RevBrasAnestesiol.2015;65(5):403---406
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
ST-segment
elevation
during
general
anesthesia
for
non-cardiac
surgery:
a
case
of
takotsubo
Leticia
Bôa-Hora
Rodrigues
∗,
Ana
Batista,
Fátima
Monteiro,
João
Silva
Duarte
Servic¸odeAnestesiologia,CentroHospitalardeSetúbal,HospitaldeSãoBernardo,Setúbal,Portugal
Received29September2014;accepted28November2014 Availableonline17August2015
KEYWORDS Takotsubo; Acutecoronary syndrome;
Generalanesthesia; Angina;
Acutemyocardial infarction; Cardiogenicshock
Abstract
Backgroundandobjectives: Takotsubocardiomyopathy,alsoknownasbrokenheartsyndrome isastress-inducedcardiomyopathy,whichcanbeinterpretedasanacutecoronarysyndrome asitprogresses withsuggestiveelectrocardiographicchanges.The purposeofthisarticle is to showtheimportance ofproper monitoringduringsurgery,aswellasthepresence ofan interdisciplinaryteamtodiagnosethesyndrome.
Casereport: Malepatient,66yearsold,withdiagnosisofgastriccarcinoma,scheduledfor diag-nosticlaparoscopyandpossiblegastrectomy.Intheintraoperativeperiodduringlaparoscopy, thepatientalwaysremainedhemodynamicallystable,butafterconversiontoopensurgeryhe presentedwithSTsegmentelevationinDII.ECGduringsurgerywasperformedandconfirmed ST-segmentelevationintheinferiorwall.Thecardiologyteamwas contactedandindicated theemergencycatheterization.Asthesurgeryhadnotyetbegunirreversiblesteps,weopted forthelaparotomyclosure,andthepatientwasimmediatelytakentothehemodynamicroom wherecatheterizationwasperformedshowingnocoronaryinjury.Thepatientwastakentothe hospitalroomwhereanechocardiogramwasperformedandshowedslighttomoderatesystolic dysfunction,withakinesiaofthemid-apicalsegments,suggestiveofapicalballooningofthe leftventricle.Facedwithsuchechocardiographicfindingandintheabsenceofcoronaryinjury, thepatientwasdiagnosedwithintraoperativeTakotsubosyndrome.
Conclusion: Becausethepatient wasproperlymonitored,theearlydetectionofST-segment elevationwaspossible.Thepresenceofaninterdisciplinaryteamfavoredthesyndromeearly diagnosis,sothepatientwasagainsubmittedtosafelyintervention,withthenecessarysecurity measurestakenforanuneventfulnewsurgicalintervention.
© 2015SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
∗Correspondingauthor.
E-mail:lboahora@yahoo.com(L.B.H.Rodrigues).
http://dx.doi.org/10.1016/j.bjane.2014.11.005
404 L.B.H.Rodriguesetal.
PALAVRAS-CHAVE Takotsubo;
Síndromecoronária aguda;
Anestesiageral; Angina;
Infartoagudodo miocárdio;
Choquecardiogênico
SupradesnivelamentodosegmentoSTduranteanestesiageralparacirurgianão
cardíaca:umcasodetakotsubo
Resumo
Justificativaeobjetivos: Acardiomiopatia detakotsubo,tambémconhecidacomo síndrome docorac¸ãopartido, éuma cardiomiopatia induzida porestresse quepode serinterpretada comoumasíndromecoronáriaaguda,poiscursacomalterac¸õeseletrocardiográficas sugesti-vas.Oobjetivodopresenteartigoémostraraimportânciadeumamonitorac¸ãoadequadano intraoperatório,assimcomoapresenc¸adeumaequipeinterdisciplinarparaodiagnósticoda síndrome.
Relatodecaso:Doentemasculino,66anos,comodiagnósticodecarcinomagástrico,proposto para laparoscopiadiagnóstica epossívelgastrectomia.Nointraoperatório durantea laparo-scopia manteve sempre estabilidadehemodinâmica, porém após aconversão para cirurgia abertaapresentouelevac¸ãodosegmentoSTemDIIefoifeitoumECGnointraoperatórioque confirmousupradesnivelamentodosegmentoSTemparedeinferior.Foicontactadaaequipe decardiologia,queindicoucateterismodeurgência.Comoacirurgiaaindanãohaviainiciado passosirreversíveis,optou-sepeloencerramentodalaparotomiaeodoentefoilevado imedi-atamenteparaasaladehemodinâmica.Foifeitocateterismoquenão evidencioulesãonas coronárias.Odoentefoilevadoparaointernamento,ondefoifeitoumecocardiogramaque mostravadisfunc¸ãosistólicaligeiraamoderada,comacinésiadossegmentosmédio-apicais, imagemsugestivadebalonamentoapicaldoventrículoesquerdo. Diantedetal achado eco-cardiográfico e na ausência de lesões coronárias, foi diagnosticada síndrome de takotsubo intraoperatória.
Conclusão:Devidoaofatodeodoenteestarmonitoradodeumaformaadequadafoipossível adetecc¸ãoprecocedosupradesnivelamentodosegmentoST.Apresenc¸adeumaequipe inter-disciplinarfavoreceuodiagnósticoprecocedasíndrome.Dessaformaodoentefoinovamente intervencionadodeformaseguraeforamtomadasasdevidasmedidasdeseguranc¸a,paraque anovaintervenc¸ãocirúrgicatranscorressesemintercorrências.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Takotsubosyndrome,alsoknownasbrokenheartsyndrome, is a stress-inducedcardiomyopathy defined asa transient and segmental left ventricular dysfunction or transient apicalballooning withelectrocardiographic (ECG)changes suggestiveofacutecoronarydisease,butwiththeabsence ofobstructivecoronaryarterydisease.1Thissyndrome sim-ulatesacutecoronarysyndrome.2
The pathophysiology of takotsubo cardiomyopathy remains elusive. Many mechanisms have been proposed including myocardial ischemia caused by multivessel epi-cardialspasm,myocardialdysfunctioninducedbyincreased circulating catecholamines, and cardiac ischemia due to changesinthemicrocirculation.
Themostlikelyhypothesisisthatitisconsequenttothe sharp rise in serum catecholamine concentrations, which happensafteramajoremotionalorphysicalstress(Wittstein et al.3,4) and is determined by an abnormal release of catecholamines(norepinephrine)fromCNStocardiac sym-patheticinnervation.Thisreleasewillevolvewithdyskinesia of the left ventricular wall whenever there is a stress-fulsituation.5Clinically,patients maydevelopchest pain, sweating, palpitations, ECG changes suggestive of acute myocardialinfarction.
Itpredominatesinwomen (upto95% ofcases),mainly postmenopausal (mean age between 60 and 80 years). In less than 3%,it occursin patientsyounger than 50years. According tothe AmericanHeartAssociationclassification (2006),6---8itisdefinedasacquiredprimarycardiomyopathy and accounts for about 1---2% of the acute coronary syn-dromecases,withincidencein theUnitedStatesofabout 7000---14,000cases/year.
ItwasfirstdescribedinJapanin1990bySatoetal.,1,9,10 andwasnamed takotsubobecausetheimageproduced by theventriculographyissimilartothecontainerusedtocatch octopus. The description of this syndrome has increased recently,withreportsworldwide.
The diagnosis of takotsubo cardiomyopathy is difficult andwilldepend ondiagnostictestsfor exclusionofacute coronarysyndrome,asitspresentationisverysimilar.Inits classicpresentation,thepatienthasprecordialpain, sweat-ing anddyspnea, followed by ECG simulating astream of myocardialinjury,i.e.,ECGmaydisplayST-segment eleva-tion,orTwaveinversion,or prolongedQTinterval.There maybeaslightelevationofcardiacenzymes,butcoronary angiographyisnormal.
ST-segmentelevationduringgeneralanesthesiafornon-cardiacsurgery 405
movementoftheleftventricleanteriorwall,withstressof kineticsofventricularbase,whichcausesatransientapical ballooning.9
Casedescriptionoftakotsubosyndromeduringsurgeryis rarebecause itis limited toan electrocardiographic find-ing, which may appeartransiently during surgery, and its documentationisdifficult.
Case
report
Male patient, 66 years old, with a history of alcoholism anddiagnosisofgastriccarcinoma,scheduledfordiagnostic laparoscopyandpossiblegastrectomy.
HewasadmittedtotheSurgeryDepartmentwith clini-calfindingsoftwomonthsevolution,withgeneralmalaise, vomiting after meals (only tolerate liquid diet), epigas-tric pain,and 20kgof weightloss. Upper gastrointestinal endoscopy with biopsy revealed peptic esophagitis+ulcer notch+gastricmixed-typecarcinoma.AbdominalCTshowed alargestasiswithcontrastaccumulationanddilutioninto thegastriccavity,withlimitedpassageinthepyloricregion. Itwasdifficulttoseethecontrastbeyondthatregionduring theexaminationtime,andpyloricstenosiswasassumed.
Before surgery, in the pre-anesthetic visit it was documented the presence of pyloric stenosis and nor-mochromicnormocyticanemia(Hb9.7g/dL),hyponatremia (Na124mol/L),andpre-stagerenalfailureintherecovery phase(initialurea(mg/dL171)andcreatinine(mg/dL2.91), whichonthedaybeforewere84.7mg/dLand1.14mg/dL, respectively).PreoperativeECGwasnormalandchestX-ray showednochanges.
Because it was an urgent situation, the patient was scheduled for surgery twodays after hospitalization, and a balanced general anesthesiawasproposed. The patient receivedmetoclopramide20min beforeinductionof anes-thesia.Intheoperatingroom,hewasplacedinthesupine position,andanewperipheralvenousaccesswasachieved withan 18GAbocath,serumtherapywasstartedwith iso-tonicsolution(SF0,%),andthepatientwasmonitoredwith 5-leadcardioscope,pulseoximetry,andnoninvasiveblood pressure.
Intubationwasperformedwiththepatientawake. Pre-viously, midazolam 2mg and droperidol 0.625mg were administered,andsupraglotticanesthesiawasadministered with 10% lidocaine spray. The procedure was unevent-ful. The patient wasintubated with 7.5mm cuffed tube, withouthemodynamicrepercussions.Afterintubation, eto-midate 20mg, fentanyl 100mcg, and atracurium 30mg bolus+infusionat0.3mcg/kg/minwereadministered.
Thesurgicalprocedurewasstarted.AftertheVeress nee-dleintroduction,apneumoperitoneumwasperformedand thediagnosticlaparoscopy started,whichshowedthatthe disease waslocated, and it wasdecided toproceed with totalgastrectomy.Atthattime,acentralvenouscatheter intherightinternaljugular,usingtheSeldingertechnique, uneventfully,andaninvasivearteriallinewereplacedand thelaparotomywasstarted.
In the intraoperative period, after conversion to open surgery (laparotomy), it was noticed the presence of ST-segmentelevationinDII,associatedwithamild hypoten-sion, maintained since the beginning of surgery. The
situationwasreportedtothesurgery teamandwe opted forintraoperativeECG,whichconfirmedthepresenceof ST-segmentelevationintheinferiorwall.Analyzeswithcardiac markersofmyocardialischemiawerealsoperformed.
At that time, the cardiology team was contacted and urgent catheterization was indicated. As the surgery had notyet begunirreversiblesteps,we optedforthe laparo-tomyclosure,andthepatientwasimmediatelytakentothe hemodynamicroom where catheterizationwas performed showingnocoronaryinjury.
The patient was taken to the hospitalroom where an echocardiogramwasperformedandshowedslightto mod-eratesystolicdysfunction,withakinesiaofthe mid-apical segments,suggestive of apicalballooning of the left ven-tricle. Cardiac markers of the first hour were negative, andbeforesuchechocardiographicfinding,withabsenceof coronaryinjury,thepatientwasdiagnosedwith intraopera-tivetakotsubosyndrome.
Discussion
The main purposeof ourcase was toreporta rare intra-operative event, which serves as a momentof reflection becauseitshows thateverythingis not whatit seems;in otherwords,nothingcouldforeseethatapatientwhohadno previouscardiacpathologywoulddevelopanacutecoronary syndromeduringsurgery.ThepresenceofST-segment eleva-tionontheECGcausedtheinterruptionofthesurgery,and thepatientwassubmittedtoanemergencycatheterization. After catheterization, many questions remained to be clarified, because the ST-segment elevation documenta-tionwasnotaccompaniedbycoronaryinjurytojustify its appearance.Prinzmetal’sanginaorintraoperativecoronary spasmtriggeredbysurgicalstresswasinitiallyhypothesized, butaftertheechocardiogramdocumentingtheleft ventricu-larapicalballooning,itbecameclearthatitwastakotsubo syndrome.
Thiswasadifficultdiagnosisbecausethecaseoccurred duringsurgery withthepatient anesthetized; thatis, the onlyclinicalfindingwastheST-segmentelevationand noth-ing could predict the course of events. The diagnosis of takotsubosyndromewasonly possibleduetothe commit-mentof the entire team involved and alsothe important collaborationofthecardiologyteam,whichperformedthe additionalteststhatenabledthediagnosis.
406 L.B.H.Rodriguesetal.
After the acute phase, there is no measure that is definitelybeneficial tothenatural evolution of takotsubo cardiomyopathy.17Becauseitisacardiomyopathytriggered bystress,thetreatmentistheprompteliminationofstress tothe patient.Ifthis is not possible,the end resultmay betheestablishmentofanirreversibleclinicalpicturewith cardiogenicshockanddeath.18
Inthisspecificcase,thestresswasinitiallytriggeredby thesurgicalprocedure(i.e.,iatrogenicandnon-emotional stress),asitiscommonlydescribedforthissyndromeonset, but the physiopathological mechanism ends up being the same--- thereisacatecholaminereleasethatactdirectlyon themyocardialwallandtriggeratransientleftventricular dysfunctionandthe appearanceof the ST-segment eleva-tion.Thisfindingsoondisappearedafterthesurgery,butthe echocardiographicchangesdidnot,whichmadeitpossible todiagnosethesyndrome.
Conclusion
Thiscase serves toshow theneed for the involvementof aninterdisciplinaryteaminthediagnosisoftakotsubo syn-drome.Thepresenceofadequate monitoringandalsothe teamworkenabledthepatienttobesafelysubmittedtoa newsurgicalintervention,and theetiologicaldiagnosis of ST-segmentelevationwasperformed.
Asthedescriptionoftakotsubointraoperativesyndrome israre,andaftersearchinginthedatabasesandonlyfinding afew documented casesin the literature,we decided to submitthiscase tothepublication,asthe documentation ofanothercase may serveasanexample andhelp inthe futuredifferentialdiagnosisofnewcases.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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