89yo male with known severe HFrEF and recurrence of bladder cancer causing haematuria and urinary retention.
- Bladder cancer – previous TURBT (2019) and palliative radiotherapy. Symptomatic recurrence.
- Significant cardiac disease
- Biventricular PPM for sinus-brady, PPM-dependent.
- IHD – CABG 06, NSTEMI 18, angina 2-3x per week.
- HFrEF, admitted with decompensation Nov ’20, EF~30%
- PAF – anti coagulated.
- CVA post CABG (nil deficit)
- CKD eGFR 42
- Borderline exercise tolerance 4.6METS DASI
- Distant ex-smoker
- Severe HF + ongoing angina
- Nil clinical e/o HF on examination.
- Known severe dx, TTE relatively unchanged from 2018 – now.
- Known to cardiologist, reviewed recently.
- Discussed with that cardiologist – nil room for further optimisation.
- Should surgery proceed?
- Palliative procedure for symptom-relief
- Low risk, low physiologic stress surgery.
- Palliative radiotherapy an option? – possibly, but the patient cost (emotional, physical, QoL) of a weeks long course of daily radiotherapy at 89yo and with his comorbidities should not be underestimated. Overall seemed that the TURBT was the most patient-centred option.
- Any optimisation possible?
- Cardiologist feels that patient is optimised. Further Ix/Mx of IHD would be invasive, low yield and may have secondary consequences with negative impact (such as delays to his symptom relief from TURBT; the need for additional anti platelet therapy which would cause further bleeding issues and be problematic in the perioperative period).