Multiple back surgeries and NSTEMI

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