Trial Short Case 1April 2021

Case Summary

51-year-old woman of Aboriginal and Torres Strait Islander Descent.

NYHA II dyspnoea on a background of known IHD.

Referral for consideration of surgery at combined Cardiac MDT meeting.

Unstable angina and NSTEMI in August and October 2020. Discussed at that time in the Cardiac MDT meeting. The consensus at that time was for medical therapy due to her comorbidities.

Unstable angina again with 2 x admissions since October and most recent admission with NSTEMI (Trop 100).

The patient is accepted for transfer to the tertiary hospital for definitive management after further investigations.

Background

IHD

T2DM (Oral Control)

COPD

Liver Cirrhosis with known HCC (EtOH causative)

Obesity

Lives alone

40 pack year smoking history

EtOH Consumption

Medications

Aspirin 100mg

Atenolol 25mg

Isosorbide mononitrate 120mg

Rosuvastatin 40mg

Irbesartan 75mg

Linagliptin 5mg

Gliclazide 30mg

Fluticasone + Salmeterol 250/25 mcg BD

Salbutamol PRN

Magnesium 1g

Thiamine 100mg

Examination

100kg, 164cm

HR 85 bpm regular

BP 105/65

JVP not elevated

Nil peripheral oedema

HSDNM

Chest – diffuse wheeze

Nil VV (peripheral scarring bilaterally on both lower limbs), Allen’s Negative, Sternum has nil deformities

Investigations

Bloods:

Hb 134, platelets 138, INR 1

K 3.4, Creat 55

Albumin 24

HbA1c 9

Hep/HIV Negative

Echo:

Normal LV Size

Basal inferoseptal akinesis and scar

Overall systolic function preserved

No valvular pathology

 
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MRI

Confirmed arterially enhancing hepatic mass with restricted diffusion of just under 2 cm in diameter in segment 8. This could well represent HCC on the background of cirrhosis.  2nd lesion at the dome of the right lobe is also identified on MRI, being less than 1 cm in diameter. It is also likely to be HCC.

 

Questions:

  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?

  2. The patient is accepted for CABG after the cardiac MDT. What is your operative plan for conduit and justification in this patient?

  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?