Trial Written Exam April 2023

Section 7: 3 Questions. 30 minutes

54M presents with troponinaemia (1170) without ECG changes in the context of an UGI bleed while on triple therapy for PVD

Cath:  severe 3VD

  • LM 50%

  • LAD prox 80%

  • RCA occluded (PDA fills retrograde)

Endoscopy: duodenal angioectasia

Background:

  • Mod AS

  • IDDM (retinopathy, peripheral neuropathy, OM 2nd left toe w/ amputation)

  • HTN

  • Dyslipidaemia

  • Asthma

  • PVD (R fem-pop bypass 2017, L fem-pop bypass 2020, redo L fem-pop 2021, angioplasty (aorto-iliac, fem-pop bypass) 2020, 2022 (Jan, Mar, Aug),

  • lumbar disc degeneration

Medications:

  • aspirin

  • rivaroxaban

  • atorvastatin

  • losartan

  • omeprazole

  • atrovent

  • insulin

Social History:

  • IADLs

  • current smoker (20/day + THC)

History:

  • Reports exercise limited to 30m due to claudication and breathlessness (more recently)

  • Denies angina

Examination:

  • Height: 165, Weight: 60, BMI: 21

  • HSD + ESM, nil carotid bruits

  • Chest clear

  • L Allens 7 seconds, no varicose veins

  • Scars on right upper arm + bilateral lower legs

Investigations:

  • Echo 2 years prior: LVEF 60%, mild LVH LVH, mod AS (MG 23, V 3.4, AVA 1.3), otherwise normal

  • HbA1C 85

  • Crt 60, eGFR >90

  • Hb 156

Spirometry: FEV1 2.67 (81%), FVC 3.18 (76%), DLCO 6.24 (75%)

Conduit mapping:

  • Lower limbs: B/L no GSV present, R SSV small in diameter (1.7mm), L SSV usable for 20cm (3mm)

  • Upper limbs: R cephalic vein absent, L cephalic vein small in diameter (1.5-1.8mm)

Carotid US: no ICA stenosis, antegrade vertebral flow

Current Echo

  • LVEF 50%, septal hypokinesis, mild LVH w/ grade 1 diastolic dysfunction

  • Heavily calcified bicuspid AV with mod-sev AS (MG 33, V 3.8, AVA 1.0), aortic annulus 23mm

  • Otherwise no sig valvular disease