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Inferolateral ST-segment Elevation in Boerhaave Syndrome
CLINICAL COMMUNICATION TO THE EDITOR
Inferolateral ST Segment Elevation in Boerhaave Syndrome To the Editor: Contamination of the sterile mediastinum can result in localized ST segment elevation that mimics myocardial injury. The specific pattern of mimicry depends on the etiology. In this report, we describe ST segment elevation in Boerhaave syndrome that is dissimilar to previously reported patterns.
CASE We present the case of a 75-year-old man who underwent emergent thoracotomy and primary repair of a distal esophageal perforation associated with pneumomediastinum, left pneumothorax, and left pleural effusion (Figure A). He tolerated the procedure well and lost 50 cc of blood, but remained intubated postoperatively for hypoxia, and required a low dose of norepinephrine for hypotension resistant to fluid correction. On the first postoperative day, the patient developed ST-segment elevation (STE) in the inferolateral leads that was not present preoperatively (Figure B). His medical history included type II diabetes mellitus and chronic obstructive pulmonary disease but no cardiac events. Vital signs were stable, and S1 and S2 sounds were normal, with regular rhythm and rate. A friction rub was not appreciated. Three sets of troponin were negative. Serial electrocardiograms (ECGs) showed no evolutionary changes. Transthoracic echocardiography showed mildly decreased left ventricular ejection fraction of 45%-50% without regional wall motion abnormalities and no pericardial effusion. On the second postoperative day, the STE resolved.
DISCUSSION We describe a case of postoperative STE mimicking that of myocardial injury. Patients with postoperative STE myocardial infarction are at a high risk for death, so prompt diagnosis followed by reperfusion therapy such as thrombolytics
Funding: None. Conflict of Interest: We declare no conflicts of interest. Authorship: Both authors had access to the data and a role in writing the manuscript. Requests for reprints should be addressed to Cynthia C. Taub, MD, Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, 1825 Eastchester Road, Bronx, NY 10461. E-mail address: ctaub@montefiore.org
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Figure Preoperative thoracic computed tomography (CT) scan without contrast and pre- and postoperative electrocardiograms (ECGs). (A) Preoperative thoracic CT without contrast showing pneumomediastinum, left pneumothorax, and food content in the left pleura (black arrow). (B) Baseline preoperative (top) and postoperative (bottom) ECGs showing ST-segment elevation in leads I, II and aVL (black arrows).
or cardiac catheterization with revascularization as well as antiplatelet therapy is required.1,2 However, in patients who had STE on ECG with no myocardial injury, these treatments may result in life-threatening bleeding complications. Our patient had several potential inflammatory and noninflammatory complications of Boerhaave syndrome that could affect repolarization of the myocardium. In a study of 28 cases of aseptic pneumomediastinum, 5 patients were found to have an STE and only one had myocardial injury. However, unlike in our patient, their STEs occurred in precordial leads with reciprocal T-wave inversions.3 In another case study, postoperative STE occurred in a patient with residual pneumoesophagus that resolved after the patient coughed a large amount of air through the drainage tube. However, the STE was in precordial leads with reciprocal ST depression, and the pattern changed with respiration.4 In pericarditis, diffuse ST- and PR-segment changes normalize within the first week. However, in a minority of patients without cardiac injury, localized STE, like that observed in our patient, occurs before normalization.5
e2
The American Journal of Medicine, Vol -, No -,
Figure
In summary, our patient had a postoperative STE on ECG that did not represent myocardial injury with spontaneous resolution within a day. Clinical history and examination, laboratory studies such as cardiac markers, and echocardiography may play important roles in clinical decision-making. Adi Shemesh, MS Cynthia C. Taub, MD Division of Cardiology Montefiore Medical Center Albert Einstein College of Medicine Bronx, NY
http://dx.doi.org/10.1016/j.amjmed.2015.09.026
-
2015
(Continued).
References 1. Devereaux P, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154(8): 523-528. 2. Group PS. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839-1847. 3. Munsell WP. Pneumomediastinum: a report of 28 cases and review of the literature. JAMA. 1967;202(8):689-693. 4. Kamimura M, Murata K, Ohtake K, Kubota T. Marked ST-T electrocardiographic changes after retrosternal reconstruction of the esophagus. Anesth Analg. 1995;81(2):411-413. 5. Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042-1046.
Inferolateral ST Segment Elevation in Boerhaave Syndrome To the Editor: Contamination of the sterile mediastinum can result in localized ST segment elevation that mimics myocardial injury. The specific pattern of mimicry depends on the etiology. In this report, we describe ST segment elevation in Boerhaave syndrome that is dissimilar to previously reported patterns.
CASE We present the case of a 75-year-old man who underwent emergent thoracotomy and primary repair of a distal esophageal perforation associated with pneumomediastinum, left pneumothorax, and left pleural effusion (Figure A). He tolerated the procedure well and lost 50 cc of blood, but remained intubated postoperatively for hypoxia, and required a low dose of norepinephrine for hypotension resistant to fluid correction. On the first postoperative day, the patient developed ST-segment elevation (STE) in the inferolateral leads that was not present preoperatively (Figure B). His medical history included type II diabetes mellitus and chronic obstructive pulmonary disease but no cardiac events. Vital signs were stable, and S1 and S2 sounds were normal, with regular rhythm and rate. A friction rub was not appreciated. Three sets of troponin were negative. Serial electrocardiograms (ECGs) showed no evolutionary changes. Transthoracic echocardiography showed mildly decreased left ventricular ejection fraction of 45%-50% without regional wall motion abnormalities and no pericardial effusion. On the second postoperative day, the STE resolved.
DISCUSSION We describe a case of postoperative STE mimicking that of myocardial injury. Patients with postoperative STE myocardial infarction are at a high risk for death, so prompt diagnosis followed by reperfusion therapy such as thrombolytics
Funding: None. Conflict of Interest: We declare no conflicts of interest. Authorship: Both authors had access to the data and a role in writing the manuscript. Requests for reprints should be addressed to Cynthia C. Taub, MD, Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, 1825 Eastchester Road, Bronx, NY 10461. E-mail address: ctaub@montefiore.org
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Figure Preoperative thoracic computed tomography (CT) scan without contrast and pre- and postoperative electrocardiograms (ECGs). (A) Preoperative thoracic CT without contrast showing pneumomediastinum, left pneumothorax, and food content in the left pleura (black arrow). (B) Baseline preoperative (top) and postoperative (bottom) ECGs showing ST-segment elevation in leads I, II and aVL (black arrows).
or cardiac catheterization with revascularization as well as antiplatelet therapy is required.1,2 However, in patients who had STE on ECG with no myocardial injury, these treatments may result in life-threatening bleeding complications. Our patient had several potential inflammatory and noninflammatory complications of Boerhaave syndrome that could affect repolarization of the myocardium. In a study of 28 cases of aseptic pneumomediastinum, 5 patients were found to have an STE and only one had myocardial injury. However, unlike in our patient, their STEs occurred in precordial leads with reciprocal T-wave inversions.3 In another case study, postoperative STE occurred in a patient with residual pneumoesophagus that resolved after the patient coughed a large amount of air through the drainage tube. However, the STE was in precordial leads with reciprocal ST depression, and the pattern changed with respiration.4 In pericarditis, diffuse ST- and PR-segment changes normalize within the first week. However, in a minority of patients without cardiac injury, localized STE, like that observed in our patient, occurs before normalization.5
e2
The American Journal of Medicine, Vol -, No -,
Figure
In summary, our patient had a postoperative STE on ECG that did not represent myocardial injury with spontaneous resolution within a day. Clinical history and examination, laboratory studies such as cardiac markers, and echocardiography may play important roles in clinical decision-making. Adi Shemesh, MS Cynthia C. Taub, MD Division of Cardiology Montefiore Medical Center Albert Einstein College of Medicine Bronx, NY
http://dx.doi.org/10.1016/j.amjmed.2015.09.026
-
2015
(Continued).
References 1. Devereaux P, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154(8): 523-528. 2. Group PS. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839-1847. 3. Munsell WP. Pneumomediastinum: a report of 28 cases and review of the literature. JAMA. 1967;202(8):689-693. 4. Kamimura M, Murata K, Ohtake K, Kubota T. Marked ST-T electrocardiographic changes after retrosternal reconstruction of the esophagus. Anesth Analg. 1995;81(2):411-413. 5. Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol. 2004;43(6):1042-1046.