86yo male, for possible (open) fenestrated cuff repair to previous aortic stent graft due to endoleak.
- 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!
- 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.
- For further discussion with surgeon about risks/benefits from their perspective.