65-year-old man for a revision of a PLIF

Background

• Lung Transplant patient – pulmonary Fibrosis
• IHD, CABG in 2010
• IDDM
• Chronic Back pain with radiculopathy.

Issues

• L5/S1 PLIF 3 months ago
• Ongoing disabling back pain since procedure, resistant to multiple therapies
• NSTEMI 2 weeks postoperatively while in rehab
• Required urgent angioplasty and stent to RCA
• 10 days post MI, had S1 screw revision due to persistent pain
• Procedure performed on DAPT
• Persistent pain, surgical revision required due to unstable construct

Discussion

Timing of Surgery

• Consulted with treating cardiologist, increased length of RCA stent and therefore a higher risk of in-stent thrombosis
• Patient on DAPT and Apixaban
• Cardiologist would prefer to wait 3 months post PCI and then perform surgery on Aspirin
• Surgery urgent due to unstable construct therefore decision made to proceed.
• Clopidogrel and apixaban ceased preoperatively

Postoperative Disposition; ICU vs Telemetry bed

• Telemetry usually provides single lead monitoring and there may not be adequate ST segment assessment in this situation
• ICU can provide ECG and haemodynamic monitoring, with the additional benefit of haemodynamic support if required
• Decision may be affected by bed availability

Postoperative Troponin measurement

• Patient should have postoperative troponin measurements for 48-72 hours as per Canadian guidelines
• Discussion centred around management of increased Troponin in this case. Noted that increase troponin may be caused by non-cardiac conditions that require urgent intervention (eg PE or sepsis)
• DAPT will be recommenced as soon as surgical team happy bleeding risk is reduced
• Vision study: noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery showed significant correlation with 30-day mortality.
• https://jamanetwork.com/journals/jama/fullarticle/2620089