Outpatient case

[seinfeld]

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Surgical h&p lists copd/ a fib. Gets cleared by partner for no further evaluation prior to surgery as EKG is unchanged from previous. I see the patient and discover after asking my normal preop questions he has some " bad valves". I call his cardiologist office and they fax me his last note. Mod- severe AS with pk gradient of 80, estimated valve area of 1.0 cm , mod MR, Lvot gradient with SAM noted, mod pulmonary HTN, EF 65%, gade 1 diastolic dysfunction. BTW you don't need a stethoscope to hear him wheezing.

Surgical procedure is removal of large left forearm mass and z-plasty.

What's your move?

 

[Surfer]

cardiology visit for "optimization." once he is optimized from their standpoint, proceed with surgery. mass has gotta come out... what if its malignant like the one i took out last week? LMA general most likely. if you're really worried feel free to do mac/regional. but a valve area of 1.0, shoot we do those all the time probably without even knowing!!

 

[dhb]

What's your move?

Regional...

next case

 

[sevoflurane]

Surgical h&p lists copd/ a fib. Gets cleared by partner for no further evaluation prior to surgery as EKG is unchanged from previous. I see the patient and discover after asking my normal preop questions he has some " bad valves". I call his cardiologist office and they fax me his last note. Mod- severe AS with pk gradient of 80, estimated valve area of 1.0 cm , mod MR, Lvot gradient with SAM noted, mod pulmonary HTN, EF 65%, gade 1 diastolic dysfunction. BTW you don't need a stethoscope to hear him wheezing.

Surgical procedure is removal of large left forearm mass and z-plasty.

What's your move?

Baseline wheezing or new finding?

How involved is the surgery and how long is it supposed to take? Regional may be a good choice.

What percent of systole is the mitral leaflet/septum causing obstruction? >30%?

Think fluids pre-op. Avoid hypovolemia.

Give a beta blocker as an EF of 65% = hypercontractility and worsening SAM.

Have phenylephrine handy... inline for both AS and SAM.

Avoid hypovolemia and reductions in SVR.

If you encounter hypotension, consider TEE to asses cause of hypotension (SAM vs AS vs hypovolemia, etc.)

A-line would be helpful.

Did I miss something? Thanks for posting a clinical scenario Seinfeld. 👍

 

[pgg]

Stupid and probably irrelevant question that I feel like I should know the answer to -

If grade I diastolic dysfunction is defined as reversal of E:A ratio (vent filling from atrial contraction > passive vent filling) how does a person in afib get this diagnosis? Is the afib new?


Really most interested in the wheezing. If this is pulm edema and a symptom of acute failure, he doesn't go today. Vital signs? Febrile?

Otherwise regional would be my first choice. In an oral board scenario, of course the block fails; then a careful GA per the usual cardiologist advice (avoid hypotension, hypoxia, tachycardia) ought to be OK.

 

[ssmallz]

Agree with others, COPD is really the most important thing to me here b/c it's the only thing that we can really change by delaying the case. If the vitals are stable and sats are good I'd proceed with your regional block of choice and minimal sedation. If sats are bad, refer to pulm for optimization

 

[imfrankie]

Regional...

next case

Infraclav or Ax block--whichever you do best. Follow up with primary/cardiologist.

 

[bigdan]

My inital thought was regional, too, but this presentation sounds like it could be an active cardiac condition, at which point I would consider holding up this case.

Did the Cardiologist say "Oh yeah, and he's ALWAYS wheezing...", or might that be new? What's the plan to rate control his AF if needed, given his COPD?

Is this line of thinking "too academic"?

 

[Surfer]

Regional is not a sure thing. I'd get cardiac recs simply to cya even though I already know how to do the case.

 

[cincincyreds]

This patient is not even a candidate to get his hair cut. Sounds like he is end stage from the AS. Probably will be dead from it in a couple of weeks from your description. Could you do an AVR and fix his arm at the same time? Or is this an ambulatory center situation?

 

[OB1🤙]

If grade I diastolic dysfunction is defined as reversal of E:A ratio (vent filling from atrial contraction > passive vent filling) how does a person in afib get this diagnosis? .

You can look at the decel time of the E wave, IVRT, and other nebulous Doppler findings.

If wheeze is baseline, proceed with regional. If not, and if increasing DOE/SOB/"I just don't feel so hot, Doc!", then postpone for optimization. Cardiac "asthma" should not produce wheezing audible without a stethoscope, so this sounds like the COPD acting up.

AVA of 1 isn't that bad, shoot, he's tolerating afib. The SAM is a problem, but you know what to do about it (see Sevo's post). Sprinkle some midaz and ketafol on him, do your arm block of choice (ax or infraclavicular maybe better than supra to keep the phrenic out of the picture). If GA becomes necessary, fine, just keep the preload and SVR up.

 

[dhb]

Sounds like he is end stage from the AS. Probably will be dead from it in a couple of weeks from your description. Could you do an AVR and fix his arm at the same time? Or is this an ambulatory center situation?

You don't have a 65%EF with end stage AS.

From the description his problem is not the heart, i agree that if you slap a pulse ox and sat is crappy + patient not feeling so hot you should delay to optimize his pulmonary function.

 

[proman]

If grade I diastolic dysfunction is defined as reversal of E:A ratio (vent filling from atrial contraction > passive vent filling) how does a person in afib get this diagnosis? Is the afib new?

Great question. If you want, I can send you a nice review article on diastology. E:A reversal can also be a normal finding in the elderly. In atrial fibrillation you can measure the lateral E' wave of the mitral annulus using tissue Doppler imaging (also septal). It is a direct measurement of myocardial relaxation and does not require a normal sinus rhythm. It can also be done in patients who are being paced and have had valve replacements. That's what I use. There are other ways also, but TDI is probably most reliable.

You don't have a 65%EF with end stage AS.

I'm not sure what end stage AS is but there are plenty of patients with preserved EF and severe AS, AVA <1cm2, with "critical" symptoms (syncope, episodes of heart failure-think diastolic failure, angina).

 

[cincincyreds]

You don't have a 65%EF with end stage AS.

From the description his problem is not the heart, i agree that if you slap a pulse ox and sat is crappy + patient not feeling so hot you should delay to optimize his pulmonary function.

From the numbers the heart doesn't sound bad. From the clinical picture he sounds aweful. I was just describing my feeling going by the clinical picture, not the echo numbers. Your right, a valve area of 1 ain't so bad, that is a little larger than a pinhole for the heart to eject through. So maybe albuterol could do the trick if it is lung and not cardiac.

But whatever the reason, I would want this patient optimized first before proceeding with elective/semi-elective surgery.

 

[sevoflurane]

You don't have a 65%EF with end stage AS.

From the description his problem is not the heart, i agree that if you slap a pulse ox and sat is crappy + patient not feeling so hot you should delay to optimize his pulmonary function.

In this situation, calculating SV is as important to me as EF... i.e. someone who has a hypertrophied heart 2/2 mod-severe AS. You can have an EF of 65% while at the same time have a punny little SV of 35mls 😱 (vs. 70mls in a normal 70 kg man).

EF = SV / EDV × 100% = EDV (now hypertrohpied and not containing as much red stuff)]-ESV/EDV

End result: EF will increase without increasing SV. SV is what gets out to perfuse your vital organs. In severe AS your heart looses the ability to compensate via contractility (increased contractility increases LVH and makes things worse)....and your SV actually ends up going even further down.

SV = EDV &#8211; ESV... which you can get with simpson's equation.

I'm not cardiac trained like proman... so I like applying the simpson's equation... mainly cuz I like to check myself and get a stroke volume... which I find to be a nice little number to keep in your head when dealing with hypertrophied hearts 2/2 AS.
I don't always do it and I know most cardiac trained guys don't go thorough the hassle cuz you just look at the picture and get an idea in your head.

For me, it only takes a couple of minutes.... which I know is precious before the bovie starts up! 🙄

 

[OB1🤙]

I find it easier to get a SV by CO/HR, getting CO in either the LVOT or the PA (VTI x Area). Or from a PAC obviously.

If this guy is surviving in afib and only had grade 1 diastolic dysfunction, he's probably not one of these guys with supermassive LVH where the heart is all muscle and no cavity, but it's a good point to make regardless.

 

[Arch Guillotti]

cardiology visit for "optimization." once he is optimized from their standpoint, proceed with surgery. mass has gotta come out... what if its malignant like the one i took out last week? LMA general most likely. if you're really worried feel free to do mac/regional. but a valve area of 1.0, shoot we do those all the time probably without even knowing!!

Disagree. What exactly do you want them to optimize? He has a presumably recent enough echo and an office visit with cardiology to boot. His heart isn't perfect but it could be a lot worse. I would be more concerned with his wheezing.

 

[sevoflurane]

If this guy is surviving in afib and only had grade 1 diastolic dysfunction, he's probably not one of these guys with supermassive LVH where the heart is all muscle and no cavity, but it's a good point to make regardless.

Correct. I just like checking things myself when I can.

Understanding the significance of a normal or high EF with a low SV in AS/LVH was one of those nice epiphanies/eureka moments during med school/residency. Everything is not always as it appears on paper. 🙂

 

[seinfeld]

After having this case handed to me in my lap I did a couple of things

1. I called and spoke with his cardiologist. I know the guy well from all my ICU interactions with him and he always know his patients well. The question i really wanted answered was whether he had any plans for further workup, ie pending date for cath, stress, Cardiac surgical consultation etc. He stated he did not, and he felt the guy was well compensated from his AS and that his most recent echo showed an improvement in the LVOT obstruction, ie better medical management. The wheezing was his COPD, which the family stated was his normal. RA SaO2 was 97% and despite the noise he actually was moving good air

2. I spoke with the surgeon, gave him a little crap for not doing a better job getting a H&P and then having his cardiologist to see him before the surgery and then told him it was Local with a "real" MAC.
(The mass as it turns out was not invading below the dermis)

3. Informed the CRNA who only does outpt anesthesia, she then went and relieved herself&#8230;well not really, but she was nervous. To the room, 2 of versed, 50 fent, 30 of propfol with 100mcg of phenylephrine for the injection. The patient was ok with being awake after that.

I posted this case mainly thinking of how complicated his medical history was but how simple this case actually was. As dhb eluded, stop mentally masturbating and do the case already. Regarding the preop "clearance" I only wanted to talk with the cardiologist as a CYA maneuver. If things did go wrong i wanted to know that he wasnt scheduled for an AVR and myomectomy next week.

 

[dhb]

I'm not sure what end stage AS is but there are plenty of patients with preserved EF and severe AS, AVA <1cm2, with "critical" symptoms (syncope, episodes of heart failure-think diastolic failure, angina).

Probably but i was refering to the possibility of pulmonary edema in this patient and i doubt that would occur with a good EF and a grade 1 diastolic dysfunction.

Yes sevo SV is often overlooked, the opposite of what you've posted are patients with dilated cardiomyopathies that can have a very low EF like 10% but decent SV due to the huge volume of the ventricules.

 

[sevoflurane]

Yes sevo SV is often overlooked, contrary to what you've posted patients with dilated cardiomyopathies can have a very low EF like 10% but decent SV due to the huge volume of the ventricules.

Exactly. You have the concept. 👍

 

[imfrankie]

Exactly. You have the concept. 👍

Excellent point, thanks

 

[jetproppilot]

After having this case handed to me in my lap I did a couple of things

1. I called and spoke with his cardiologist. I know the guy well from all my ICU interactions with him and he always know his patients well. The question i really wanted answered was whether he had any plans for further workup, ie pending date for cath, stress, Cardiac surgical consultation etc. He stated he did not, and he felt the guy was well compensated from his AS and that his most recent echo showed an improvement in the LVOT obstruction, ie better medical management. The wheezing was his COPD, which the family stated was his normal. RA SaO2 was 97% and despite the noise he actually was moving good air

2. I spoke with the surgeon, gave him a little crap for not doing a better job getting a H&P and then having his cardiologist to see him before the surgery and then told him it was Local with a "real" MAC.
(The mass as it turns out was not invading below the dermis)

3. Informed the CRNA who only does outpt anesthesia, she then went and relieved herself…well not really, but she was nervous. To the room, 2 of versed, 50 fent, 30 of propfol with 100mcg of phenylephrine for the injection. The patient was ok with being awake after that.

I posted this case mainly thinking of how complicated his medical history was but how simple this case actually was. As dhb eluded, stop mentally masturbating and do the case already. Regarding the preop "clearance" I only wanted to talk with the cardiologist as a CYA maneuver. If things did go wrong i wanted to know that he wasnt scheduled for an AVR and myomectomy next week.

Nice job man.👍