Trial Short Case 1

Case Summary

67 year old man

Referred from cardiologist

Complaint: worsening dyspnoea on exertion. Stopping for breath after 2 flights of stairs, 200 meters on flat. Progressive over 6-9 months.

Background:

Left Upper Lobectomy 3 years ago. T3 N2 M0 SCC. Adjuvant chemotherapy, radiotherapy.

Postoperative PE. Three months of Clexane.

Aortoiliac PVD: Stable claudication

Dyslipidaemia

Ex smoker. Ceased 15 years ago.

Medications:

  • Pantoprazole 40mg

  • Atorvastatin 80mg

  • Aspirin 100mg

  • Clopidogrel 75mg

  • Metoprolol 50mg

  • Perindopril 10mg

  • ISMN 120mg

Examination

97kg, 180cm, BMI 30

135/95. SR 72. Sats 97% RA

Left posterolateral thoracotomy

Allens test: -ve bilaterally

No varicose veins

2+ pulses femoral, popliteal, DP and PT bilterally

Respiratory Function Tests

FEV1: 2.49L (73% predicted)

FVC: 4.29 (96% predicted)

FEV1/FVC: 58%

Echo:

Normal LV Size

LV EF 50-55%

Inferior Wall akinesis

Normal RV size and function

AV sclerosis

Trivial MR, Trivial TR, Trival PR

 

Questions:

  1. In your discussion with your referring cardiologist, what considerations would you raise about revascularisation strategy?

  2. You and the cardiologist decide that surgery is the chosen strategy. What would be your patient specific considerations be for this patient?

  3. His concern is about postoperative pulmonary embolus. Explain how you would manage this risk.