Case 1

Clinical History (1.1)

• 65 year old gentleman
• CVRF  hypertension, diabetes (insulin)
• Chronic kidney disease (eGFR 30)
• No prior cardiovascular problem

• Consulted from the surgeon for cholelithiasis

pre-op
 Questions
• What is your plan for this patient?
• Do you need more data?
Eur Heart J 2014;35:2383-2431.
Eur Heart J 2014;35:2383-2431.
 Hasil Laboratorium
• Ureum 150
ISSUE
• Cr 3,4
• Koreksi Albumin?
• Na/K/Cl : • Diuretik?
138/4,1/100 • Apa jenis diuretiknya?
• GDS 233 on insulin
• Keton urine (+)
• AGD
7,4/32/98/-3/18/96%
• Edema
• Albumin 3,0
 • Diskusi:
• 7.4 / 32 / 98 / -3 / 18 / 97%
• Na 138; K 4,1; Cl 100; Alb 3.0; Edema
(a) Na-Cl effect
 (138 – 100) - 38 = 0

(b) Albumin effect

 0,25x(42 - 30) = 3

(c) Unmeasured Anion Effect

 UA = - 3 – (0) – (3)= - 6 (keton?)
 Anaesthesia & Analgesia
• What is the strategy?
• How to tackle the acid base problem that
might occur perioperatively?
• ICU post operative?
 Follow Up
• Laparascopic procedure was performed
uneventful
• Patient was discharged in good condition
Well Done Doc
Eur Heart J 2014;35:2383-2431.
CASE 2
 Clinical History (2.1)
• 35 year old lady
• Referred by the obstetrician with cardiac murmur
• NYHA Fc II
• Gravid 34 week (first pregnancy)
ECG
 Questions
• What are the problems?
• What is your plan for this patient?
• Do you need more data?
 Echo
• LA-RA-RV dilation
• Good LVEF
• Reduced RVEF
• Mitral Valve: mVG 12 mmHg; MVA 0,5 cm2; MR
mild
(Wilkins Score 12, bi-commisural calcification)
• Tricuspid Valve: TR mild; TVG 45 mmHg
• eRAP 8 mmHg
Eur Heart J 2014;35:2383-2431.
 Step 2
Active or Unstable Cardiac Conditions
Conditions
If Yes
• Unstable angina pectoris
• Acute heart failure • Postpone the procedure
• Significant cardiac • Treatment options should
arrhythmias be discussed in a multi-
disciplinary team involving
• Symptomatic valvular
all peri-operative care
heart disease
physicians
• Recent myocardial
infarction & residual
myocardial ischemia Surgery

Eur Heart J 2014;35:2383-2431.

 Step 3
Risk of Surgical Procedure
“30 day cardiovascular death & MI”

Without consideration
of patient’s comorbidity
Eur Heart J 2014;35:2383-2431.
 Low Risk Surgical Procedure
• Initiation of titrated low dose
beta blocker before surgery
• Identify risk
(Class IIb/ Level B)
factors
• ACEi in patient with heart
• Lifestyle &
failure & systolic dysfunction
medical
(Class IIa/ Level C)
treatment based
on guidelines • Initiation of statin therapy for
vascular surgery (Class IIa/
Level B)

Eur Heart J 2014;35:2383-2431. Surgery

 Recommendation
Class IIb
• Elevated-risk elective noncardiac surgery
using appropriate intraoperative and
postoperative hemodynamic monitoring may
be reasonable in asymptomatic patients with
severe mitral stenosis if valve morphology is
not favorable for percutaneous mitral balloon
commissurotomy. (Level of Evidence: C)

Circulation 2014;130:278-333.
 Questions
• The obstetrician asks us when will be the
appropriate time for delivery…?
• Delivery strategy?
• Anaesthesia or analgesia?
 Follow Up
• Patient was given beta blocker and
diuretic
• Pregnancy was continued until aterm
• Delivery  C-section

• Further echocardiogram  planned for MV

surgery
 Clinical History (2.2)
• Patient complained shortness of breath
• BP 150/100 mmHg; HR 120 bpm; SpO2 88%
• Rh +/+

• The obstetrician asks for your help…what can

you do?
 Clinical History (2.3)
• Hypotension occurred in the same patient
during Pre-Op
• BP 60/40 mmHg; HR 130 bpm
• Rh +/+, cold extremities

• The obstetrician asks for your help…what

can you do?
THANK YOU DOC
Eur Heart J 2015;36:3075-
3123.
 IE Prophylaxis (Class IIa/ Level C-LD)
• Prophylaxis against IE is reasonable before dental
procedures that involve manipulation of gingival tissue,
manipulation of the periapical region of teeth, or perforation
of the oral mucosa in patients with the following:
1. Prosthetic cardiac valves, including transcatheter
implanted prostheses and homografts.
2. Prosthetic material used for cardiac valve repair, such as
annuloplasty rings and chords.
3. Previous IE
4. Unrepaired cyanotic congenital heart disease or repaired
congenital heart disease, with residual shunts or valvular
regurgitation at the site of or adjacent to the site of a
prosthetic patch or prosthetic device.
5. Cardiac transplant with valve regurgitation due to a
structurally abnormal valve

Circulation 2017.
Circulation 2017.
CASE 3
 Clinical History (3.1)
• 64 year old gentleman
• CVRF  hypertension, diabetes & ex
smoker

• The patient was admitted with

decompesated heart failure due to unstable
angina (second admission this year)
despite optimal medical therapy
• Coronary angiogram  3VD
CAG
 Clinical History (3.1)
• Patient also complained of a mass at inguinal
region with severe abdominal pain
• Can not defecate for 7 days, bloating (+),
flatus (-), fever (-)

• Laboratory  increased WBC

 Questions
• What are the problems?
• What is your plan for this patient?
Eur Heart J 2014;35:2383-2431.
 Clinical History (3.2)
• The same patient  after intensive
monitoring in HCU  abdominal pain
diminished
• Flatus (+), bowel movement and passing
(+)
• The surgeon wants to do elective surgery
 Questions
• What is your plan for this patient?
• Do you need more data?
 Step 2
Active or Unstable Cardiac Conditions
Conditions If Yes
• Unstable angina pectoris
• Postpone the procedure
• Acute heart failure
• Treatment options should
• Significant cardiac be discussed in a multi-
arrhythmias disciplinary team involving
• Symptomatic valvular all peri-operative care
heart disease physicians
• Recent myocardial
infarction & residual
myocardial ischemia Surgery

Eur Heart J 2014;35:2383-2431.

 Step 3
Risk of Surgical Procedure
“30 day cardiovascular death & MI”

Without consideration
of patient’s comorbidity
Eur Heart J 2014;35:2383-2431.
 Step 5
Consider risk of surgery
• Additional functional capacity (METS):
✓<4 METS (moderate or poor) with
intermediate risk surgical procedure
• Non invasive testing (Class IIb/ Level B)
• Baseline ECG (Class I/ Level C)

Surgery
Eur Heart J 2014;35:2383-2431.
 Step 6
<4 METS with High Risk Surgical Procedure

• If cardiac risk factors ≤2 

Cardiac Risk Factors rest echo & biomarkers of
LV function (Class IIb/
Level B-C)  Surgery

• If cardiac risk factors ≥3 

cardiac stress test (Step 7)

Eur Heart J 2014;35:2383-2431.

 CMR  LVEF 35% with
largely viable myocardium
 Step 7
Cardiac Stress Test
1. No/ moderate stress-induced ischaemia  Surgery
2. Extensive Ischaemia

SURGERY

Eur Heart J 2014;35:2383-2431.

 Questions
• Revascularization strategy?
• CABG or PCI?
• PCI strategy?
Eur Heart J 2014;35:2541-2619.
 Prophylactic Coronary Revascularization in
Stable Cardiac Patients

For high risk surgery  prophylactic revascularization may

be considered

For low and intermediate risk surgery  prophylactic

revascularization is not recommended

Eur Heart J 2014;35:2383-2431.

 PCI
• Ikari IL 3.5/ 6 Fr GC; Sion Blue GW
• Sequent Neo SC balloon 2.5x15 mm (8 ATM)
• DEB Sequent Please 2.5x30 mm (10 ATM-1 min)

SC
balloon
 PCI
• Sequent Neo SC balloon 2.5x15 mm (6 ATM)
• DEB Sequent Please 2.5x30 mm (7 ATM-1 min)
 PCI
Sequent Neo SC balloon 2.5x15 mm (6 ATM)
 Follow Up

➢ Functional
class was
significantly
improved
➢ Since PCI 
no more
cardiac event
➢ Patient was
discharged
with DAPT
 Question
• Herniotomy is being scheduled, when is
the appropriate time according to you?
• Anaesthesia and analgesia strategy?
• CAD medications?
1. New generation DES/ DCS
2. DEB/ DCB
3. BVS/ BRS

Circulation 2014;130:278-333.
 Clinical History (3.3)
• The same patient had new onset AF one
day before surgery
• What should you do?
• How to manage the anticoagulant and
antiplatelet?
 Follow Up
➢DAPT for one month
➢Herniotomy with MESH was performed
uneventful
THANK YOU DOC
 Timing of Angiography for NSTE-ACS
Eur Heart J 2011;32:2999–3054.

• Refractory angina
• Severe heart failure
• Life-threatening ventricular arrhythmias, or
Hemodynamic instability
At least one < 2 hour
Urgent coronary angiography
none

• Relevant rise or fall in troponin

• Dynamic ST- or T-wave changes
(symptomatic or silent)
• Grace risk score > 140
At least one < 24 hour
Early invasive strategy

none

• Diabetes mellitus
• Renal insufficiency
(eGFR <60 mL/min/1.73 m²)
• Reduced LV function (EF <40%) At least one < 72 hour
• Early post infarction angina
• Recent PCI
• Prior CABG
• GRACE risk score 109-140

none

• Non- invasive investigation At least one Elective if indicated

Eur Heart J 2014;35:2541-2619.