The Cardiac Patient Undergoing Noncardiac Surgery

Abstract

A preoperative consultation was requested on a 64-year-old male prior to radical cystectomy and ileal conduit formation. Three weeks previously he had been diagnosed with acute myocardial infarction (MI) type 2 (peak troponin I 5.6 μg/L) resulting in congestive cardiac failure, acute respiratory failure, acute exacerbation of chronic kidney injury, and acute liver injury. He had a background of type 2 diabetes, diabetic nephropathy, hyperlipidemia, hypertension, COPD, and obesity with a BMI of 39.2. Obstructive sleep apnea was suspected but undiagnosed. He had quit smoking over 20 years prior to this presentation. The acute coronary syndrome was treated with intravenous heparin anticoagulation and dual anti-platelet therapy with aspirin and clopidogrel. This resulted in frank hematuria. Computed tomography (CT) scan revealed a large 8 cm bladder mass with proximal left hydroureteronephrosis, small external iliac chain lymph nodes, and retroperitoneal lymph nodes. Dual anti-platelet therapy and heparinization were discontinued. A bladder tumor biopsy obtained at transurethral resection of bladder tumor revealed a high-grade muscle invasive urothelial cell carcinoma. Due to poor renal function, he was not a candidate for chemotherapy, and external beam radiotherapy was deemed to be a suboptimal approach compared to cystectomy.