Severe cardiac complication as coronary artery spasm during bronchoscopy: a case report

Introduction

Bronchoscopy has been widely used in clinical diagnosis and treatment. Although previous researches showed the morbidity and mortality of bronchoscopy were low, malignant complications especially cardiac complications may lead to poor clinical outcomes (1). We report a patient who suffered a sudden chest pain and dyspnea, ST-segment elevation during the procedure of bronchoscopy. Acute malignant coronary vasospasm was considered based on the symptoms, electrocardiogram (ECG) changes and cardiac biomarker, subsequent coronary angiogram showed normal coronary artery anatomy with no severe coronary stenosis. The patient underwent conservative medical treatment and discharged smoothly. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-43/rc).

Case presentation

A 52-year-old man was admitted to the respiratory department with a complaint of intermittent fever, cough and shortness of breath for 7 months. The patient was previously diagnosed in other hospital as pulmonary abscess mycobacterium infection by next-generation sequencing of bronchoalveolar lavage fluid samples and received a combined anti-nontuberculosis mycobacteria regimen for 6 months. Because the pulmonary lesions had not improved significantly, he transferred to our hospital for treatment. He reported no coronary risk factors such as hypertension, hyperglycaemia, hyperlipidaemia or smoking. Physical examination was unremarkable except that wheeze was found in the right lung. Initial laboratory results showed inflammatory indicators slightly elevated. Enhanced computed tomography showed a solid lesion in the posterior superior lobe of right lung with a little of pleural effusion. The histopathologic examination of pleural fluid showed hyperplasia of mesothelial cells and some heterotrophic cells. For further differential diagnosis such as lymphoma, bronchoscopy was scheduled again. The routine preoperative ECG examination was normal (Figure 1).

Figure 1 The basic electrocardiogram examination before bronchoscopy was normal.

During the whole procedure of bronchoscopy, ECG and oxygen monitoring device were performed routinely and vital signs could be measured incessantly. Usual anesthesia protocol was performed. Lidocaine aerosol inhalation was performed for local anesthesia before bronchoscopy, 0.05 µg fentanyl and 120 mg propofol was administrated for anesthesia induction. Also, oxygen administration was given routinely through a nasal cannula and conventional oxygen flow rate was controlled between 2 to 3 liters per minute. In the beginning, the basic oxygen saturation measured by pulse oximetry (SpO₂) was 99% to 100%, cardiac frequency was 72 beats per minute and blood pressure was 120/75 mmHg. The patient suffered a sudden chest pain and shortness of breath and appeared shock manifestation including diaphoretic and hypotensive. Immediate 12-lead ECG showed ST-segment elevation in leads II, III, augmented limb lead F and V3–V6 (Figure 2). Acute coronary syndrome was considered and the procedure of bronchoscopy was terminated immediately. The blood pressure decreased to 80/50 mmHg. Meanwhile, the parameter of oxygen saturation decreased slightly to 95% and the heart rate was 80 to 90 beats per minute. Fluid infusion and vasopressor therapy were given rapidly. Antiplatelet agents were administered and low-dosage nitroglycerin was also used based on stable blood pressure. After 30 minutes of the urgent treatment, the patient felt better and the chest pain was relived obviously. The instant 12-lead ECG showed the original elevated ST-segment in leads II, III, augmented limb lead F and V3–V6 significantly declined (Figure 3). Emergent coronary angiography suggested by cardiovascular specialist opinion was performed and showed normal coronary artery without any coronary stenosis (Figure 4). The follow-up ECG showed the ST-segment in the inferior leads completely declined to the baseline after 3 hours. Although the cardiac biomarker was normal at the sudden situation, the next-day troponin-I revealed slightly elevated to 0.985 ng/mL. The diagnosis of coronary spasm was considered by the ECG and coronary angiography. He was discharged with treatment for vasospastic acute coronary syndrome with diltiazem. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient and his relevant family member for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 2 Twelve-lead electrocardiogram showed ST-segment elevation in leads II, III, augmented limb lead F and V3–V6.

Figure 3 Elevated ST-segment in leads II, III, augmented limb lead F and V3–V6 significantly declined after emergent medication treatment.

Figure 4 Coronary angiography showed normal coronary artery without any coronary stenosis.

Discussion

Bronchoscopy has become an important diagnosis and treatment method for respiratory diseases in recent years. The complications related to bronchoscopy depends on several factors including patients’ underlying diseases, the situation of the lesions and also the operators’ proficiency and ability of teamwork (1). Previous studies reported the overall complications rate ranged from 1–25%; moreover, the incidence of intraoperative or early was significantly higher than the incidence of late stage (2,3). Non-traumatic complications such as roar spasms, tracheospasm, cardiac arrhythmia, anesthesia-related complication, cerebrovascular accident, despite the incidence of non-traumatic complication is low, it can make serious or even fatal effect on the patient.

Cardiac arrhythmia and myocardial ischemic infarction are the most common cardiac complications, especially in elderly patients with coronary artery disease, hypertension, smoking history, and hypoxemia. Arrhythmias commonly include sinus tachycardia, atrial or ventricular premature contractions, T wave changes, Q-T interval prolongation, or cardiac arrest (4). Jacomelli et al. found that 0.03% of patients could have cardiac arrest during bronchoscopy (5). According to “2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery”, the main complications of non-cardiac surgery in patients with coronary heart disease (CHD) are myocardial ischemia and acute heart function deterioration (6). The imbalance of cardiac oxygen supply and demand, aggravated myocardial ischemia, hemodynamic instability may lead to impaired cardiac function and disabled to meet the body’s needs under stress. The cases of acute myocardial ischemia for patients without CHD during the procedure are even rare, but there are also relevant cases reported (7).

Our patient had sudden chest pain and soon developed to shock symptoms during bronchoscopy. The ECG changes suggested extensive myocardial infarction. Although immediate cardiac biomarkers of myocardial injury showed no abnormalities, it was considered that the time between blood collection and coronary ischemia was too short. The next-day elevated troponin-I still suggested that acute myocardial infarction did occur. According to the rapid relief of patient’s symptoms and the reduction to normal of ST segment, the likelihood of coronary spasm was considered and was also confirmed by emergent coronary angiography.

The mechanism of coronary spasm in our case is mainly analyzed as follows. Firstly, low oxygen and relative airway obstruction during bronchoscopy may lead to the weakening of the inhibitory effect of lung stretch receptors on the sympathetic nervous system. Hypoxia activates central and peripheral sympathetic chemoreceptors, further increasing the secretion of catecholamine and triggering coronary spasm (8). Secondly, preoperative or intraoperative usage of drugs may induce hypersensitivity reactions and lead to coronary spasm. Such kind of situations is clinically defined as Kounis syndrome. Kounis syndrome is described as acute coronary syndrome caused by mast cell and platelet activation following allergic events (9). The syndrome divided into three types: vasospastic allergic angina, allergic myocardial infarction with or without preexisting coronary artery disease and stent thrombosis with occluding thrombus (10). Our patient might be classified as vasospastic allergic angina for normal coronary artery. Moreover, researchers even found some patients with raised cardiac biomarker existed endothelial dysfunction or microvascular angina (11). The preoperative usage of antibiotics and intraoperative usage of narcotic drugs in our case should be considered to induce the allergic reaction. Several cases reported coronary spasm based cardiac events under the administration of propofol (12). However, in our case, routine dosage of narcotic drugs was used and the duration of drug application was short. The direct influence to coronary spasm by narcotic drugs deserves further investigation. Based on the possibility of Kounis syndrome, anaphylactic shock should be paid more attention for the clinical characteristics similar to cardiac shock. Therefore, corticosteroids and antihistamines may be beneficial to the emergency treatment. Thirdly, chronic inflammatory state induces coronary spasm. Our patient had a long-standing lung disease history and focal lesions may make the body exist in a chronic inflammatory state. Inflammatory response can directly cause vascular endothelial dysfunction, resulting in abnormal myocardial contractility, stimulating vascular smooth muscle contraction, and inducing coronary artery spasm (13).

Conclusions

Our case reported the occurrence of acute coronary artery spasm during bronchoscopy in a patient without underlying coronary artery disease. The potential mechanisms include low oxygen, hypersensitivity reactions and chronic inflammatory. Since the incidence is low and rarely recognized, overall assessment preoperative and intraoperative should be focused on especially. Early and appropriate treatment can make good effects on patients and have better clinical outcomes.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-43/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-43/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-43/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient and his relevant family member for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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