89yo male with known severe HFrEF and recurrence of bladder cancer causing haematuria and urinary retention.

Background

• 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
• Hypothyroidism
• Borderline exercise tolerance 4.6METS DASI
• Distant ex-smoker

Issues

• 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.

Discussion

• 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).