TURBT with massive PE and LVOT obstruction

Gabrielle Morris

82-year-old lady for Cystoscopy and TURBT on background of haematuria

Background:

  • Previous spontaneous ‘Massive’ PE in 2014 and bilateral PE’s in 2016
  • Provoked DVT many years ago – cancer
  • On lifelong anticoagulation for PE’s
  • Bowel cancer and splenectomy 1994
  • Hypertension

Issues:

  • Massive PE in March 2021 – haemodynamically compromised
  • Had recently ceased NOAC due to haematuria. Was thrombolysed in ED
  • ICU admission complicated by haemodynamic instability and AKI
  • Echo during ICU admission showed Dynamic LVOT obstruction and queried severe AS

Discussion:

Echocardiographic Findings

  • Echo done in the setting of haemodynamic compromise and tachycardia
  • Repeat study ordered in clinic – no significant AS, Moderate AR, PASP 38mmHg, and septal angulation with increased velocity in LVOT related to AR
  • Discussed at cardiology meeting – previous echo done in setting of acute unstable clinical state. Excellent demonstration of the effects of tachycardia and HD instability on the function of an already impaired heart
  • Value in repeating echo in this circumstance
  • Cardiologist recommends avoidance of tachycardia and ensure patient is adequately filled preoperatively

Timing of surgery

  • Respiratory physician recommends 3 months post most recent PE
  • Haematuria is ongoing but mild on anticoagulation
  • Concerning regarding cessation of anticoagulation for surgery

Investigation of PE’s

  • Cause never elucidated
  • Previous Factor V Leiden and anticardiolipin antibodies normal
  • No haematology review

Plan:

  • Await ongoing respiratory advice
  • Refer to haematologist