Ivor-Lewis Oesophagectomy with Ischaemic Heart Disease

PIG Meeting: 18th February 2021

69 year old man with Oesophageal cancer

Background

  • Routine preoperative CPET testing revealed ischaemic ECG changes, suspicious of LM disease

Issues

  • Asymptomatic. Noted to have an excellent exercise tolerance on DASI.
  • Exercised to 90% of predicted HR with AT of 15.6ml/kg/min and VE/VCO2 24.6. This represents excellent exercise capacity and would usually indicate patient is fit to proceed to major surgery.
  • Discussed with Dr Collins at the Perioperative Cardiology meeting. Concern re left main coronary artery disease – recommended angiogram
  • Coronary angiogram which revealed mid-eccentric LAD stenosis of 60-70% with normal LVEF
  • No coronary intervention required. Plan to proceed with surgery

Discussion

  • Value of CPET in this instance. Was it a useful test?
  • Discussion centered around the finding of a pathology that didn’t require any intervention.
  • Patient didn’t perform Prehab due to possibility of coronary disease. Was he disadvantaged?
  • Should we be performing CPET in all patients for major surgery or just in those who are clinically borderline candidates?
  • Consensus that there is sufficient evidence for CPET testing perioperatively for major surgery. This patient performed well despite recent completion of NAC and that provides treating team with good prognostic information perioperatively.
  • No delays to surgery and prehabilitation unlikely to improve fitness further as already excellent.

Plan

Laparoscopic radical nephrectomy with unoptimised ischaemic heart disease

PIG Meeting: 11th February 2021

57yo male with renal cancer for radical nephrectomy.

Background:

  • BMI high ++
  • T2DM
  • Dyslipidaemia
  • HTN

Issues

  • ? Ischaemic heart disease
    • Exertional chest pain
    • GP arranged a stress ECG – positive
    • Saw cardiologist –  stress ECG again positive and the patient experienced chest pain, but stress echo negative for ischaemia. Discharged from cardiologist’s care.
    • CTCA arranged which showed severe RCA vessel narrowing.
    • Reviewed at cardiology-anaesthetics meeting – suggested angiogram and likely PCI.
    • Discussed with surgeon –
      • Will operate on aspirin but not on clopidogrel
      • Based on tumour imaging suggesting nil capsular invasion, ok to delay surgery 3/12 to enable cardiac stenting and short duration DAPT.

Discussion

  • Why did this patient have so many non-invasive cardiac tests?
    • Usually patients have invasive cardiac testing (angiography) if one non-invasive test is positive, especially in the setting of symptoms.
    • Perhaps due to GP’s strong suspicion that there was underlying IHD.
  • What are the current guidelines around duration of DAPT after PCI?
    • Case-by-case basis, with multiple factors influencing decision (essentially bleeding v. Stent thrombosis)
      • Patient – diabetes, ACS, age, LV function
      • Stent – calibre, overlaps, branching, length, DES v. BMS
    • AHA guidelines recommend 3 months of dual antiplatelet therapy post drug-eluting stent (See diagram below).
    • Recent database evidence from Denmark suggests risk of MI and cardiac death after DES is elevated only with surgery within the first month after stent placement (See attached paper).
    • All such cases require consultation with the treating cardiologist and surgeon to reach a compromise.