Perioperative ST-elevation myocardial infarction: with time of the essence, is there a case for guidelines?

Intraoperative Myocardial Infarction During Elective Laparoscopic Cholecystectomy: A Case Report

Laparoscopic cholecystectomy has become the gold standard for treating symptomatic cholelithiasis due to its minimally invasive nature and faster recovery times compared to traditional open surgery, but it is not without risks. A key component of this procedure is the creation of pneumoperitoneum. This is achieved by insufflating the abdomen with carbon dioxide (CO2). This process causes an increased intra-abdominal pressure (IAP), reduced venous return, and disrupted myocardial oxygen supply and demand. These changes may predispose vulnerable patients to acute cardiac events, particularly those with underlying cardiovascular risk factors. We present a case study of an intraoperative myocardial infarction (MI) that occurred during an elective laparoscopic cholecystectomy. During the procedure, the patient exhibited acute haemodynamic instability (bradycardia and hypotension). Electrocardiographic findings and cardiac biomarkers later confirmed the diagnosis. Immediate intraoperative interventions, including stabilisation of haemodynamics and removal of pneumoperitoneum. Postoperative recovery was monitored in the intensive care unit (ICU), with subsequent investigations identifying pre-existing but previously undiagnosed coronary artery disease as a contributing factor. This case highlights the importance of thorough preoperative cardiovascular evaluation, particularly in patients with risk factors for coronary artery disease, even for procedures considered minimally invasive. It also stresses the potential role of pneumoperitoneum in precipitating acute cardiac events due to its significant haemodynamic impact. Timely intraoperative management, combined with prompt access to cardiology expertise, evaluation, and invasive interventions, is essential for optimising patient outcomes in such cases.

Critical values of monitoring indexes for perioperative major adverse cardiac events in elderly patients with biliary diseases

BACKGROUND

Major adverse cardiac events (MACE) in elderly patients with biliary diseases are the main cause of perioperative accidental death, but no widely recognized quantitative monitoring index of perioperative cardiac function so far.

AIM

To investigate the critical values of monitoring indexes for perioperative MACE in elderly patients with biliary diseases.

METHODS

The clinical data of 208 elderly patients with biliary diseases in our hospital from May 2016 to April 2021 were retrospectively analysed. According to whether MACE occurred during the perioperative period, they were divided into the MACE group and the non-MACE group.

RESULTS

In the MACE compared with the non-MACE group, postoperative complications, mortality, hospital stay, high sensitivity troponin-I (Hs-TnI), creatine kinase isoenzyme (CK-MB), myoglobin (MYO), B-type natriuretic peptide (BNP), and D-dimer (D-D) levels were significantly increased (P < 0.05). Multivariate logistic regression showed that postoperative BNP and D-D were independent risk factors for perioperative MACE, and their cut-off values in the receiver operating characteristic (ROC) curve were 382.65 pg/mL and 0.965 mg/L, respectively.

CONCLUSION

The postoperative BNP and D-D were independent risk factors for perioperative MACE, with the critical values of 382.65 pg/mL and 0.965 mg/L respectively. Consequently, timely monitoring and effective maintenance of perioperative cardiac function stability are of great clinical significance to further improve the perioperative safety of elderly patients with biliary diseases.