pulmonary HTN case

[fakin' the funk]

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This is pulm venous HTN and a chronically pressure overloaded RV. This is a BAD-@SS RV. It's not gonna give two flying f!cks about NO, or N2O, or high CO2, or vaso.

I'd do preinduction art line and keep systemic pressures normal throughout the case. CVP for sure. +/- epidural, most likely not.

To say nothing of the "emergent" nonsense

 

[pgg]

This is pulm venous HTN and a chronically pressure overloaded RV. This is a BAD-@SS RV. It's not gonna give two flying f!cks about NO, or N2O, or high CO2, or vaso.

This is an excellent point, well put.

 

[amyl]

I am well versed in acc/aha guidelines.... Re-read what you posted.... Valve repair is indicated based on symptoms AND severity of valve disease. In the future we may find we are being too cavalier -- but proceeding in this case doesn't violated the guidelines in my mind as she was asymptomatic. This seems to be the current thinking in Preop..... Symptoms and functional class rules all.... Anesthesia is safer than it's ever been and surgeries are becoming less invasive.... I suppose we will know in a few years if this current thinking is right

 

[itwasalladream]

This is the first post specifically stating she was asymptomatic. Given her pathology, forgive me for assuming.

Still: severe MR, severe TR, RVSP 70 plus (suggestive of left heart failure), COPD, 3L home O2 qhs, and "poor exercise tolerance." My argument would be that patient is assuredly symptomatic, it just depends on how you ask the questions, and what symptoms you attribute to what disease. But you were there and spoke to the patient at length, I wasn't.

But even if we say she is truly asymptomatic -
Asymptomatic severe primary MR with preserved LVEF is a Class I indication for MV surgery.
You mentioned her LV function was normal but didn't specify the type of MR. That's why I asked in an earlier post what kind of MR it was, and said there was a clear indication if primary. For secondary, the indications are softer. In the setting of normal LVEF, severe secondary MR seems less likely.

And IF you're operating on the MV, fixing asymptomatic severe TR at that time is a Class I indication.

All that being said, I thought nimbus had a good point that proceeding with cardiac surgery could put her at a higher risk than the gyn surgery done with her bad valves. But it still deserves careful thought - otherwise you could justify doing almost any elective surgery without fixing the valves first.

 

[amyl]

I should be more clear.... She basically was not very active.... So I guess unknown exercise tolerance is more accurate. She did not have symptoms and had a preserved EF but a negative stress test.... Only the presence of symptoms would make it a class I recommendation per the new acc aha guidelines. Although it wasn't documented it seems from the history that it's likely to be primary MR.... But still as asymptomatic isn't a class I rec.

 

[itwasalladream]

These are the most recent guidelines I'm aware of.

 

[amyl]

not a class I indication I meant.
The cardiologist saw her and didn't want to fix her.
this is a tough situation. Am I supposed to tell him how to do his job? I certainly don't want a cardiologist telling me how to do anesthesia.

 

[urge]

not a class I indication I meant.
The cardiologist saw her and didn't want to fix her.
this is a tough situation. Am I supposed to tell him how to do his job? I certainly don't want a cardiologist telling me how to do anesthesia.

How many people would tell their mother to undergo valve surgery in the setting of recurring UTIs?

Next thing is urosepsis and endocarditis.

 

[WholeLottaGame7]

How many people would tell their mother to undergo valve surgery in the setting of recurring UTIs?

Next thing is urosepsis and endocarditis.

This was my concern, also. It seems like it's almost a semi-palliative procedure to keep her from being constantly infected (and I'm sure delirious), and I don't know that subjecting her to a high-risk surgery in order to improve her odds of surviving a low-intermediate risk surgery seems questionable.

 

[deleted171991]

subjecting her to a high-risk surgery in order to improve her odds of surviving a low-intermediate risk surgery seems questionable.

Mmm... I tend to disagree.

First, this would be an at least intermediate risk surgery (depending on the level of butchery and resuscitation fluids needed). Second, one could use your argument to clear any similar patient for 80% of elective surgeries, which is a very slippery slope.

Third, this lady is not asymptomatic. She just doesn't know she's symptomatic, unless asked specific questions. Even a stage 3 CHF will be "asymptomatic" is s/he lives like a vegetable in a chair. Four, she will probably need heart surgery in a few years anyway. Even now, she might qualify for a transcatheter MV repair.

I would love to read that stress test, to see whether it was maximal. Because if it was, she'll probably do fine. If it wasn't, it shouldn't be admitted as evidence. 🙂

 

[deleted171991]

This was my concern, also. It seems like it's almost a semi-palliative procedure to keep her from being constantly infected (and I'm sure delirious)

A 6-7 hour-procedure is not palliative. I think nobody would argue against a 2-3 hour-palliative one with a good surgeon, an LMA, and no big pain or fluid movements, as an outpatient. That would be a low-risk surgery.

How many people would tell their mother to undergo valve surgery in the setting of recurring UTIs?

Next thing is urosepsis and endocarditis.

This should be the main argument for having this surgery before fixing the valves.

But even then, the patient doesn't get to refuse preop optimization and low-risk workup, as deemed necessary. That's where the line should be drawn. As I said before, if she doesn't want to do her part in getting ready for the procedure, the incontinence must not be that bad.

 

[deleted171991]

This is pulm venous HTN and a chronically pressure overloaded RV. This is a BAD-@SS RV. It's not gonna give two flying f!cks about NO, or N2O, or high CO2, or vaso.

I'd do preinduction art line and keep systemic pressures normal throughout the case. CVP for sure. +/- epidural, most likely not.

To say nothing of the "emergent" nonsense

So if the CVP goes up, that means exactly what? 🙂

P.S. Sorry, pet peeve.

 

[urge]

So if the CVP goes up, that means exactly what? 🙂

If it is 50 you know you are in deep doo doo.

 

[itwasalladream]

OK Amyl, I think we're on the same page now. You must believe her EF was >60%. I don't, unless you saw it specifically calculated and reported. So then yes, given her pHTN, she'd fall to a IIa guideline - "it is reasonable" to perform MV surgery. Fair enough.

Earlier in the thread, I mentioned that "normal EF" in MR and "normal RV function" in TR are often not truly normal. That's reflected in the guidelines' cutoff of LVEF of 60% and still labeling it dysfunctional. I look at echoes daily, and not once have I seen a cardiologist call "EF 60%, mild dysfunction in the setting of MR." They just say "normal EF." Given her pHTN, I don't really believe her LV function is truly normal and I'm willing to bet her "preserved EF" is somewhere 50-60%. But you are right. If it is >60% and she is truly asymptomatic (We disagree on that one), I concede it's not a class I indication.

My overall stance is still that she needed her valves addressed before a 6-7hr elective surgery. If she gets evaluated, has a real discussion about options (not on the day of surgery), and still declines cardiac surgery -- optimize, document, and proceed.

Hopefully I am not coming off as overly critical about your decision. I recognize it's a difficult situation, especially when the cardiologist does not feel the patient needs a cardiac surgery evaluation. It's unclear at that point if the patient benefits from canceling the surgery, since the cardiologist won't refer her to a surgeon. On the other hand maybe it would trigger a re-evaluation and real discussion with the patient. But as to your point of telling the cardiologist how to do their job, you have to draw the line somewhere. Otherwise you risk letting them dictate how you do your job.

 

[fakin' the funk]

So if the CVP goes up, that means exactly what? 🙂

P.S. Sorry, pet peeve.

My intended meaning was "CVC" for infusion/blood/sampling/CVP monitoring, not CVP monitoring as the primary indication. There are cases where I can measure CVP and don't; this is not one of those.

But to answer your question, you know (and I know) that it doesn't mean "exactly" anything, that it could indicate either left sided or right sided failure, and that in the absence of echo the treatment is likely to be the same and likely to be effective regardless

 

[WholeLottaGame7]

Mmm... I tend to disagree.

First, this would be an at least intermediate risk surgery (depending on the level of butchery and resuscitation fluids needed). Second, one could use your argument to clear any similar patient for 80% of elective surgeries, which is a very slippery slope.

I agree with your disagreement about her being asymptomatic. I think it's a widespread problem, and would bet that many of the patients that I interview that deny symptoms, would actually be symptomatic if I had them do the things I asked them about.

Second, the level of butchery point is fair, especially since we don't know the actual surgery. Some of our routine gyn surgeries end up being high-risk affairs. I'm assuming that the surgeon in this scenario is reasonable.

Third, it would be helpful to know what her functional status is at baseline. Even if she were a candidate based on cardiographic findings, would you do an open valve repair on a nursing home invalid? If this patient had presented with a hip fracture (and probably will if she remains infected), we wouldn't be talking about whether to fix her valve first or not. That's kind of what I'm envisioning, and what I meant by semi-palliative.

Maybe that's the wrong way to look at it? I dunno.