56-year-old man for a Radical prostatectomy for prostate cancer

Background:

• Asthma – well-controlled
• Lifelong smoker – 30 pack years
• Active, goes to the gym daily >4METS

Issues:

• Inferior TWI noted on perioperative ECG
• No history of symptoms
• Echocardiogram showed ‘moderately hypertrophic LV with marginally reduced systolic function, Grade 1 diastolic dysfunction, infiltrative process cannot be excluded, and ASD with small left>right shunt.’

Discussion:

• Discussed at cardiology meeting regarding need for further investigations preoperatively. Cardiologist recommended that surgery proceeds, cancer surgery.
• Differential diagnosis:
• Ischaemic Heart disease – relatively normal LV systolic function is reassuring.
• Infiltrative process – E.G. Amyloidosis, unlikely but at present it is not significant. Not obvious on echo and voltages preserved on ECG. Recommends post-op outpatient cardiology review and cardiac MRI
• AHA guidelines would support proceeding without further cardiac investigations
• Normal sestamibi would be reassuring but abnormal result would likely cause delay and not change intraoperative management

Plan:

• Proceed with planned procedure
• Refer to GP for postoperative cardiology referral and consideration of cardiac MRI and stress test.