[HSF] RE: Timing of Surgery

Tue Apr 1 13:22:58 EDT 2008

How is your patient doing?

Sent via BlackBerry by AT&T

-----Original Message-----
From: "Ajit Damle" <damle at cableone.net>

Date: Mon, 31 Mar 2008 21:19:43 
To:<OpenHeart-L at lists.hsforum.com>
Subject: [HSF] RE: Timing of Surgery

Thank you for your prompt advice. I repeated the CT scan yesterday. No
change at the site of ruptured plaque. Left it alone and did AVR+CABG today.

Ajit Damle 

-----Original Message-----
From: Lytle, M.D., Bruce [mailto:LYTLEB at ccf.org] 
Sent: Monday, March 31, 2008 10:54 AM
To: damle at cableone.net
Subject: Re: Timing of Surgery

Stent the descending aorta then do the heart surgeryn or, alternatively,
just do the heart surgery.  Bruce Lytle

----- Original Message -----
From: Ajit Damle <damle at cableone.net>
To: 'Ajit Damle' <Ajit.Damle at meritcare.com>
Sent: Fri Mar 28 07:20:23 2008
Subject: Timing of Surgery

I need advice on this patient urgently.

77yr old man presents with unstable angina. Previous nucleide test showed
reversible ischemia in LAD territory. While waiting for an angio, he was
admitted to the referring hospital 48 hours ago. In addition, to the usual
treatment, he received 75 mgm of clopidogrel and 100 mgm of Enoxaparin. EKG
initially showed ST changes anteriorly that resolved.

He also developed severe back pain and had a CT. This shows a penetrating
ulcer on the undersurface of the aorta, at the junction of the arch and
descending portion. There is an intramural hematoma, not very big, and also
I think some subadventitial hemorrhage that extends for 3-4 cms. It is hard
to tell if it is chronic or not, but with his history of back pain, I think
it is probably recent. Further down, the descending thoracic aorta is
aneurysmal, some 4.5cms and horribly atherosclerotic in its entire course.
There was also an abdominal aortic aneurysm that was operated on last year.

He had an angio today that shows a non-stentable, ostial, tight lesion of
proximal LAD. The left main is diseased, 20-30%. There is also severe AI 3
to4 +++.

Fortunately he is pain free for now, although this morning he had an episode
of chest pain, with anterior ST changes, that reversed after half an hour.
He is very hypertensive, on multiple therapy and also I/V NTG. The back pain
has subsided.

I am worried that if I operate on him urgently, the heparinization (and
post-op coagulopathy, should he develop one) could worsen the descending
aortic bleeding. I am tentatively planning to operate on him on Monday
(today is Thursday), unless he becomes symptomatic before. I will keep him
on I/V NTG, beta blockers. He is also on Aspirin.

What do you think? Should I do him sooner?

Ajit Damle

Fargo ND

March 27, 2008

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