself but then again I'm not TEE trained. Another one of my cardiac colleagues would usually be busy in a case. In other words its either I say they accept the risk, or I tell cards to come down and write a note. Is there any timeframe you would be comfortable proceeding without doing anything? Say he had been off for a week?

I would be comfortable doing the case right the second cards put in a note about it being OK to proceed given his AF/stroke risk and with their recs on when to start/restart A/C.

 

[IMGASMD]

Consult. Cards, geriatrics and palliative care. All at once. Maybe neurology too. Spread the wealth.

But I’d document the sh.. out of the conversation between you, the patient and possibly the daughter. I don’t know the number for rupture, but if that number can be given to the patient by vascular, it may be a more fruitful conversation.

Or just go with approach number 1.

 

[Iso4ane]

Is it just me, or are vascular surgeons right up there with ortho, ‘a bone/vessel is hurt, I need to fix it.’ (And I’m not talking ruptured AAA or similar, I’m talking AVF , varicose veins.....)

 

[GassYous]

Is it just me, or are vascular surgeons right up there with ortho, ‘a bone/vessel is hurt, I need to fix it.’ (And I’m not talking ruptured AAA or similar, I’m talking AVF , varicose veins.....)

Nah they understand their disease pathology very well and get that their patients are sick trainwrecks.

 

[deleted875186]

Is it just me, or are vascular surgeons right up there with ortho, ‘a bone/vessel is hurt, I need to fix it.’ (And I’m not talking ruptured AAA or similar, I’m talking AVF , varicose veins.....)

Ulceration is a disaster waiting to happen. Have to weigh the risks of a VTE versus the risk of rupture or clot forming around the ulceration. Cardiology should be the ones to make the decision, need a consult. Honestly, the decision to stop anticoagulation has already been made, he had hematuria that required stopping it, now might be the in my time to do the surgery.

 

[Planktonmd]

An 88 Y/O has no business being anticoagulated for Afib or some vague history of DVT period! He has an aneurysm, he wants it fixed, fix it.
These patients have more risk dying of complications of anticoagulation than dying of a thrombo-embolic event, and he already proved to you that anticoagulation is not good for him by developing hematuria, and the next step would have been a GI bleed that would likely kill him.
This is the kind of patient who should get maybe Aspirin but no other anticoagulation. Actually to be honest with you, one should wonder if this aneurysm really needs to be fixed?

 

[drmwvr]

Is it just me, or are vascular surgeons right up there with ortho, ‘a bone/vessel is hurt, I need to fix it.’ (And I’m not talking ruptured AAA or similar, I’m talking AVF , varicose veins.....)

Not even in the same galaxy.

 

[vector2]

An 88 Y/O has no business being anticoagulated for Afib or some vague history of DVT period! He has an aneurysm, he wants it fixed, fix it.
These patients have more risk dying of complications of anticoagulation than dying of a thrombo-embolic event, and he already proved to you that anticoagulation is not good for him by developing hematuria, and the next step would have been a GI bleed that would likely kill him.
This is the kind of patient who should get maybe Aspirin but no other anticoagulation. Actually to be honest with you, one should wonder if this aneurysm really needs to be fixed?

I’m generally with you vis a vis old AF people and A/C but this guy had a confirmed PE, not a DVT.

 

[fakin' the funk]

Hey guys, I had a case I would like your opinion on/what to do for the future.

88 year old, robust, found to have incidental infrarenal aortic ulceration after CT imaging done in ED for hematuria 3 weeks prior. Findings include: aneurysmal dilation of the infrarenal abdominal aorta measuring up to 4.0 cm in greatest transverse dimension with associated saccular outpouching measuring up to 2.6 cm.

He was on eliquis for PE's found in February (segmental in the left lower lobe with further propagation) and history of atrial fibrillation (for which he's not sure if he was on anticoagulation for). History of CHF, on diuretics. No recent echo. RHC/LHC done in 2016, clean coronaries, normal PA pressures, normal EF, CO 5.5.

Patient here for an EVAR. Has been off of anticoagulation for 3 weeks since episode of hematuria. Hematuria lasted only a couple of days, likely a stone. Hgb normal and other labs unremarkable. CHADSVASC2 calculated is 5.

Discussed with patient and daughter who seemed to not know anything about a fib and stroke risk. Told them he was at increased risk perioperatively, especially because he had been off anticoagulation for 3 weeks and given his high CHADSVASC score. Told surgeon who really didn't care.

Procedure is mostly elective since hes old af and incidental finding. Would you guys not bother with this detail or does it concern you?

Increased risk? Relative to what? Dude, your guy failed anticoagulation due to bleeding, end of story, do the case.

 

[DrOwnage]

He didn't fail anticoagulation. He had transient hematuria that resolved in 2 days after discontinuing his oral anticoagulant. Its obvious no one told him when to reinitiate the medication, hence the problem. I did do the case, without cards blessing.

 

[BobLoblaw78]

Interesting scenario. Thanks for sharing and finishing the story (I hate it when I don't get to hear how the case ended up)

 

[chocomorsel]

He didn't fail anticoagulation. He had transient hematuria that resolved in 2 days after discontinuing his oral anticoagulant. Its obvious no one told him when to reinitiate the medication, hence the problem. I did do the case, without cards blessing.

He has an ulcerated aorta no? Is it a good idea to be AC with an ulcerated aorta?

 

[chocomorsel]

Interesting scenario. Thanks for sharing and finishing the story (I hate it when I don't get to hear how the case ended up)

Did I miss it? 😳

 

[IMGASMD]

Did I miss it?

Just he did the case without involving cards.

 

[BobLoblaw78]

Did I miss it? 😳

Post # 16. I will forgive you for missing the lengthy summary! And I will assume it went without incident or any remarkable events

 

[DrOwnage]

It’s funny how you think if an aortic ulceration ruptures that being anti coagulated is going to make a difference. It’s an 88 year old with comorbidities. They will die regardless. My goal is damage control. The patient having a stroke is exactly the opposite of that and is a real possibility. Case went fine. GETA and a line. Maintained decreased chronotropy. Luckily the surgeons were good and quick.

You deleted your post, nice job

 

[MDanesth]

Hey guys, I had a case I would like your opinion on/what to do for the future.

88 year old, robust, found to have incidental infrarenal aortic ulceration after CT imaging done in ED for hematuria 3 weeks prior. Findings include: aneurysmal dilation of the infrarenal abdominal aorta measuring up to 4.0 cm in greatest transverse dimension with associated saccular outpouching measuring up to 2.6 cm.

He was on eliquis for PE's found in February (segmental in the left lower lobe with further propagation) and history of atrial fibrillation (for which he's not sure if he was on anticoagulation for). History of CHF, on diuretics. No recent echo. RHC/LHC done in 2016, clean coronaries, normal PA pressures, normal EF, CO 5.5.

Patient here for an EVAR. Has been off of anticoagulation for 3 weeks since episode of hematuria. Hematuria lasted only a couple of days, likely a stone. Hgb normal and other labs unremarkable. CHADSVASC2 calculated is 5.

Discussed with patient and daughter who seemed to not know anything about a fib and stroke risk. Told them he was at increased risk perioperatively, especially because he had been off anticoagulation for 3 weeks and given his high CHADSVASC score. Told surgeon who really didn't care.

Procedure is mostly elective since hes old af and incidental finding. Would you guys not bother with this detail or does it concern you?

Goal for this patient is to get back on thinners as soon as possible and I'd just make sure surgeon had a plan for that which is likely he/she does for sure as it's not his/her first rodeo.

You said he has a history of A-fib. Is he in A-fib in Preop?

 

[aafisahar]

Patient here for an EVAR. Has been off of anticoagulation for 3 weeks since episode of hematuria. Hematuria lasted only a couple of days, likely a stone. Hgb normal and other labs unremarkable. CHADSVASC2 calculated is 5.

Discussed with patient and daughter who seemed to not know anything about a fib and stroke risk. Told them he was at increased risk perioperatively, especially because he had been off anticoagulation for 3 weeks and given his high CHADSVASC score. Told surgeon who really didn't care.

Procedure is mostly elective since hes old af and incidental finding. Would you guys not bother with this detail or does it concern you?

Stroke is calculated on a yearly basis. As others have said, he failed AC due to bleeding anyways. I don't think surgery changes the calculus. We have patient stop their eliquis for procedures all the time with afib.

His fresh PE is a bigger concern than his afib.

Do the case based on the merits, not some vague stroke risk that's spread out over a year.

 

[deleted697127]

I would get some bull**** test or consult so that someone else can inherit this trainwreck since it is a bull**** surgery anyway.

Why is it a bs surgery?

 

[deleted171991]

Stroke is calculated on a yearly basis. As others have said, he failed AC due to bleeding anyways. I don't think surgery changes the calculus. We have patient stop their eliquis for procedures all the time with afib.

His fresh PE is a bigger concern than his afib.

Do the case based on the merits, not some vague stroke risk that's spread out over a year.

Seriously? Have you heard of perioperative thrombotic risk and prophilactic anticoagulation in surgical inpatients? You know, just all those tons of SQ heparin used in the US, because they do save lives.

He's at a higher stroke/PE risk not just because they stopped his anticoagulation, but especially because they are doing major surgery on him, and we already know he's prone to PEs.

What percentage of patients who die in the ICU (for various reasons) have (even just subclinical asymptomatic) PEs on autopsy? 30%. Just give the immune system a reason to get seriously inflamed, and it will also promptly generate thrombi.

 

[aafisahar]

Seriously? Have you heard of perioperative thrombotic risk and prophilactic anticoagulation in surgical inpatients? You know, just all those tons of SQ heparin used in the US, because they do save lives.

He's at a higher stroke/PE risk not just because they stopped his anticoagulation, but especially because they are doing major surgery on him, and we already know he's prone to PEs.

What percentage of patients who die in the ICU (for various reasons) have (even just subclinical asymptomatic) PEs on autopsy? 30%. Just give the immune system a reason to get seriously inflamed, and it will also promptly generate thrombi.

Sure, but it doesn't change the calculus and I've never seen a TEE done to assess for preop thrombus unless it was cardiac surgery. Put him on ppx as is the standard of care, but there's no need to get bent out of shape over being off anticoagulation for his afib.

Restart his anticoagulation when it's safe after the procedure. He's going to need to stop anticoagulation regardless for the procedure, and he has no other cardiac contraindications. Put him under, get the EVAR in, restart his eliquis prior to discharge. His ulcerating aorta is way more concerning than his afib stroke risk.

 

[deleted171991]

Sure, but it doesn't change the calculus and I've never seen a TEE done to assess for preop thrombus unless it was cardiac surgery. Put him on ppx as is the standard of care, but there's no need to get bent out of shape over being off anticoagulation for his afib.

Restart his anticoagulation when it's safe after the procedure. He's going to need to stop anticoagulation regardless for the procedure, and he has no other cardiac contraindications. Put him under, get the EVAR in, restart his eliquis prior to discharge. His ulcerating aorta is way more concerning than his afib stroke risk.

It's the PE that's concerning, possibly while already on anticoagulation. Most PEs (if not all) are NOT atrial in origin. That recent unprovoked PE is a much higher indication for anticoagulation than AFib at that age, in my book, and a much higher periop risk if not bridged (probably by an order of magnitude after 10 months off-AC). I'm not afraid of a stroke as much I'm afraid of a periop PE, or some other thrombus/embolus, especially after an atheroma shower. This is something the patient needs to be explained.

One can also debate how urgent is surgery in an asymptomatic aortic ulceration (does it also matter how big it is?). I don't know. Most surgeons wouldn't touch an unbridged patient off PE-anticoagulation with a pole, not without a medicine/cardiology note, so I'll have to assume they don't differentiate between symptomatic and asymptomatic aortic ulcers. As everything in medicine, this is a risk vs benefits discussion, but I strongly doubt his uncoagulated periop thromboembolic risk is as low as in AFib (i.e. just a few percent per YEAR).

Anyway, probably the best approach is what has been said before: explain the risks, do the case, restart AC ASAP post-op.

 

[deleted697127]

He's going to need to stop anticoagulation regardless for the procedure, and he has no other cardiac contraindications.

Lol. Definitely losing credibility with this comment bruh.

 

[nimbus]

Sure, but it doesn't change the calculus and I've never seen a TEE done to assess for preop thrombus unless it was cardiac surgery. Put him on ppx as is the standard of care, but there's no need to get bent out of shape over being off anticoagulation for his afib.

Restart his anticoagulation when it's safe after the procedure. He's going to need to stop anticoagulation regardless for the procedure, and he has no other cardiac contraindications. Put him under, get the EVAR in, restart his eliquis prior to discharge. His ulcerating aorta is way more concerning than his afib stroke risk.

Typically during an EVAR, we give a bolus of heparin after groin access.

 

[aafisahar]

Lol. Definitely losing credibility with this comment bruh.

What I've always seen is anticoagulation stopped for arterial access then can bolus all the heparin or angiomax you want. Venous access is mostly operator dependent but many seem fine to continue.