Marfans and cardiac decompensation

76-year-old man for excision and reconstruction of right tibio-peroneal trunk, posterior tibial and peroneal aneurysms


  • Marfan-like syndrome – dilated aortic root, aneurysms, high-arched palate
  • AF – apixaban and metoprolol
  • OSA – compliant with CPAP
  • CVA – right MCA in 2019. Residual Left hemiparesis
  • Monoclonal gammopathy – surveillance


Type A aortic dissection  

  • AVR and ascending arch repair in 2005
  • Known residual aneurysm
  • Aortic Root and Ascending aortic aneurysm increasing in size – reviewed by CTS and deemed unsuitable for further surgery. High complexity and multiple co-morbidities

Exertional dyspnoea

  • Increasing in severity over last 7/12
  • NYHA class 2
  • Decreased exercise tolerance – 3.6 MET’s. Limited by dyspnoea
  • No orthopnoea, PND, angina.
  • Overtly fluid-overloaded with pitting oedema to both knees at clinic
  • Admission in March with Dyspnoea – treated for Strep Viridans endocarditis
  • ECHO/TOE – no evidence of endocarditis, Severely Dilated ascending aortic aneurysm (75mm), severely dilated AR (49mm), Moderate RA dilation, severe LA Dilation, LV and RV function normal.
  • No regular cardiology follow-up

Lower Limb Aneurysms

  • Asymptomatic
  • Risk of rupture requiring emergency intervention
  • Previous superior gluteal artery aneurysm rupture requiring repair with glue after failed embolization
  • Option for surveillance



  • Current fluid overload concerning
  • Cardiology review and optimisation of therapy required preoperatively
  • Patient feels not at best baseline and keen to wait until cardiology review
  • Surgery not time-critical

Conduct of anaesthesia

  • Surgery will be long and complex
  • GA recommended to provide optimal surgical conditions and minimise physiological stress response
  • Spinal discussed however consensus that haemodynamic changes more difficult to control and surgery will require patient to lie very still for prolonged period.


  • Cardiology review preoperatively
  • Postpone surgery for 3 months