Laparoscopic surgery for colorectal cancer is a minimally invasive procedure that is associated with less postoperative pain, fewer complications, faster recovery, and greater early social rehabilitation [1, 2]. Therefore, it is suitable for high-risk patients, especially those with frailty and in the elderly. In recent years, laparoscopic surgery in such high-risk populations has been reported to have fewer complications and lower mortality rates compared with open laparotomy [3,4,5]. Meanwhile, in patients with low cardiac or pulmonary function, a pneumoperitoneum would exacerbate cardiopulmonary function by decreasing cardiac output and pulmonary compliance . Therefore, it is essential to evaluate cardiopulmonary function prior to laparoscopic surgery. Our patient had a history of multiple cardiovascular diseases, and we performed echocardiography to evaluate her current cardiovascular status, which incidentally revealed severe AS. Symptoms of AS such as shortness of breath and palpitation at the time of exertion may not be readily apparent in the elderly with reduced activity, and in cancer patients, anemia and fatigue caused by the disease itself can mask the presence of cardiopulmonary symptoms. Our case serves to confirm the importance of careful preoperative evaluation, especially in elderly cancer patients.
AS is a narrowing of the aortic valve opening that leads to the obstruction of the left ventricular outflow, subsequent left ventricular systolic dysfunction, and ultimately heart failure in the long-term. In patients undergoing non-cardiac surgery, severe AS is a known high-risk factor of mortality and morbidity because it reduces coronary perfusion under surgical stress and hemodynamic changes. The European Society of Cardiology guidelines recommend SAVR in symptomatic severe AS patients prior to non-cardiac surgery , while in asymptomatic severe AS patients, SAVR is recommended only when the risk of non-cardiac surgery is high, and the risk of SAVR is low. Our patient did not meet the absolute indications for SAVR because of her poor symptoms; however, we thought it was better to prioritize the treatment of AS using TAVI over colectomy because AS severity and symptoms, which can increase the risk of colectomy, may not be apparent in such an elderly cancer patient.
TAVI is a minimally invasive approach for replacing the aortic valve that differs from SAVR in that it requires no cardiac arrest, extracorporeal circulation, or thoracotomy. In high-risk or ineligible patients, the PARTNER trial showed that treatment outcomes, including mortality rates, LV function recovery, and morbidity after TAVI were either comparable to or superior to those of conventional therapy [8,9,10]. Therefore, TAVI has become the standard alternative treatment in high-risk surgical patients. Furthermore, specific advantages of TAVI have been reported in cancer patients, as it does not require cardiopulmonary bypass (CPB). These include a possible reduction in the risks associated with tumor bleeding due to anticoagulant disorders or anticoagulants administration, and tumor dissemination due to immunosuppressive and inflammatory effects of CPB [11, 12]. In patients with severe AS requiring cancer treatment, TAVI not only enables a smooth transition to the next treatment strategy due to its minimally invasive nature but also confers an oncological advantage. Thus, TAVI was considered most suitable for our patient. Importantly, our patient felt an improvement in her physical condition after TAVI even though there were no obvious symptoms, and our case serves to highlight the fact that, in addition to careful preoperative evaluation, it is also necessary to make prudent decisions on treatment strategy in elderly patients whose symptoms are often less apparent.
We prescribed a single drug antiplatelet regimen with aspirin alone after TAVI, and laparoscopic colectomy was performed 22 days after TAVI with perioperative heparin bridging. We selected this treatment regimen, even though dual antiplatelet therapy using clopidogrel and aspirin is recommended for the first 6 months after TAVI, to avoid ischemic complications, because of the higher risk of tumor bleeding in our patient. Recent reports have shown that, compared with dual antiplatelet therapy, aspirin alone could reduce the risk of life-threatening/major bleeding while not increasing the risk of ischemic events following TAVI . Although the preventive effects of aspirin alone in cancer patients with thrombotic tendencies remain unknown, we treated our patient with aspirin alone for fear of tumor bleeding. It is possible that heparin bridging may not have been necessary because of its unclear benefit, and one meta-analysis has shown that antiplatelet therapy at the time of non-cardiac surgery is associated with minimal bleeding risk . Thus, it is possible that the colectomy could have been performed earlier in the absence of heparin bridging.
Due to factors such as age, heart failure, and cancer, 30–50% of symptomatic AS patients are considered ineligible for SAVR [15,16,17]. Previously, elderly cancer patients with severe AS similar to our patient may have been forced to forego treatment of severe AS and cancer, but TAVI can potentially help these patients. To the best of our knowledge, this is the first report of a patient undergoing laparoscopic colectomy for cancer after TAVI even though a few surgical reports of cancer surgery after TAVI are available [18,19,20]. There is no evidence on the feasibility of TAVI in severe AS patients scheduled for cancer surgery and its effects on subsequent surgery. Further studies are required to assess variables such as adequate treatment interval between TAVI and cancer surgery, a perioperative antiplatelet agent, and surgical indications.