46-year-old for consideration of laparoscopic cholecystectomy

Background

• Chronic pain – ankle injury at work. In Cam Boot since November 2021. Awaiting chronic pain specialist input
• Complex PTSD
• Difficult social circumstances/isolation

Issues:

• HFREF – New diagnosis in January 2022
  • Dilated cardiomyopathy, EF 37%. Moderate functional MR
  • Admission with decompensated heart failure post-covid infection.
  • Alcohol-related, drinking 2 litres of wine per day
  • Commenced on optimal medical management: bisoprolol, Entresto (Sacubitril/Valsartan), spironolactone and furosemide. See figure below.
  • Symptoms stable – no orthopnoea/PND. Mild pitting ankle oedema.
  • DASI – 5 Met’s

Pharmacological management of HFrEF

MRA – mineralocorticoid antagonist. ARNI – angiotensin-receptor neprilysin inhibitor

• Cholelithiasis – recurrent biliary colic. No admissions or cholecystitis.
• Alcohol abuse – abstinent since January but currently struggling with this.

Discussion

• Cardiology meeting discussion with repeat echocardiogram
  • Some improvement in echo but not as much as expected 3 months post-event.
  • LV now mildly dilated, LVSF unchanged/slightly improved. MR mild.
  • Outpatient review with cardiologist required preoperatively
  • Ensure euvolemia and careful cardiac monitoring perioperatively
  • NT proBNP = 298. Borderline, suggestive of increased perioperative risk and therefore aids in decision-making with regards to perioperative monitoring and level of postoperative care.

• Alcohol abuse
  • Multiple significant contributors
  • Discussed options for support, patient keen to engage.

Plan:

• Await cardiologist review
• Aim for surgery with 3 months.