Type 2 MI after THR

63-year-old lady presenting for ORIF of a periprosthetic hip fracture


  • No significant past medical history. Current smoker.
  • Elective total hip replacement 2 weeks prior to presentation
  • Procedure performed as ‘Public in Private’
  • Simple fall on discharge resulting in periprosthetic fracture


  • Initial THR – Postoperative hypotension resulting in type 2 MI.
  • Troponin rise to 900
  • Required 5-day admission to ICU for vasopressor support, had profound vasoplegia
  • Commenced on Aspirin and Beta-blocker
  • Developed wound haematoma and had drop in haemoglobin, requiring transfusion
  • Cardiologist review as inpatient, Echo unremarkable with normal LV function and no regional wall motion abnormalities
  • For CTCA, not yet performed
  • Patient experienced multiple issues due to being a public patient in the private hospital, clinical governance concerns


Perioperative hypotension

  • Uneventful intraoperative course with minimal blood loss
  • On revisiting the history, patient stated she had a similar issue many years ago
  • Uncertain cause – discussed possibility of undiagnosed pulmonary hypertension (not seen on echo), anaphylaxis unlikely, possibility it was a type 1 MI should be considered.
  • Likely COPD, required bronchodilators during ICU admission.
  • Current smoker, has cardiac risk factors.

Management of Current Procedure

  • Emergent procedure, little value in CTCA preoperatively. Cardiologist in agreement.
  • Postoperative troponin measurement – cardiologist opinion that it would be prudent in this case.
  • Expectation that troponin will rise to around 800-900 but any further increases would warrant a cardiologist review
  • CCU not an ideal location for post-surgical care, ICU bed more appropriate due to potential vasopressor requirement
  • See above table from Canadian CV Guidelines

‘Public in private’ patients

  • General opinion that patient selection for this criterion is complex and may not be being performed optimally at present
  • Anaesthetists report they are encountering cases that are not suitable to be performed in some private hospitals  due to complex comorbidities, lack of postoperative monitoring etc
  • Suggestion that it is important that we provide feedback on this issue, it may not be apparent to the relevant department.
  • Concerns expressed regarding the movement of the patient between 3 different hospitals and subsequent discharge before completion of investigations
  • Decision to discuss at M&M regarding clinical governance issues