Severe IHD for H&N Cancer Surgery

82yo male for WLE of left and right ear lesions and right sided neck dissection. 

Background

  • IHD
    • NSTEMI Aug ’20 -> 2 x DES to LAD, 1 x DES to OM2, balloon angioplasty to OM1.
    • Angiogram for ongoing exertional angina June 2021 showed severe ostial LCx dx and PDA dx (70%)
    • Pt discussed at cardiology MDT, where possibility of CABG was raised.
  • Right facial SCC with metastasis to local nodes.
  • HTN
  • Dyslipidaemia

Issues

  • Difficulty communicating with the treating cardiologist
    • Cardiologist referred patient for recent angiogram, based on stable exertional angina
    • Cardiologist was happy for DAPT to cease for surgery but could not comment on whether further revascularization should occur before cancer surgery without reviewing the patient in person, which could not occur for several weeks.

Discussion

  • Should revascularization be considered?
    • Exercise tolerance very reassuring – mows lawns, 7.3 METS on DASI.
    • Further revascularisation (PCI or CABG) would require DAPT for a period, delaying cancer surgery.
    • Revascularization may be indicated for symptom relief, unlikely in this patient to provide survival benefit or reduced perioperative risk, based on current evidence (ISCHAEMIA trial)
  • What to do about difficulties with communication with cardiologist?
    • Discussion at cardiology-anaesthetic weekly MDT – previous experience of canvassing opinions of additional cardiologist. If patient already known to one cardiologist, can create uncertainty with conflicting opinions.

Plan

  • Attempt to contact cardiologist and emphasise desire to avoid delays to cancer surgery to wait for delayed in-person review.
    • Update: Contacted cardiologist, who advised that surgery should proceed based on reassuring TTE showing normal LV systolic fx and patient’s very good exercise tolerance.
    • Procedural anaesthetist to be updated on plan.