An Unusual Complication During Bronchoscopy: Hypotension, Global ST Segment Elevation, and Acute Severe Left Ventricular Systolic Dysfunction

Abstract

Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice.

Transcutaneous carbon dioxide monitoring during flexible bronchoscopy under sedation: A prospective observational study

“…Most of the patients undergoing bronchoscopy are elderly, which increases the likelihood of cardiac arrest due to arrhythmias or cardiac ischemia during bronchoscopy [12]. The heart has rich innervation from the parasympathetic and sympathetic limbs of the autonomic nervous system, and autonomic nervous imbalance is believed to be a crucial factor in these cardiac events [13]. A bronchoscopy can trigger spasms and plaque disruption in the coronary arteries due to an increase in sympathetic activity caused by tension and anxiety.…”

Systemic arterial gas embolism (SAGE) as a complication of bronchoscopic lung biopsy: a case report and systematic literature review

“…Our case demonstrated inferior ST segment elevations, bradycardia and AV nodal blockade, and similar findings had a high frequency in our review of published cases with cardiac involvement-all consistent with preferential right coronary artery involvement in the supine position. Acute right ventricular failure from proximal right coronary artery (RCA) occlusion could also explain the cases of complete cardiovascular collapse noted in this series (6,18,19,22,31), compounding neurologic injury from direct cerebral gas embolism (with which it is often concurrent).…”

“…After removing duplicates, 24 case reports (5-28) and 2 case series (each containing two individual case reports) (29,30) of patients who presented with SAGE after bronchoscopic biopsy procedures were identified. The search revealed two reports of idiopathic complications during bronchoscopic procedures (31,32) under clinical circumstances so remarkably similar to the presentation of SAGE that we included these in our review, for a total of 30 unique patient reports. The clinical circumstances from one case, presented at a national meeting, could not be obtained (25), and another case report was excluded due to the high likelihood that the cerebral gas embolism had occurred due to central line manipulation rather than bronchoscopy, leading to venous air embolism (26).…”

“…There appears to be greater awareness regarding the risk of SAGE during ablative airway procedures (2). Multiple case reports did not acutely consider SAGE as a possible etiology despite acute cardiac and neurologic complications consistent with this diagnosis (31,32). Amongst other published case series, fewer than half of the known case reports published at the time were included (19), and few discussed the possibility of coronary emboli despite acute cardiogenic manifestations.…”

Takotsubo Cardiomyopathy and Subsequent Seizures Induced by Flexible Bronchoscopy

“…Only a few similar cases have been reported. [9][10][11][12] In this case, takotsubo cardiomyopathy occurred due to physical stress from a bronchoscopic examination. A temporary lack of oxygen in her brain due to cardiogenic shock caused by the takotsubo cardiomyopathy is thought to have caused the seizures.…”