Trial Short Case 3 April 2022

Case Summary

76 yo male

SOB while sitting on couch on background increasing SOBOE.

Negative troponins, underwent angiogram given risk factors

Could walk 4-5Km/day with breathlessness on hills, hill tolerance slowly declining past 12 months. Now struggles to walk 10 minutes on flat.

referred for consideration of surgical revascularization

Background

IHD – prev PCI to LAD, Lcx and RCA

AF – anticoagulated for 6 years

COPD

FEV1 1.84L (64% predicted), FVC 2.76L (75% predicted), FEV1/FVC 0.66 (83% pred)

DLCO 68% predicted

Anxiety/depression

Chronic kidney disease: Cr 130umol (eGFR 46)

T2DM: HbA1c 7

Medications

Aspirin 100mg

Rivaroxaban 10mg BD

Rosuvastatin 20mg

Fluticasone + Salmeterol 250/25 mcg BD

Citalopram 20mg

Olmisartan 40mg / hydrochlorothiazide 25mg

Gliclazide 30mg

Linagliptin 5mg

Examination

78kg, 172cm, BMI 26.37

HR 90 irregular

BP 118/76

JVP 5cm

Nil peripheral oedema

Fixed, split second heart sound, no murmurs

Chest – clear

No varicose veins, Allens brisk 2 sec bilaterally, no chest scars or deformities

Investigations

HB 118, Plt 201, INR 1.6

K 3.8 , Cr 138

Albumin 36

HbA1C 7.1

Serology – all negative

ECG

AF

LBBB

CXR

NAD

CT chest (non-contrast)

Smooth interstitial thickening consistent with mild interstitial oedema

No emphysema or bronchiectasis

TOE

3cm sinus venosus ASD

Anomalous right upper lobe pulmonary vein draining to SVC/RA junction

3 pulmonary veins draining into LA - well visualized

Remainder of exam as per TTE

Angiogram

TTE

Right Heart Cath

Questions:

What are the potential causes of pulmonary hypertension in this patient? What features of the investigations included make you think one is more or less likely than others. What, if any, further investigations would you consider?
Briefly discuss embryological basis for a sinus venosus ASD and its anatomical location? What, if any, are the other pertinent cardiac lesions associated with a sinus venosus ASD?
What is your surgical approach to this patient?