66-year-old lady for TKR – initial preop 2019

Background:

• IHD – Normal stress echo 2020. No angina. 
• AF
• MVP
• Asthma

Issues

• Bradycardia – 45bpm. Fatigued, no syncope.
• Discussed at cardiology meeting.
  • Referred to own cardiologist
  • Recommended PPM
• Bilateral pitting peripheral oedema. Complaining of orthopnoea and PND. 
• DASI – 3.97, limited by fatigue
• Echo 2020. 
  • dilated cardiomyopathy
  • severely dilated LV and LA
  • MR with prolapse 
  • Severe AS
• Returned to clinic this week for PPM insertion
• Thyroid function checked: 
  • TSH = 8 hypothyroidism.
  • on thyroxine but not checked regularly
• Echo repeated due to oedema, orthopnoea, and PND:
  • Normal Aortic Valve. No stenosis!

Discussion:

Does patient need PPM?

• Likely that symptoms be attributed to hypothyroidism
• Imperative that hypothyroidism is addressed first

Hypothyroidism

• Medication compliance issue should be considered
• Timescale for expected changes with treatment of hypothyroidism.
  • weeks for improvement of symptoms 
  • 3 months for biochemical changes
• Important to look at clinical picture as well as biochemistry when making decisions regarding fitness for surgery 
• Current clinic guidelines for TFT’s:
  • ‘Monitoring is usually performed serially by GP. Consider testing peri-operatively if not done within 12 months if stable disease or sooner if frequent medication changes required/new cardiac arrhythmias/or signs and symptoms of thyroid disease.’ www.perioptalk.org
• If request TFT’s will only get TSH value and need to request T3/T4 separately if required or if TSH abnormal

Aortic Stenosis?

• Need to revisit cardiac imaging – possibility of error with previous echo regarding documented AS
• Discuss at Cardiology MDT – ideal place to consolidate this information and facilitate liaison with regular cardiologist

Plan

• Postpone for 6 weeks
• Cardiology MDT 
• Review perioperative guidelines for Thyroid Function testing