Update – CPET result, hepatectomy

Gabrielle Morris

Background

  • Hepatocellular carcinoma – segment III
  • HFrEF 25%. Severe global systolic dysfunction.
  • Recent episode of decompensated cardiac failure after inadvertent cessation of furosemide. Quick resolution with recommencement of therapy.
  • Current smoker 20 pack years and Marijuana use 1g per week
  • CKD – stage 3. Diabetic and hypertensive nephropathy
  • IDDM. Hba1c – 8.3%
  • Anaemia of chronic disease. Hb = 105.
  • Excellent exercise tolerance – DASI 7.25 MET’s. chops wood, mows lawns. 
  • Referred to cardiologist and for CPET

CPET Result 

  • Sub maximal test ceased due to ST elevation- 6mm in V4. Asymptomatic.
  • Peak VO2 11.6 mL/kg/min
  • Anaerobic threshold 9.4 mL/kg/min
  • Nadir VE/VCO2 32.4 
  • BP rise normal throughout
  • HR Recovery at min 1 was 2 beats/minute
Table Description automatically generated

See https://www.bjaed.org/article/S2058-5349(19)30021-6/pdf for a beginner’s guide to CPET.

Cardiologist Review

  • On optimal therapy – would consider addition of ARNI post-treatment of HCC
  • Echo unchanged
  • Candidate for defibrillator in long-term
  • CPET result noted, cardiologist felt that it was artifact
  • Cardiology advice – cardiomyopathy or CPET results wouldn’t preclude the patient from proceeding with hepatectomy. However, if he were to have significant blood loss or develop perioperative arrhythmias, he would struggle to compensate from a cardiac perspective. 

Discussion

  • Consensus that patient is too high risk for hepatectomy at this stage. 
  • CPET results not reassuring. AT borderline, HRR low indicating very poor baseline fitness.
  • There is another non-surgical option for treatment – radiotherapy carries 70-80% efficacy as a curative therapy in this case
  • Stress imaging – Not indicated at this point, as per AHA guidelines. Additional investigation will not change management. 

Plan:

  • Discussed with surgeon – proceed to radiotherapy
  • Cardiologist will continue to review