Trial Short Case 2 April 2021 Answers

Question 1

1.      What are the possible aetiologies for this case, how will these impact your decision making, and what do you think would be the most likely in this circumstance.  

Answer

Potential aetiologies –

Non-infectious valvular endocarditis 2ary auto-immune disorder (SLE>Anti-phospholipid syndrome>rheumatoid arthritis)

Non-infectious valvular endocarditis 2ary malignancy most commonly adenocarcinomas (Non-lung adenocarcinoma>pancreatic Ca> lung )

Culture -ve endocarditis (HACEK, Coxiella, brucella)

Pass - Identifies potential aetiologies and gives a favourite aetiology.

Strong  pass - clearly demonstrates infectious aetiology is lower down on the list than non-infectious aetiology given absence of infective symptoms, absence of locally destructive process and the presence of thrombophilia.

Factors in the aetiology that will influence management decisions (not patient factors) –

Recent stroke

Thrombophilia

As yet to be determined true aetiology ? will require further invasive investigations in the near future

Pass identifies 1 factor and explains importance

Strong pass identifies all 3

Question 2

The patient and family would like to discuss the risk and benefits of surgery, prosthesis types and impact on future life and health in particular with regards to raising a family. What are the indications to operate in this circumstance

Answer

Indications for surgery: Multiple frequent emboli with presence of mobile vegetation although only moderate size.

In general risk of operation low given no end organ dysfunction and no medical background.

Specific risks in this case– haemorrhagic transformation of recent stroke needs to be balanced with risk of ongoing strokes from untreated valve disorder (has been started on prophylactic antibiotics and empirical steroid treatment prior to most recent stroke thus already on maximal medical management)

Unknown aetiology – risk of prosthetic valve becoming involved

Risk of not determining aetiology from microbiology and histopathology

Likely difficult operation given very small stature and small aortic dimension, root enlargement/replacement.  Discussion of prosthesis choices – impact of anticoagulation on future child-bearing if necessary

Likely need for further invasive investigation needs to be considered in prosthesis choice given absence of conclusive diagnosis

Operation options: bioprosthesis vs mechanical valve with root enlargement, aortic root replacement (mechanical or bioprosthetic valve), homograft root replacement, Ross procedure

Pass – identifies specific risks in operation – haemorrhagic transformation and potential involvement of prosthesis, acknowledges difficulty in operation due to small size, identifies impact of anti-coagulation on age and desire for children. Develops plan that address aortic size and considered approach for prosthesis type.

Strong pass – identifies all issues in the case with regard to operative risks, potential future risks – need for further investigation, non-diagnostic result, impact of anticoagulation, impact on future lifestyle.

Question 3

You decide to operate, what factors will influence you operative plan and how will you address these factors in particular. 

Answer

Candidate to select operation to be performed and detail why chosen and what the benefits and drawbacks of other potential procedures

Things that need to be considered

·       Patient size

·       Patient age

·       Hypercoagulability

·       Recent stroke

·       Uncertain aetiology of pathology

·       Potential need for future invasive investigation

·       Likely need for some future anticoagulation given DVT regardless of operation performed

·       Awareness of what needs to be arranged to facilitate diagnosis – d/w microbiology and rheumatology

identification of all operation options and appropriate and considered selection based on patients risks

Pass – determines safe operation with consideration to patient factors

Strong pass – considers importance of future diagnosis and impact on future health investigations