Another case

[toughlife]

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53 y/o hx of ICM, EF 15%, admitted with NSTEMI, LHC shows severe 3-vessel disease, 3+ MR, now scheduled for CABG and MVR.

PMHx remarkable for CAD, HTN and an episode of vertigo on early 2006 which she attributed to 'a pneumonia'. During workup on this presumed vertigo episode, TCD of posterior circulation showed elevated flow velocities on basilar artery with severe stenosis of same vessel.


What is your next question/step regarding the pre-op eval of this patient?

 

[armygas]

53 y/o hx of ICM, EF 15%, admitted with NSTEMI, LHC shows severe 3-vessel disease, 3+ MR, now scheduled for CABG and MVR.

PMHx remarkable for CAD, HTN and an episode of vertigo on early 2006 which she attributed to 'a pneumonia'. During workup on this presumed vertigo episode, TCD of posterior circulation showed elevated flow velocities on basilar artery with severe stenosis of same vessel.


What is your next question/step regarding the pre-op eval of this patient?

Well there is going to be a 6% risk of periop stroke with this patient. Its hypothesized that neck positioning similar to that for intubation reduces flow leading to thrombus formation which can free postintubation when the neck motion is free. Is there any way to do a TCD velocity study with the patient's neck extended to give you some idea if that is going to be a problem?

 

[Noyac]

Well there is going to be a 6% risk of periop stroke with this patient. Its hypothesized that neck positioning similar to that for intubation reduces flow leading to thrombus formation which can free postintubation when the neck motion is free. Is there any way to do a TCD velocity study with the patient's neck extended to give you some idea if that is going to be a problem?

Shouldn't be much risk of thrombus while heparinized. I can't imagine a thrombus would form in the 30sec it takes to intubate. I would also imagine that in the past 1 1/2 yrs that this stenotic area has been known about, she has had her neck in that position without complication.

My gut feeling is to do the case keeping the mean at a reasonable value (depends on her baseline pressure) until heparinized at least.

A few years back I did a case were we did a CEA on a guy packed it then did a 4 vessel bypass off pump and then came back to close the neck. It was a mess. The neck bled the whole time he was heparinized. Not a huge amount but enough. The surgeon and I looked at each other after the case and almost simultaneously said, "Well thats the last time I do that".

 

[Noyac]

If a pt needed a CEA and a bypass I'd rather do the carotid first then come back later to do the bypass. How about you guys?




I think I may have officially hijacked this thread.😎

 

[armygas]

Shouldn't be much risk of thrombus while heparinized. I can't imagine a thrombus would form in the 30sec it takes to intubate.

True, but I was talking about the position the patient remains while intubated.

 

[jwk]

True, but I was talking about the position the patient remains while intubated.

???? Supine ????

 

[Planktonmd]

53 y/o hx of ICM, EF 15%, admitted with NSTEMI, LHC shows severe 3-vessel disease, 3+ MR, now scheduled for CABG and MVR.

PMHx remarkable for CAD, HTN and an episode of vertigo on early 2006 which she attributed to 'a pneumonia'. During workup on this presumed vertigo episode, TCD of posterior circulation showed elevated flow velocities on basilar artery with severe stenosis of same vessel.


What is your next question/step regarding the pre-op eval of this patient?

I think toughlife is asking what to do next, and I think a cerebral angiogram is needed to determine if that vertebral stenosis is being compensated for by the carotids or not.
The plan of action will depend on that.

 

[urgewrx]

During workup on this presumed vertigo episode, TCD of posterior circulation showed elevated flow velocities on basilar artery with severe stenosis of same vessel.

Said person who was working up her vertigo (presumably a neurologist) should deal with the findings of tests ordered. The best answer is "wait for recommendations" as this is out of our expertise.

Does she need an angiogram, a Ct, a MRI, a stent, or nothing at all? I have no idea.

 

[VentdependenT]

Now that somebody opened the can o' worms with the vertebral artery I'd like a Neurologist to get MRA/angiogram for adequate collateral flow to the areas in jeopardy. Thats MY next step.

Now what's her PFT's like. Just yoking. hehe


Why do I care?

If the Heart takes a while to recover, if it recovers, and the pt requires pressors/inotropes and thusly (dunno if thats a word but I felt like using it)her CO, and ultimately her MAP, takes a dive then there's your stroke.

 

[toughlife]

I think toughlife is asking what to do next, and I think a cerebral angiogram is needed to determine if that vertebral stenosis is being compensated for by the carotids or not.
The plan of action will depend on that.

Right, that was my question. So MRA of brain/COW ordered and results are as follows:

"Occlusion of the right cervical vertebral artery at its origin or
proximal to the visualized distribution. Severe stenosis of the
proximal basilar artery and moderate stenosis of the origin right
M2 MCA branch."

So now the patient has more disease that initially suspected. Would you still proceed with case?

 

[Planktonmd]

Right, that was my question. So MRA of brain/COW ordered and results are as follows:

"Occlusion of the right cervical vertebral artery at its origin or
proximal to the visualized distribution. Severe stenosis of the
proximal basilar artery and moderate stenosis of the origin right
M2 MCA branch."

So now the patient has more disease that initially suspected. Would you still proceed with case?

There is a good chance that the cerebellar circulation is going to be inadequate during CPBP, on the other hand there is a good chance this patient is going to die soon from MI/ CHF without the surgery, so you have to weigh the risks against the benifits: Cerebellar stroke versus heart failure and death.
The main issue is the severe stenosis of the basilar artery, and in a young patient like this one, a basilar artery angioplasty and stent might be the solution before the heart surgery.

 

[VentdependenT]

Have a discussion with the referring cardiac surgeon, primary, and neurologist. I'd like to see if ANYTHING can be done for this condition PRIOR to undergoing a major surgery.

Can they stent this thing or do an angioplasty?

If not, then fine, the CARDIAC SURGEON and yourself need to have a frank discussion with the patient about possibility of severe post op disability/morbidity related to the brain in addition to the heart. Double whammies are great aint they?

 

[toughlife]

Have a discussion with the referring cardiac surgeon, primary, and neurologist. I'd like to see if ANYTHING can be done for this condition PRIOR to undergoing a major surgery.

Can they stent this thing or do an angioplasty?

If not, then fine, the CARDIAC SURGEON and yourself need to have a frank discussion with the patient about possibility of severe post op disability/morbidity related to the brain in addition to the heart. Double whammies are great aint they?

Nothing offered except good old aspiring and plavix since stenting would require anticoagulation and that would delay surgery.

 

[VentdependenT]

There ya have it.

So how'd it go?

 

[jetproppilot]

53 y/o hx of ICM, EF 15%, admitted with NSTEMI, LHC shows severe 3-vessel disease, 3+ MR, now scheduled for CABG and MVR.

PMHx remarkable for CAD, HTN and an episode of vertigo on early 2006 which she attributed to 'a pneumonia'. During workup on this presumed vertigo episode, TCD of posterior circulation showed elevated flow velocities on basilar artery with severe stenosis of same vessel.


What is your next question/step regarding the pre-op eval of this patient?

With an EF of 15% at fifty-three years old, her future is a crapshoot to begin with.

3 vessel disease and 3+ MR are MAJA PLAYA problems, which could lead to sudden death at any moment.

Yeah, you can play the CVA-risk card. But more than likely some heart-s hits gonna happen first.

ARE YA FEELIN' THE IMPACT? ANY MOMENT? SUDDEN DEATH???

So my next question/step regarding the pre-op eval of this patient is:

WHAT TIME IS YOUR HEART SURGERY SCHEDULED FOR TOMORROW???

 

[jetproppilot]

.

 

[jetproppilot]

I think toughlife is asking what to do next, and I think a cerebral angiogram is needed to determine if that vertebral stenosis is being compensated for by the carotids or not.
The plan of action will depend on that.

SPOKEN LIKE A TRUE FLEA.

THANK YOU, DOCTOR INTERNAL MEDICINE PLANKTON, MD, PhD, DDS, MBA, MS, CFA, DDRP, HUYT, DFOP, SUCK.


TICK TICK TICK......

multi-vessel dz and 3+ MR AND severely decompensated left ventricular function...

TICK TICK TICK

OH........SORRY......LEMME THINK LIKE A FLEA FOR A JUSTA MINUTE MORE AND DELAY THE OBVIOUS SUMMORE.....HMMMMM.....HOW ABOUT THYROID FUNCTION???? YEAH!!!! Lets get a full thyroid workup in addition to the carotid stuff that we know is gonna be dismal....and while we're at it, lets get a BMP, a full liver profile, a twenty-four hour urine, a twenty-four-hour Holter monitor for arrythmias, a tox-screen in case the depressed myocardial function is from illicit substance abuse, some PFTs, a CT of the chest and abdomen, consult the allergist because the patient's sister's cousin's brother was allergic to PCN, consult the endocronologist since the glucose was 107 mg/dl, AND,

FINALLY,

Consult psych.

Pt becoming unmanageable due to all unneeded work done upon her.


UHHHH.............

cant remove the stroke risk.

But da chick aint gonna see 55 without a heart surgeon's signature on her chest.

LETS ALL CONCEDE TO THE FACT THAT THIS PATIENT'S OUTCOME, OVER THE NEXT FIVE YEARS, IS PRETTY BAD.

SO WE'RE GONNA HAVE TO TAKE SOME RISKS TO AMELIORATE THE OBVIOUS, WHICH IS PRIMARILY MYOCARDIAL DYSFUNCTION.
SHE NEEDS A NEW MITRAL VALVE. AND SOME CORONARY GRAFTS.

PERIOD.

SO GET TO WORK. AND STOP DELAYING THE SURGERY.

 

[IceDoc]

If the Heart takes a while to recover, if it recovers, and the pt requires pressors/inotropes and thusly (dunno if thats a word but I felt like using it)her CO, and ultimately her MAP, takes a dive then there's your stroke.

"Thusly" is not a word. You brought back my memories of being shot down by the hard core freshman English teacher. But, I've never used thusly again.

And I'm sure that after this pt strokes out post op the family will ask "How could this be? She was so healthy yesterday, thusly it's your fault she had a stroke!"

 

[militarymd]

If I were a poker playing man....I would bet she doesn't come off bypass at all , and if she does....it will be with a balloon pump or LVAD.....

If your preop information is correct...that is.

EF 15% with 3+ MR......is not a good combo...

UT...your thoughts.

 

[VolatileAgent]

long talk with family and patient. make sure they understand the risk/benefit/poor prognosis. do the case. 30k of heparin she's gonna get to get on the pump will ameliorate some of the concerns with the stenotic lesion while she's in the case. even coming off-pump this lady is going to stay tubed for at leat 24h in the cvicu, so you won't get blamed for any bad outcome.

 

[Planktonmd]

SPOKEN LIKE A TRUE FLEA.

THANK YOU, DOCTOR INTERNAL MEDICINE PLANKTON, MD, PhD, DDS, MBA, MS, CFA, DDRP, HUYT, DFOP, SUCK.


TICK TICK TICK......

multi-vessel dz and 3+ MR AND severely decompensated left ventricular function...

TICK TICK TICK

OH........SORRY......LEMME THINK LIKE A FLEA FOR A JUSTA MINUTE MORE AND DELAY THE OBVIOUS SUMMORE.....HMMMMM.....HOW ABOUT THYROID FUNCTION???? YEAH!!!! Lets get a full thyroid workup in addition to the carotid stuff that we know is gonna be dismal....and while we're at it, lets get a BMP, a full liver profile, a twenty-four hour urine, a twenty-four-hour Holter monitor for arrythmias, a tox-screen in case the depressed myocardial function is from illicit substance abuse, some PFTs, a CT of the chest and abdomen, consult the allergist because the patient's sister's cousin's brother was allergic to PCN, consult the endocronologist since the glucose was 107 mg/dl, AND,

FINALLY,

Consult psych.

Pt becoming unmanageable due to all unneeded work done upon her.


UHHHH.............

cant remove the stroke risk.

But da chick aint gonna see 55 without a heart surgeon's signature on her chest.

LETS ALL CONCEDE TO THE FACT THAT THIS PATIENT'S OUTCOME, OVER THE NEXT FIVE YEARS, IS PRETTY BAD.

SO WE'RE GONNA HAVE TO TAKE SOME RISKS TO AMELIORATE THE OBVIOUS, WHICH IS PRIMARILY MYOCARDIAL DYSFUNCTION.
SHE NEEDS A NEW MITRAL VALVE. AND SOME CORONARY GRAFTS.

PERIOD.

SO GET TO WORK. AND STOP DELAYING THE SURGERY.

LOL

Sure she needs a CABG and MVR, but If you ask a flea question you get a flea answer!
also some people might prefer to die than live after a cerebellar stroke!

I like The "Colorful" style though 🙂

 

[UTSouthwestern]

If I were a poker playing man....I would bet she doesn't come off bypass at all , and if she does....it will be with a balloon pump or LVAD.....

If your preop information is correct...that is.

EF 15% with 3+ MR......is not a good combo...

UT...your thoughts.

Had a page long reply just get eated up by the SDN internet gremlins:

Short version: This is not an uncommon patient you see in any CV practice. A short intraop stress test with 2-10 mcg of epi and continuous TEE can reveal the presence or absence of cardiac reserve by noting improved or worsened contractility.

If you can avoid a prolonged pump run or repeat pump runs through TEE detection of appropriate ring/replacement size, SAM, etc., this patient should be able to come off pump, likely with a balloon, but not necessarily with huge amounts of inotropes and vasopressors. I see this type of case several times a month.

Had a case example from a few weeks ago done by a CV guy we do not cover, and in the short version, they went back to surgery immediately after the cath, without even attempting to optimize the variables of the patient (specifically, no coronary vasodilators on board and HR of 110 on arrival), and that patient crashed about 20 minutes after intubation. Survived but needed 7 days in the ICU for a 4V CABG on a 54 year old male.

All other teaching points sacrificed to the SDN monsters.

 

[VentdependenT]

HIJACK:

UT I'll be applying to Texas Heart for 08-09. Maybe I'll see you around. Or just follow the legacy. Or just skin rattlesnakes and make men's thongs out of em. Whoops did I just write that?

 

[UTSouthwestern]

HIJACK:

UT I'll be applying to Texas Heart for 08-09. Maybe I'll see you around. Or just follow the legacy. Or just skin rattlesnakes and make men's thongs out of em. Whoops did I just write that?

Call me if you decide to look at Dallas for a job or if you can swing by Dallas.