Elderly frail patient with severe AS for rectosigmoid cancer resection

garychleung

PIG Meeting: 8th July 2021

77yo male with rectosigmoid cancer causing PRB and significant anaemia requiring transfusion recently.

Background:

  • Severe AS – Balloon valvuloplasty 30th June with reduction in valve gradient to 44mmHg and large improvement in symptoms (SOB and presyncope resolved).
  • Minor non-obstructive CAD on angiogram 2020
  • NIDDM
  • Cognitive impairment. MMSE 19/30. Recent delirium in setting of severe anaemia.
  • Cerebrovascular disease with old lacunar infarct
  • Dyslipidaemia
  • Severe hip OA. THR postponed due to other medical issues.

Issues

  • Severe aortic stenosis
    • Discussed with Dr Hatton (patient’s cardiologist): Very reassured by improvement of symptomatology. Expected deterioration with time. May never be a candidate for TAVI due to cognitive status but may have repeat balloon valvuloplasty in the future.
    • Low exercise tolerance with DASI 2.9, however able to climb up/down 4 FOS and walk 100m on flat, slowly with walking stick, no pauses or symptoms.
  • Cognitive decline
    • Delirium risk perioperatively
    • Noticeable decline over last year. Cardiologist said some decline may be attributable to his severe AS, there may be some improvement post- valvuloplasty.

Discussion

  • Perioperative risk
    • Long discussion with patient and daughter about NSQIP-guided risks of death (3.6%), serious complications (16%), delirium (21%) and functional decline (44%).
    • Daughter insistent that any additional functional needs postop will be catered for with family assistance and care packages at home.
    • Pt has a quiet life at home, especially during COVID-era, but enjoys his life and feels strongly that he’d like surgery to give him the best chance of cure. Accepting of risks.
    • Palliative radiotherapy (necessary due to current PRB if surgery didn’t proceed) would not be without burden for the patient/family.
    • Advanced care planning discussed, and he would like all active measures deemed suitable by the medical team.  
  • ? optimisation possible
    • May need further transfusion or iron preop
    • Severe hip OA and cognition make physical prehabilitation challenging
    • Aortic valve at its best now, cardiologist suggested ideal to proceed now.

Plan:

  • Repeat FBC and Fe studies
  • Proceed with surgery.
  • ICU level 2 postop for haemodynamic monitoring/support given severe AS.