Aortic regurgitation

[deleted875186]

Would you do this case?

90yo patient for a hip ORIF. Dementia, CKD3, DM, COPD, prior mitral valve repair, echo from a year ago showing moderate-severe AR and moderate TR, there is a dilated RV and LV, LVEF35%, pHTN with PA pressures up to 50. I don’t have a prior echo to compare or understand progression, but I assume long-standing AR that got worse after mitral valve repair.

Patient has new heart failure and hypoxia. There was a small trop bump up to 0.15 with ST depressions in the lateral leads. Case delayed overnight for diuresis. After a couple doses of diuretics, creatinine has bumped up, not much improvement, unable to wean below 3L oxygen or so. I see the patient today.

What would you need to do the case in terms of hosptial setting and backul available?

How would you do it?

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[DrOwnage]

Yikes so basically all that badness and a new NSTEMI (probably just demand, but still). What was this patient's mobility beforehand? I feel that their morbidity and mortality is much higher doing the case than non-operative management especially given the acute CHF. The only way to do this safely would be regional with no sedation. However putting an epidural in this lady might prove difficult. If they did fix it, it would have to be one of those short half assed percutaneous pins not a full blown ORIF.

Edit: Hopefully patient just on aspirin for her mitral valve repair.

 

[deleted875186]

Yikes so basically all that badness and a new NSTEMI (probably just demand, but still). What was this patient's mobility beforehand? I feel that their morbidity and mortality is much higher doing the case than non-operative management especially given the acute CHF. The only way to do this safely would be regional with no sedation. However putting an epidural in this lady might prove difficult. If they did fix it, it would have to be one of those short half assed percutaneous pins not a full blown ORIF.

Edit: Hopefully patient just on aspirin for her mitral valve repair.

Also, got eliquid day of admission to the hosptial now about 2 days ago, plus AKI so probably still on board. Also demented and probably won’t lay still.

 

[Blockit]

The one-year mortality for this patient whether you fix this hip fracture or not is extraordinarily high. I’m sure the orthopedist will sing the usual song and dance about “we have to fix it within 24 hours”
We all know that this patient should be on hospice.
My personal opinion is that she should get no more than a dynamic hip screw and that they should be done under isobaric spinal after the apixaban is gone.

 

[DrOwnage]

Agree with above. Normally 72 hours for eliquis hold and neuraxial but with new AKI could be iffy. I would definitely get a new echo with intent on seeing actually how bad the RV function is if I'm doing neuraxial. If the echo is significantly worse, which there's a good chance it is, even doing a spinal might be risky especially in an aggressively diuresed patient. 1.5cc isobaric spinal might be the only way to go.

 

[Arch Guillotti]

Wait for eliquis to clear. Spinal and hope sedation isn't a problem. Make sure you have a come to jesus talk with the family and surgeon.

 

[MirrorTodd]

Y'all are going about this all wrong. Cadiac set up, get the echo you need, go to bypass. Ortho can do the hip at the same time as the heart transplant.

 

[deleted875186]

So, it looks like patient has a WBC as well, perhaps hypoxia is mostly from PNA, hard to tell. Would explain why she did not dourness much.

Assuming this was a PNA and patient didn’t have any heart failure, would be interested what people do for hip fractures with a PNA.

 

[Radetzky]

The oft quoted reason for doing these hopeless cases is that not doing it is consigning the patient to a miserably painful and slow death. This is not true

Results of non-operative treatment following hip fracture compared to surgical intervention - PubMed

We followed all consecutive hip fracture patients admitted between 2004 and 2006, identified cases in which the intention was to treat non-operative and compared their functional outcome and mortality with a similar cohort treated surgically over the same period. We recorded length of hospital...

pubmed.ncbi.nlm.nih.gov

Surgical Repair of Hip Fracture in Nursing Home Residents With Advanced Dementia

This cohort study compares survival rates among nursing home residents with advanced dementia and hip fracture managed surgically vs nonsurgically.

jamanetwork.com

 

[dchz]

Obviously come to Jesus talk with patient and famil. Establish goals of care.

I would do this case because the course for the patient would not get better without surgery.

GETA. a line with good IV access. Epi drip on standby. Hopefully the surgeon would wait until anti coags could be stopped.

What would you need to do the case in terms of hosptial setting and backul available?

Inside a hospital with blood products available.

 

[nimbus]

The oft quoted reason for doing these hopeless cases is that not doing it is consigning the patient to a miserably painful and slow death. This is not true

Results of non-operative treatment following hip fracture compared to surgical intervention - PubMed

We followed all consecutive hip fracture patients admitted between 2004 and 2006, identified cases in which the intention was to treat non-operative and compared their functional outcome and mortality with a similar cohort treated surgically over the same period. We recorded length of hospital...

pubmed.ncbi.nlm.nih.gov

Surgical Repair of Hip Fracture in Nursing Home Residents With Advanced Dementia

This cohort study compares survival rates among nursing home residents with advanced dementia and hip fracture managed surgically vs nonsurgically.

jamanetwork.com

Even though it may not be statistically significant, it appears the operative group did better. They certainly didn’t do worse.

 

[dchz]

Edit: Hopefully patient just on aspirin for her mitral valve repair.

Do your pts typically get anti coags for mitral valve repair?

 

[DrOwnage]

Do your pts typically get anti coags for mitral valve repair?

I believe most mitral repairs get VKAs for at least a little while following repair then maybe transitioned to aspirin. I feel like I've seen people with repairs on VKAs, could be wrong. Maybe a cardiac guy could chime in.

 

[vector2]

I believe most mitral repairs get VKAs for at least a little while following repair then maybe transitioned to aspirin. I feel like I've seen people with repairs on VKAs, could be wrong. Maybe a cardiac guy could chime in.

3 months of coumadin s/p mitral repair has been the standard I've seen at a couple different institutions.

 

[Arch Guillotti]

What would you need to do the case in terms of hosptial setting and backul available?

What kind of backup?

 

[dchz]

I think we need more info on the dementia. How bad is it?

 

[GassYous]

What kind of backup?

Spiritual