Laparoscopic radical nephrectomy with unoptimised ischaemic heart disease

garychleung

PIG Meeting: 11th February 2021

57yo male with renal cancer for radical nephrectomy.

Background:

  • BMI high ++
  • T2DM
  • Dyslipidaemia
  • HTN

Issues

  • ? Ischaemic heart disease
    • Exertional chest pain
    • GP arranged a stress ECG – positive
    • Saw cardiologist –  stress ECG again positive and the patient experienced chest pain, but stress echo negative for ischaemia. Discharged from cardiologist’s care.
    • CTCA arranged which showed severe RCA vessel narrowing.
    • Reviewed at cardiology-anaesthetics meeting – suggested angiogram and likely PCI.
    • Discussed with surgeon –
      • Will operate on aspirin but not on clopidogrel
      • Based on tumour imaging suggesting nil capsular invasion, ok to delay surgery 3/12 to enable cardiac stenting and short duration DAPT.

Discussion

  • Why did this patient have so many non-invasive cardiac tests?
    • Usually patients have invasive cardiac testing (angiography) if one non-invasive test is positive, especially in the setting of symptoms.
    • Perhaps due to GP’s strong suspicion that there was underlying IHD.
  • What are the current guidelines around duration of DAPT after PCI?
    • Case-by-case basis, with multiple factors influencing decision (essentially bleeding v. Stent thrombosis)
      • Patient – diabetes, ACS, age, LV function
      • Stent – calibre, overlaps, branching, length, DES v. BMS
    • AHA guidelines recommend 3 months of dual antiplatelet therapy post drug-eluting stent (See diagram below).
    • Recent database evidence from Denmark suggests risk of MI and cardiac death after DES is elevated only with surgery within the first month after stent placement (See attached paper).
    • All such cases require consultation with the treating cardiologist and surgeon to reach a compromise.