66-year-old lady for TKR – initial preop 2019
- IHD – Normal stress echo 2020. No angina.
- 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!
Does patient need PPM?
- Likely that symptoms be attributed to hypothyroidism
- Imperative that hypothyroidism is addressed first
- 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
- 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
- Postpone for 6 weeks
- Cardiology MDT
- Review perioperative guidelines for Thyroid Function testing