Case from Today

[TheEleventhReel]

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Interesting case from today.
-66 yo male scheduled for aortic valve replacement. Critical AS with AVA 0.5 cm2. Peak gradient 81, mean gradient 50.
-EF 20% by cath.
-Moderate MR.
-Pulm HTN with mean PAP in 50s.
-No evidence of coronary/carotid disease
-Poorly controlled IDDM with BG -300
-Morbid obesity (patient weighed in at 450 lbs)
-Severe OSA, patient on BIPAP, must lay at 45 degrees.
-Pulm edema on CXR with large right pleural effusion on CT Chest.
-Also on CT chest questionable glottic/supraglottic mass.

Physical exam
-Mobid obesity. Dyspnea when speaking. 2L NC with SPO2 95%. BP 140/90 HR 85
-MP 4, TM distance > 3 FB. Poor dentition, large tongue. Large beard. + upper lip bite test
-Brusing on right neck with erythema and possible ulceration (patient had PA catheter placed by cards during cath).
-Diffuse wheezing
-One heplocked 20g IV in left AC.
-2+ pitting edema in LE. Multiple ulcers on feet/toes

Patient has had GA before without problems. States he has been bed-bound for past three months.

Any thoughts?

 

[sevoflurane]

Baseline or can he be optimized? CHF/plum edema doesn't sound as if it is... but maybe chronic.

Waz up with the neck mass? Does it compress the trachea?

If you are afraid of the AW shave the beard off.

Fix his glucose and make sure that 20G works before going to sleep.

 

[sevoflurane]

If this guy is actually going to the OR he prolly needs a preop ballon pump.

 

[Bertelman]

pent + sux + tube

...WSJ on pump

 

[Bertelman]

...or maybe you can call the CT guy from cincincy's group, tell him you've got another great PulmHTN case for him since he declined the last one.

 

[urge]

pent + sux + tube

...WSJ on pump

I concur.

 

[Bertelman]

I concur.

* catchphrase most likely copyrighted by urge

 

[pgg]

* catchphrase most likely copyrighted by urge

And all variations thereof

pent sux tube..... cpr

pent, sux, botched tube, trach

pent sux tube...... m&m

A way of life, not a recipe. 😀

 

[dhb]

The patient needs a little tune up before induction: a little diuretics, insuline and drainage of the lung effusion, better iv access. Could be done in pre-op if you have a little time.

Awake fiberoptic, awke a-line gentle induction and let the surgeons do their thing. He will probably do poorly post-op but he should make it out of the OR.

 

[jwk]

Baseline or can he be optimized? CHF/plum edema doesn't sound as if it is... but maybe chronic.

Waz up with the neck mass? Does it compress the trachea?

If you are afraid of the AW shave the beard off.

Fix his glucose and make sure that 20G works before going to sleep.

Ahhh, I wish more people recognized this.

 

[Gas you down]

Interesting case from today.
-66 yo male scheduled for aortic valve replacement. Critical AS with AVA 0.5 cm2. Peak gradient 81, mean gradient 50.
-EF 20% by cath.
-Moderate MR.
-Pulm HTN with mean PAP in 50s.
-No evidence of coronary/carotid disease
-Poorly controlled IDDM with BG -300
-Morbid obesity (patient weighed in at 450 lbs)
-Severe OSA, patient on BIPAP, must lay at 45 degrees.
-Pulm edema on CXR with large right pleural effusion on CT Chest.
-Also on CT chest questionable glottic/supraglottic mass.

Physical exam
-Mobid obesity. Dyspnea when speaking. 2L NC with SPO2 95%. BP 140/90 HR 85
-MP 4, TM distance > 3 FB. Poor dentition, large tongue. Large beard. + upper lip bite test
-Brusing on right neck with erythema and possible ulceration (patient had PA catheter placed by cards during cath).
-Diffuse wheezing
-One heplocked 20g IV in left AC.
-2+ pitting edema in LE. Multiple ulcers on feet/toes

Patient has had GA before without problems. States he has been bed-bound for past three months.

Any thoughts?

consult re: pulm eff Tx and this glottic mass.
preop radial Aline and IV.
awake FOI (being sure to wear my Depends)
of course, leave his swann, but add a TEE and femoral Aline.

call a priest?

 

[BLADEMDA]

Interesting case from today.
-66 yo male scheduled for aortic valve replacement. Critical AS with AVA 0.5 cm2. Peak gradient 81, mean gradient 50.
-EF 20% by cath.
-Moderate MR.
-Pulm HTN with mean PAP in 50s.
-No evidence of coronary/carotid disease
-Poorly controlled IDDM with BG -300
-Morbid obesity (patient weighed in at 450 lbs)
-Severe OSA, patient on BIPAP, must lay at 45 degrees.
-Pulm edema on CXR with large right pleural effusion on CT Chest.
-Also on CT chest questionable glottic/supraglottic mass.

Physical exam
-Mobid obesity. Dyspnea when speaking. 2L NC with SPO2 95%. BP 140/90 HR 85
-MP 4, TM distance > 3 FB. Poor dentition, large tongue. Large beard. + upper lip bite test
-Brusing on right neck with erythema and possible ulceration (patient had PA catheter placed by cards during cath).
-Diffuse wheezing
-One heplocked 20g IV in left AC.
-2+ pitting edema in LE. Multiple ulcers on feet/toes

Patient has had GA before without problems. States he has been bed-bound for past three months.

Any thoughts?

Here is the real issue: Airway and Induction considering his Obesity, AS, Sleep Apnea with Bipap, ? Supraglottic mass combined with a low EF.

Those A/C Iv's are notoriously unreliable. ENT should have examined that mass/CT of his larynx. Will it bleed when you put a scope on it? The A-line is a good idea preinduction but the key is to maintain this guy's saturation during induction.

If you lose the airway and his Saturation drops to 50% then the Pulm HTN will worsen combined with severe AS and LOW EF he likely codes.

If you decide to do an awake intubation good airway blocks are vital as sedation will increase his PCO2 and worsen his Pulm HTN.

I'd likely get an ENT consult and a better grasp of the supraglottic mass; also, i would have a glidescope nearby ready to go.

Sux as the paralyzing agent seems sound considering his obesity and the fact he can't lie flat prior to induction (vs. high dose Rocuronium).

Once ENT agrees the supraglottic mass isn't a big concern and Pulmonary Medicine thinks the Effusion isn't a big deal I'd do an RSI on him with good, solid, preoxygenation (100% FIO2 here).

I'd consider Etomidate as my induction agent and have vasopressin, Epi (dilute) and Norepi ready in a syringe plus our usual phenylephrine. I'd likely use 1 unit of vasopressin if the BP drops to correct hypotension.

This is a good case but the number one issue is still his airway due to extreme morbid obesity and ? supraglotiic mass. Remember to keep in mind this guy will be almost impossible to emergently trach by anyone before he codes and dies. If you lose the airway and the LMA fails he isn't going to survive long enough for a trach or retrograde wire. So, bring your difficult airway stuff to the OR just in case.

That said, I'd likely preoxygenate well, Etomidate, Sux then tube.

(All Valves should get a TEE as that is the standard of care)

 

[lushmd]

This is a good case but the number one issue is still his airway due to extreme morbid obesity and ? supraglotiic mass. Remember to keep in mind this guy will be almost impossible to emergently trach by anyone before he codes and dies. If you lose the airway and the LMA fails he isn't going to survive long enough for a trach or retrograde wire. So, bring your difficult airway stuff to the OR just in case.

That said, I'd likely preoxygenate well, Etomidate, Sux then tube.

I agree that this patient has a number of issues and that securing the airway is always a prime concern, particularly given this patient's hx/co-morbid conditions. In light of this, why RSI instead of awake fiberoptic intubation?

 

[BLADEMDA]

I agree that this patient has a number of issues and that securing the airway is always a prime concern, particularly given this patient's hx/co-morbid conditions. In light of this, why RSI instead of awake fiberoptic intubation?

My post was a real world answer as I would handle the case. An awake fiberoptic intubation is a fine decision. Remember, he has to tolerate your airway blocks and sedation must be minimal in order not to worsen his Pulm HTN; yet, your blocks must be good enough to allow the intubation to proceed without the patient's BP shooting through the roof. The patient can't lie flat so you may need a standing stool to topicalize the airway.

Since he has been intubated before I feel confident that I can do it again. I have my glidescope, LMA, Intubating LMA, fiberoptic, etc. on standbye.

 

[imfrankie]

extra set of hands

 

[BLADEMDA]

extra set of hands

 

[sevoflurane]

The A-line is a good idea preinduction ....

It's not just a good idea... it's an absolute must for multiple reasons.
Pull out the sonosite and get it on your first stick. That's what I do for these biggen's.... and that is what I'm going to do next week with my BMI of 76. 😱

 

[cincincyreds]

...or maybe you can call the CT guy from cincincy's group, tell him you've got another great PulmHTN case for him since he declined the last one.

I just got a laugh out of this. Luckily, the CT guys will actually do the case since the procedure is in the chest.

 

[TheEleventhReel]

I appreciate all the replies and sound advice. Here's how the case went:

-Plan for awake FOI with lidocaine neb + atomizer. Backup plan was awake trach by ENT.
-ENT consulted morning of - looked at CT and decided it was a respiratory variant and NOT a mass (heavily overread by radiology)
-16g PIV placed before we went back to OR.
-Defib pads placed, patient moved to OR table.
-Preinduction Aline placed in left radial after a few attempts at brachial (my attending thought d/t patients BMI a radial catheter may kink once arms were tucked). So we put in a 4'' radial catheter without difficulty.
-Topicalization went smoothly with judicious fentanyl. We avoided glyco to try and eliminate unwanted tachycardia.
-FOI took two attempts by our airway resident but went well and patient tolerated it well.
-Once tube was in, 14 mg Etomidate and 250 of fentanyl. Patient's HR never > 85 and he remained normotensive
-Attempted left IJ x 3 but could not pass the MAC because the catheter couldn't pass under the clavicle - the wire kept bending. I have no idea how cards got it in but wish they would've left the PAC in place. Subclavian MAC easily placed.
-Case went well with no real issues. Patient's PAP remained in the 40-50s but his post-valve ECHO looked improved. I could barely see wall movement before the valve was fixed. CT drained 1500 ml of pleural effusion off this guy's right lung after the chest was opened.

The reason I brought this case up was because a few of our attendings blew off the airway issues on this patient and thought an RSI would probably be fine. Even without the beard, I'm pretty certain I wouldn't be able to ventilate this patient. I'm also pretty sure if I missed the airway, the consequences would've been devastating. In my mind and in my CA-2 hands, I thought awake FOI was the way to go since this patient had no pulm reserve and had sig. cardiac problems. Even without the AS and cardiomyopathy, I still think I would've intubated him awake. Why risk the chance of killing this patient if I were wrong?

 

[NoodleIncident]

Why the Etomidate and Fentanyl? You've already got the tube in. Just crank on the vaporizor and do an inhalational induction. I'd prefer to avoid any fingers pointed an me for post-op hypotension/adrenal insufficiency. Also, you've avoided the stimulation with direct laryngoscopy. Just getting the Fentanyl on board early for skin/sternotomy?

 

[Bertelman]

Why the Etomidate and Fentanyl? You've already got the tube in. Just crank on the vaporizor and do an inhalational induction. I'd prefer to avoid any fingers pointed an me for post-op hypotension/adrenal insufficiency. Also, you've avoided the stimulation with direct laryngoscopy. Just getting the Fentanyl on board early for skin/sternotomy?

I could point about 5 fingers at some other, much more likely cause of hypotension post-op in this guy before I would ever consider a single etomidate bolus.

One problem with letting him breath down is making the transition between his spontaneous hypoventilation and your controlled ventilation. In the mean time, his ET sevo is 4, producing the exact hypotension you were trying to avoid with an IV induction.

For better or worse, my anesthetic plan in cardiac is far more narrow than general cases. I tend to believe that this patient population has too many physiologic variables that could lead to catastrophe, thus for my own simple mind I prefer not to change the variables that I introduce. At least then when **** goes down hill, I can narrow my differential Dx to the things that I am accustomed to doing, thus accustomed to treating. If you typically do an inhalational induction on all your cardiac cases, which is just fine, then go for it. But this is not the kind of case I would care to try something new for, even if I use that technique every other day in the peds rooms. Of course, if you're the kind of person that does peds cardiac, than doing an inhalational induction is right in your wheelhouse, so go for it.

Ignoring your awake FOI, you would have induced this guy with fent + midaz or fent + etomidate, because you know exactly what to expect from that combo. The presence of an ETT in situ doesn't require changing that plan.

 

[NoodleIncident]

Why would he need an ET of 4 for sevo? You already have the tube in. Gently let it get up to 1-1.5 ish and then push the relaxant. No need to get him so deep as to tolerate DL b/c you don't need it. I've seen it produce less hypotension than an IV induction. So you perform an IV induction with all of your awake intubations? How about when you have an intubated icu pt on the vent? Still IV induction or inhalational? I just don't understand why it should be different. Different strokes for different folks I guess.

I could point about 5 fingers at some other, much more likely cause of hypotension post-op in this guy before I would ever consider a single etomidate bolus.

One problem with letting him breath down is making the transition between his spontaneous hypoventilation and your controlled ventilation. In the mean time, his ET sevo is 4, producing the exact hypotension you were trying to avoid with an

For better or worse, my anesthetic plan in cardiac is far more narrow than general cases. I tend to believe that this patient population has too many physiologic variables that could lead to catastrophe, thus for my own simple mind I prefer not to change the variables that I introduce. At least then when **** goes down hill, I can narrow my differential Dx to the things that I am accustomed to doing, thus accustomed to treating. If you typically do an inhalational induction on all your cardiac cases, which is just fine, then go for it. But this is not the kind of case I would care to try something new for, even if I use that technique every other day in the peds rooms. Of course, if you're the kind of person that does peds cardiac, than doing an inhalational induction is right in your wheelhouse, so go for it.

Ignoring your awake FOI, you would have induced this guy with fent + midaz or fent + etomidate, because you know exactly what to expect from that combo. The presence of an ETT in situ doesn't require changing that plan.

 

[epidural man]

I appreciate all the replies and sound advice. Here's how the case went:

-Plan for awake FOI with lidocaine neb + atomizer. Backup plan was awake trach by ENT.
-ENT consulted morning of - looked at CT and decided it was a respiratory variant and NOT a mass (heavily overread by radiology)
-16g PIV placed before we went back to OR.
-Defib pads placed, patient moved to OR table.
-Preinduction Aline placed in left radial after a few attempts at brachial (my attending thought d/t patients BMI a radial catheter may kink once arms were tucked). So we put in a 4'' radial catheter without difficulty.
-Topicalization went smoothly with judicious fentanyl. We avoided glyco to try and eliminate unwanted tachycardia.
-FOI took two attempts by our airway resident but went well and patient tolerated it well.
-Once tube was in, 14 mg Etomidate and 250 of fentanyl. Patient's HR never > 85 and he remained normotensive
-Attempted left IJ x 3 but could not pass the MAC because the catheter couldn't pass under the clavicle - the wire kept bending. I have no idea how cards got it in but wish they would've left the PAC in place. Subclavian MAC easily placed.
-Case went well with no real issues. Patient's PAP remained in the 40-50s but his post-valve ECHO looked improved. I could barely see wall movement before the valve was fixed. CT drained 1500 ml of pleural effusion off this guy's right lung after the chest was opened.

The reason I brought this case up was because a few of our attendings blew off the airway issues on this patient and thought an RSI would probably be fine. Even without the beard, I'm pretty certain I wouldn't be able to ventilate this patient. I'm also pretty sure if I missed the airway, the consequences would've been devastating. In my mind and in my CA-2 hands, I thought awake FOI was the way to go since this patient had no pulm reserve and had sig. cardiac problems. Even without the AS and cardiomyopathy, I still think I would've intubated him awake. Why risk the chance of killing this patient if I were wrong?

I think you should have induced with midazolam, 10-20mg. It is as smooth as sheeeeeit. (plus I hate etomidate)

Regarding the beard, a great trick my hero Rick Bellars taught me (over at UCSD) was place a large tegaderm over the beard and mouth, poke a hole through the mouth - and you got yourself a perfect seal with your mask!

 

[dhb]

Why would he need an ET of 4 for sevo? You already have the tube in. Gently let it get up to 1-1.5 ish and then push the relaxant.

I was thinking the same thing, that's how i do it.

 

[Arch Guillotti]

Why the Etomidate and Fentanyl? You've already got the tube in. Just crank on the vaporizor and do an inhalational induction. I'd prefer to avoid any fingers pointed an me for post-op hypotension/adrenal insufficiency. Also, you've avoided the stimulation with direct laryngoscopy. Just getting the Fentanyl on board early for skin/sternotomy?

Has anyone ever actually had the "etomidate finger" pointed at them after a case? We seem to talk about it every now and again but I am not sure if it really happens.

 

[Bertelman]

Why would he need an ET of 4 for sevo? You already have the tube in. Gently let it get up to 1-1.5 ish and then push the relaxant. No need to get him so deep as to tolerate DL b/c you don't need it. I've seen it produce less hypotension than an IV induction. So you perform an IV induction with all of your awake intubations? How about when you have an intubated icu pt on the vent? Still IV induction or inhalational? I just don't understand why it should be different. Different strokes for different folks I guess.

OK, OK, I was being a little histrionic with an ET of 4. But just because I "already have the tube in" doesn't mean he's just gonna sit there and enjoy it. I know I don't have to get him deep enough to DL, but he needs to be deep enough to paralyze so I can deliver an adequate MV, which he may not be able to do effectively as he drifts off.

Do I perform an IV induction with all my awake intubations? In general, yes. I can hit them with propofol and fent faster than I can get ET agent to an acceptable level for paralysis and control of mechanical vent. And I tend to believe a patient in that situation wants to be asleep as soon as possible, not drifted off gently as I tell them to relax and take nice deep breaths of agent.

How about when I have an intubated ICU patient on the vent? No, I just hook them up to the gas, but that's an entirely different population. In general, they have sedation dripping, because they have proven to tolerate the tube for hours, if not days. Completely different than a guy that is wide awake and following commands.

Point is, this IS NOT your typical awake FOI, so it really doesn't matter how I do awake FOI in all my other patients.. I'm not going to rehash the clinical picture, but I will say that I don't want to sit back and watch him hypoventilate. Hypoxia and hypercarbia will worsen his pHTN, drop his preload in a sick LV, and generally lead to badness. Whether you do an RSI or FOI, my goal would be to take over ventilation as soon as possible. I can better predict that course with IV induction than gas, whether it's an awake FOI or mask induction.

 

[Frank Rizzo]

Ahhh, I wish more people recognized this.

I have given patients the option of shaving their beard or having an awake intubation a couple of times. They have all chosen the shave... go figure.

 

[DrN2O]

1. What does having a beard have to do with the need for awake fiber? Difficult mask doesn't mean difficult intubation.
2. Diuresis and possible thoracentesis for effusion.
3. Really, someone would actually skip the a-line before induce?
4. Get lined up pre-induction, can't be that bad since he tolerated the cath lab.
5. Preop IABP is not a bad idea, or at least get femoral access first.
6. Norepi would be my pressor of choice given critical AS and low EF (beta)
7. Get his last GA record, I doubt his airway is that bad. He probably has tissue redundance, which I would worry more about residual weakness and dynamic obstruction postop, but I leave that to the ICU.

 

[Frank Rizzo]

1. What does having a beard have to do with the need for awake fiber? Difficult mask doesn't mean difficult intubation.

Not talking about OP's case necessarily. Guess i should have added that in the handful of cases where I have posed this question to the patient, there were other prognostic indicators suggesting that the airway may not be easy. With a potential difficult airway, you got to maximize every variable you can to increase the patients safety and your chances of success.

 

[fakin' the funk]

States he has been bed-bound for past three months.

Then he's going to be bedbound for another couple of days while a medicine or cardiology team tunes up his systolic failure, volume overload, hyperglycemia, etc, and ENT takes a look at his airway mass. His valve can wait.

 

[TrustMe]

1. What does having a beard have to do with the need for awake fiber? Difficult mask doesn't mean difficult intubation.


I had a guy admitted to our ICU yesterday (in MICU right now) for volume overload and respiratory insufficiency. BMI = 99 (5'4" and 575 lbs). Pt. had huge beard. First thing I told him was the beard's gotta go. Allowed BiPAP mask to seal and avoid intubation. If intubation would have been needed it allows for the possibility of mask ventilation as I changed my pants prior to trying to get the tube in.

If someone is fat and looks like difficult airway the beard has to go. I had an attending make an Amish guy shave his beard for surgery. That is a HUGE request. Guy didn't ask questions.

 

[fabfive5]

1. What does having a beard have to do with the need for awake fiber? Difficult mask doesn't mean difficult intubation.


I had a guy admitted to our ICU yesterday (in MICU right now) for volume overload and respiratory insufficiency. BMI = 99 (5'4" and 575 lbs). Pt. had huge beard. First thing I told him was the beard's gotta go. Allowed BiPAP mask to seal and avoid intubation. If intubation would have been needed it allows for the possibility of mask ventilation as I changed my pants prior to trying to get the tube in.

If someone is fat and looks like difficult airway the beard has to go. I had an attending make an Amish guy shave his beard for surgery. That is a HUGE request. Guy didn't ask questions.

Did he walk or roll in?

Seriously though...good call on getting rid of the beard. If he gave you any trouble I would discuss his LIFE versus his beard. BiPAP can def save lives...

 

[urge]

I had an attending make an Amish guy shave his beard for surgery. That is a HUGE request. Guy didn't ask questions.

Did they use a candle lit laryngoscope? I would shave too. Beard might catch on fire....

Food for thought.

 

[epidural man]

Did they use a candle lit laryngoscope? I would shave too. Beard might catch on fire....

Food for thought.

 

[TrustMe]

Fat dude was transferred from an OSH so he was rolled in on a stretcher. He told me he could walk but looking at this dude I would wager 6 moths salary that there was no way he could move those tree trunks around.

Did the Amish guys surgery outside in the sunlight so we didn't need candles. Worked out great. May have to try that one more often.

 

[Robert Loblaw]

Interesting case from today.
-66 yo male scheduled for aortic valve replacement. Critical AS with AVA 0.5 cm2. Peak gradient 81, mean gradient 50.
-EF 20% by cath.
-Moderate MR.
-Pulm HTN with mean PAP in 50s.
-No evidence of coronary/carotid disease
-Poorly controlled IDDM with BG -300
-Morbid obesity (patient weighed in at 450 lbs)
-Severe OSA, patient on BIPAP, must lay at 45 degrees.
-Pulm edema on CXR with large right pleural effusion on CT Chest.
-Also on CT chest questionable glottic/supraglottic mass.

Physical exam
-Mobid obesity. Dyspnea when speaking. 2L NC with SPO2 95%. BP 140/90 HR 85
-MP 4, TM distance > 3 FB. Poor dentition, large tongue. Large beard. + upper lip bite test
-Brusing on right neck with erythema and possible ulceration (patient had PA catheter placed by cards during cath).
-Diffuse wheezing
-One heplocked 20g IV in left AC.
-2+ pitting edema in LE. Multiple ulcers on feet/toes

Patient has had GA before without problems. States he has been bed-bound for past three months.

Any thoughts?

Did you make this up? It just seems like the oral board exam question from hell.

In all seriousness, if I were assessing this patient I would be a little skeptical about the preop echo if it states that the gradients were as high as they were with the LV function as poor as it is. I'm not saying it isn't possible but if the LVEF is really 20% WITH MR...I would be suprised if the gradients are truly that high. Either way, the AVA is what it is, regardless of the gradients. I'm just making the point that his LV function is probably better than 20%.

The PaHTN in the setting if severe AS, mild MR and probable OSA is not that bad, to be honest (what was the HCO3, by the way?. The MR and the systolic LV failure will tend to drive the PAPs up, but so will the rock pile on his AV impeding forward flow.

More important and not listed--and this is a crucially important learning point for the residents--is that the RV size and function is not reported. If his RV is dilated and hypokinetic, that is far more important to know than the PA pressures. A patient can have a PAP of 60 in the setting of chronic AS with a hypertrophied and non-dilated RV and be healthy as a horse. In this type of patient, if the PA is significantly less (from hypovolemia, say after CPB) the LV will be EMPTY and the BP/SvO2 will be low. This type of patient will need volume to drive the PAs up to a level sufficient to open a stiff, hypertrophied LV in diastole. By the same token, a patient in right heart failure can have a reported PAP of 25 yet be on death's doorstep. An echo in this patient will show a dilated and hypokinetic failing RV. This is why it's so important to know (or estimate) the RV morphology when interpreting PAPs. I thick hypertrophied ventricle with preserved function can handle volume but is closer to its ischemic threshold. I dilated hypokinetic ventricle has a Starling curve that is essentially a vertical line and volume is not well tolerated.

 

[TheEleventhReel]

Did you make this up? It just seems like the oral board exam question from hell.

In all seriousness, if I were assessing this patient I would be a little skeptical about the preop echo if it states that the gradients were as high as they were with the LV function as poor as it is. I'm not saying it isn't possible but if the LVEF is really 20% WITH MR...I would be suprised if the gradients are truly that high. Either way, the AVA is what it is, regardless of the gradients. I'm just making the point that his LV function is probably better than 20%.

The PaHTN in the setting if severe AS, mild MR and probable OSA is not that bad, to be honest (what was the HCO3, by the way?. The MR and the systolic LV failure will tend to drive the PAPs up, but so will the rock pile on his AV impeding forward flow.

More important and not listed--and this is a crucially important learning point for the residents--is that the RV size and function is not reported. If his RV is dilated and hypokinetic, that is far more important to know than the PA pressures. A patient can have a PAP of 60 in the setting of chronic AS with a hypertrophied and non-dilated RV and be healthy as a horse. In this type of patient, if the PA is significantly less (from hypovolemia, say after CPB) the LV will be EMPTY and the BP/SvO2 will be low. This type of patient will need volume to drive the PAs up to a level sufficient to open a stiff, hypertrophied LV in diastole. By the same token, a patient in right heart failure can have a reported PAP of 25 yet be on death's doorstep. An echo in this patient will show a dilated and hypokinetic failing RV. This is why it's so important to know (or estimate) the RV morphology when interpreting PAPs. I thick hypertrophied ventricle with preserved function can handle volume but is closer to its ischemic threshold. I dilated hypokinetic ventricle has a Starling curve that is essentially a vertical line and volume is not well tolerated.

I didn't make this up and I kept thinking before this case that this seemed like an awful oral boards case.

I don't remember the RV function. As to the EF, when we dropped the ECHO probe down, his LV was severely hypokinetic. The walls barely moved.

It was a good case and I'm glad I was a part of it. Thanks for the education.