67-year-old man for re-consideration of EVAR
Background:
- 5.5cm infra-renal AAA
- Previous perioperative assessment and CPET for this procedure
- Deemed too high risk based on CPET results
- Progress over last 6/12;
- Optimised from cardiac perspective, has commenced Entresto and fluid balance improved
- Commenced a daily exercise program
- 30 minutes daily on treadmill at 3.6km/hr
- DASI 5.6 MET’s
- 14kg weight loss
Issues:
- IHD
- Inferior MI 2008. Multiple stents to distal RCA 90% stenosis
- Infrequent episodes of stable angina. On maximal medical therapy
- SESTAMIBI – large, fixed perfusion defect in anterior wall with no reversibility demonstrated
- HFrEF – 49%. Hypokinesis of inferior and posterior walls. Moderate Pulmonary hypertension, Increased LV filling pressures.
- NIDDM – HbA1c = 6.7%
- BMI 45, after recent 14kg weight loss
- Severe OSA/OHS
- compliant with CPAP. AHI = 97, SpO2 = 94% RA, HCO3 = 28
- AHI reduced to 1 with CPAP however pressures inadequate and patient reluctant to increase.
- SpO2 82% overnight with CPAP
- Asthma/COPD – post-BD FEV1 = 2.47 (84%), FVC = 4.2 (112%), DLCO = 67%
- ICU admission 2021 with PR bleeding and type II respiratory failure requiring NIV
CPET:
1st CPET – April 2021
- Sub-maximal test
- Stopped after 2 minutes of cycling due to hypertension (SBP>180 as per AAA protocol)
- Excessive ventilatory response – as demonstrated by VE/VO2 slope
- CPET MDT advised that patient was not a suitable candidate for any surgery.
- Recommended prehabilitation
2nd CPET – October 202
- Sub-maximal test – RER 1.05
- Stopped due to SBP exceeding 200mmHg
- Peak VO2 12.2ml/kg/min
- AT 1.5L/min or 9.2ml/kg/min
- Nadir VE/VCO2 34.8 (using actual body weight)
- HRR 7bpm
- VE/V02 graph for second test:
Discussion:
Optimisation
- CPET results reassuring that patient has been optimised
- Symptomatic HF treated – can now lie flat, previous orthopnoea
- Exercise also beneficial physically and psychologically in this case
- Remains a high-risk patient, RCRI 3, NSQIP risk of death 2%, cardiac complication 3.5%, and serious complication 15%.
- Patient and family understand and are accepting of risks
- Discussed with surgeon – surgery carries prognostic and QoL value even if life-expectancy limited.
CPET
- Near-maximal test and values for peak VO2 and AT obtained on recent CPET
- Retrospective data indicates poor long-term prognosis and life-expectancy based on inability to complete the test. See doi:10.1093/bja/aet193
- Results are based on actual body weight and not modified for ideal body weight.
- Maximal SBP values pre-determined in conjunction with vascular surgeon in cases of AAA to minimise risk to patient.
Plan:
- Proceed to EVAR
Perioperative Talk 