PIG Meeting: 24th June 2021

83yo male with a 6.7cm aortic aneurysm. 

Background:

• CAD
• CABG + MVR 2009 – on warfarin
• CCF EF 19%
• COPD on home O2, ex-smoker
• Severe Pulmonary HTN
• Last TTE May 2021 – mildly dilated LV with severe global systolic dysfunction, severely dilated LA (volume 53mls/m2), well-seated mechanical mitral valve, severe pulmonary HTN (PASP 68), moderate TR, mild AR, EF 19%

Issues

• Current inpatient with CCF exacerbation
• Recent reduction in exercise tolerance
• Referred to ED from perioperative clinic with SpO2 80% after 20m walk. NYHA class 4 dyspnoea.

Discussion

• Should surgery proceed?
  • Life expectancy? Is he likely to die from his aneurysm or his cardiorespiratory comorbidities first (rupture rate for 6.7cm AAA is ~ 20% per year)
  • EVAR is a low physiologic stress procedure. 
  • Need clear documentation of ceilings of care (i.e., not for open procedure in emergency or if complications from EVAR)

• Anaesthetic technique
  • GA may facilitate faster procedure and less IV contrast use (protecting from renal injury) due to improved immobility.
  • Can be done under LA/sedation if patient can lie flat/still and cooperate with breath holds

Plan:

• Await outcome of current admission and liaise with surgical team (who are aware of admission)