Wang Zilong, Yuan Huisheng, Chu Junhao, Duan Shishuai, Zhang Zhihui, Song Changze, Wang Muwen
Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China.
Department of Urology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
Front Pharmacol. 2025 Jan 3;15:1477715. doi: 10.3389/fphar.2024.1477715. eCollection 2024.
Radical cystectomy constitutes the standard therapeutic approach for high-risk urothelial carcinomas of the bladder. Contemporary guidelines advise urologists to discontinue anticoagulation therapy during the perioperative period to mitigate the risk of significant intraoperative or postoperative hemorrhage. Nevertheless, in elderly patients with a history of coronary artery disease, the cessation of anticoagulant medication elevates the risk of acute myocardial infarction, thereby posing a substantial threat to their survival. Therefore, the necessity and optimal strategy for anticoagulation therapy in patients with acute myocardial infarction following radical cystectomy remains a subject of ongoing debate. This study aims to contribute clinical insights for clinicians to manage high-risk patients with acute myocardial infarction post-major surgery.
The 64-year-old male patient was admitted for multiple high-grade urothelial carcinomas of the bladder. The preoperative computed tomography angiography revealed intra-luminal stenosis of the coronary arteries. However, the patient declined further assessment via preoperative coronary angiography, thereby precluding the accurate prediction of postoperative myocardial infarction risk. The patient subsequently underwent laparoscopic radical cystectomy with Bricker conduit urinary diversion and the postoperative pathological examination confirmed the diagnosis of high-grade urothelial carcinoma (T1N0M0, G3). Regrettably, on the first postoperative day, the patient experienced an acute anterior wall ST-segment elevation myocardial infarction. Consequently, the patient underwent emergency percutaneous coronary intervention and was administered dual antiplatelet therapy consisting of aspirin and ticagrelor. The daily pelvic fluid drainage, routine blood and coagulation parameters remained within normal ranges. Following the second percutaneous coronary intervention and dual antiplatelet therapy, the patient was discharged after 2 days. Over a 3-year follow-up period, all hematological parameters consistently remained within normal ranges, and there were no incidents of bleeding or anastomotic leakage.
This study demonstrates that postoperative percutaneous coronary intervention, in conjunction with continued dual antiplatelet therapy, is a safe and effective antithrombotic strategy for managing perioperative acute myocardial infarction. This finding suggests a potential paradigm shift in the management of antithrombotic therapy for high-risk surgical patients, advocating for a tailored approach rather than the routine discontinuation of such therapy.
根治性膀胱切除术是高危膀胱尿路上皮癌的标准治疗方法。当代指南建议泌尿外科医生在围手术期停止抗凝治疗，以降低术中或术后大出血的风险。然而，对于有冠状动脉疾病史的老年患者，停用抗凝药物会增加急性心肌梗死的风险，从而对其生存构成重大威胁。因此，根治性膀胱切除术后急性心肌梗死患者抗凝治疗的必要性和最佳策略仍是一个持续争论的话题。本研究旨在为临床医生管理重大手术后高危急性心肌梗死患者提供临床见解。
一名64岁男性患者因多发性高级别膀胱尿路上皮癌入院。术前计算机断层扫描血管造影显示冠状动脉腔内狭窄。然而，患者拒绝通过术前冠状动脉造影进行进一步评估，从而无法准确预测术后心肌梗死风险。患者随后接受了腹腔镜根治性膀胱切除术及Bricker回肠膀胱术，术后病理检查确诊为高级别尿路上皮癌（T1N0M0，G3）。遗憾的是，术后第一天，患者发生急性前壁ST段抬高型心肌梗死。因此，患者接受了紧急经皮冠状动脉介入治疗，并给予阿司匹林和替格瑞洛组成的双联抗血小板治疗。每日盆腔引流量、血常规和凝血参数均保持在正常范围内。在第二次经皮冠状动脉介入治疗和双联抗血小板治疗后，患者于2天后出院。在3年的随访期内，所有血液学参数一直保持在正常范围内，未发生出血或吻合口漏事件。
本研究表明，术后经皮冠状动脉介入治疗联合持续双联抗血小板治疗是管理围手术期急性心肌梗死的一种安全有效的抗栓策略。这一发现提示高危手术患者抗栓治疗管理可能发生范式转变，主张采用个体化方法而非常规停用此类治疗。
