86yo male, for possible (open) fenestrated cuff repair to previous aortic stent graft due to endoleak.

Background:

• IHD
  • AMI ’95, medical therapy since.
  • On aspirin/clopidogrel
  • Sestamibi (organised by vascular surgeons) shows large, fixed defect and no reversible ischaemia. EF 30-35%.
• DCM due to above (EF 35%).
• TIA 5yrs ago, no residual
• EVAR 2018
• RCRI 3-4 = elevated risk
• DASI 7.5METS, chops wood!

Issues:

• Should surgery proceed?
  • Appeared well at F2F review and DASI very reassuring
  • Advanced age with multiple significant comorbidities – ABS data suggests 6yr life expectancy for the average 86yo Australian male

• Is his heart failure optimised?
  • Discussed at cardiology meeting:
  • Biventricular pacing to improve EF? – unlikely to improve cardiac function in this patient. Indicated with wider QRS which is indicative of desynchrony.
  • Suggested addition of loop diuretic or spironolactone (doesn’t clinical appear overloaded)
  • Cardiologist opinion – patient has significant IHD with a substantial effect on his cardiac function. Recommended to reconsider surgery given high risk for poor perioperative outcome.

Plan:

• For further discussion with surgeon about risks/benefits from their perspective.