Elderly patient with severe heart disease for laparoscopic cholecystectomy

PIG Meeting: 4th March 2021

73yo male booked for lap chole due to recurrent choledocholithiasis


  • Choledocholithiasis – several admissions with sepsis requiring IV Abx and ERCPs
  • Cardiac disease
    • Missed STEMI 2019 – DES to LAD, LCx occluded, not amenable to PCI
    • Polymorphic VT arrest 2019 2 days post ERCP, hypokalaemic.
    • 2nd polymorphic VT arrest 2/7 later (K+ normal)
    • AICD placed, nil shocks since.
    • Bisoprolol and amiodarone
  • Paroxysmal AF – on dabigatran
  • GORD
  • Smoker
  • Ex tolerance 5 METS as per DASI


  • Cardiac status
    • TTE – EF 30-35%, stage I diastolic dysfx, mild MR, mild AR, e/o inferolateral RWMAs, biatrial moderate to severe enlargement.
    • Reviewed by cardiologist – Nil current e/o CCF, exercise tolerance only mildly limited


  • Should he have surgery?
    • SORT score 5.4% risk of death
    • Severe cholangitis in this man carries a high risk of morbidity and mortality, as does emergency surgery.
    • While his risk of death with elective surgery is not insignificant it is likely the lower risk option.
  • Opportunities for optimisation?
    • Cardiologist r/v suggests HF reasonably controlled. Suggested ceasing Dabigatran 48h preop and switching to aspirin until resumption of anticoagulation.
  • Postoperative care location
    • >5% risk of perioperative mortality widely considered to represent ‘high risk’ however limited ICU bed spaces necessitates thoughtful rationing of resources.
    • Extended recovery (i.e. 4hr stay) is a useful option – observe for dysrythymias, replenish electrolytes as needed, support normal physiology then, provided no issues arise, discharge to normal ward.