Severe cardiac complications of extended pleurectomy and decortication: a case report

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Introduction Extended pleurectomy and decortication is a specialised procedure performed typically in elderly patients with comorbidities (1). The nature of surgery presents significant physiological stress to the cardiovascular system. Here we report an an unexplained complication of EPD that occurred in our operating theatre. Methods A 70 year-old underwent an EPD for mesothelioma, following neoadjuvant chemotherapy. He was an ex-smoker with moderate chronic obstructive airways disease, hypertensive and hyperlipidemic, and a normal preoperative electrocardiogram and echocardiogram. He had an uneventful induction of anaesthesia and the airway was secured with 41 French left double lumen tube, and maintained with desflurane and intermittent boluses of 0.25% levobupivacaine through a thoracic epidural (T4/T5 space). Routine and invasive arterial and central venous pressure monitoring were used. Surgery was uneventful with a blood loss of 250 mls and minimal dysrrhythmias during pericardectomy. At the closure of thoracotomy, sudden marked ST elevation noted was on the five-lead ECG and posterolateral ischaemic changes on a 12-lead recording (see figure 1A), associated with hypotension requiring boluses of adrenaline. No obvious precipitating event was noted. An adrenaline infusion of 0.15microg/kg/min was started to provide cardiovascular stability. Results Once transferred for angiography, the ST segments had normalized (figure 1B) and his adrenaline requirements dropped. A stable plaque in the left anterior descending artery with no flow limitation was detected. A transoesophageal echocardiogram was normal. The patient was extubated the following day on the ICU. A troponin rise (table) and persistent T wave changes (figure 1C) were detected. Discussion Intra-operative dysrhythmias are not uncommon during EPD whilst the pericardium is manipulated but rarely seen at the end of surgery (1-3), but sudden unexplained ST elevation has not to our knowledge previously been reported. Multiple breeches to the visceral pleura occur during surgery, and we speculate a small gas embolus to a coronary artery or sudden hypotension-related myocardial oxygen supply-demand mismatch may explain the severe but transient clinical and electrocardiographic findings and type two myocardial infarction, given the normal coronary angiography and post-operative echocardiography.