Trial Short Case 1 April 2021 Answers
Question 1
What are the indications for the surgical treatment in this patient? What are the confounding medical and social issues for this patient in consideration of management of her IHD?
Answer
Indications for Surgical Tx:
Disabling angina despite maximal non invasive therapy
Two-vessel disease with signification proximal LAD stenosis w/ demonstrable ischemia on non invasive testing
Consideration if for PCI Tx:
Class I recommendation to continue DAPT for at least 12 months after an acute coronary syndrome (ACS) and at least 6 months after revascularization in the setting of stable ischemic heart disease (1). The issue of compliance needs to be addressed in this patient
Discuss with Aboriginal and Torres Strait Islander health care worker and primary peripheral team. Note - Upon this discussion it is evident that the patient would not be compliant with DAPT.
Confounding issues:
EtOH use and the need for drug and alcohol input.
Liver HCC – what is the diagnosis and prognosis of the known Liver HCC? What is her Child Pugh score? What is the outcome of the liver MDT? Can the patient be on DAPT whilst undergoing Tx for the HCC? What is her life expectancy? Note – Child Pugh B (results next slide). Liver MDT agreeable that that patient can undergo repeated CyberKnife stereotactic body radiotherapy and can be done on DAPT. Ultimate treatment would be a liver transplant but not appropriate due to EtOH abuse.
Diabetic control – Obese, poorly controlled HbA1c – needs review from Endocrinology team whilst in tertiary hospital include full review (feet, eyes etc).
Lung function and ability to be able to recover from OT – the results from the PFTs are extremely concerning due to her smoking history. Will she recover post operatively with poor lung function?
Reference: 1 - Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST‐Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non‐ST‐Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016; 134:e123–e155.
Question 2
The patient is accepted for CABG after the cardiac MDT. What is your operative plan for conduit and justification in this patient?
Answer
Noted scar peripherally on lower limbs (trauma induced) - ability to get venous conduit may be compromised. Either pre operative venous mapping on intraoperative CTS team ultrasound prior to incision to confirm conduit.
Her long term survival with known Child Pugh B, HCC undergoing treatment and long term chronic EtOH abuse– debate of venous vs arterial grafting?
If taking the LIMA – Cohort studies have demonstrated decreased lung function after LIMA harvesting and the debate over leaving the pleura intact or not (1). Patient already has compromised PFTs which can worsen with LIMA harvesting.
Particular to the case – ATSI patients tend to have very small LIMA conduit (Anecdotal but is noted).
Question 3
The patient was discharged day 6 post operatively. The patient represented during her out patient CyberKnife treatment with increased SOB and ECG proven AF. TTE has demonstrated a mild-moderate pericardial effusion. What are your considerations for management?
Answer
Multiple issues:
1. Pericardial effusion
The TTE result of effusion – patient requires a clinical examination, are they showing signs of tamponade? The TTE results should be reviewed with a Cardiologist to confirm severity. The patient should be admitted with serial TTE to ensure not worsening.
If treating AF with NOAC – also prudent to ensure admission and repeat TTE so that the effusion doesn’t worsen on NOAC therapy.
2. AF
Must be stated that the goal of CABG was to prevent the patient being on NOAC. Now in AF are you going to treat the patient?
If treating AF with NOAC – also prudent to ensure admission and repeat TTE so that the effusion doesn’t worsen on NOAC therapy.
Need to confirm with hepatic team over CyberKnife and NOAC.
AF – warfarin vs NOAC in a patient with Child Pughs B liver cirrhosis. Would this patient go on warfarin considering liver history?