Case Report

Postoperative ST‑segment Elevation: Not a Blocked Coronary

Artery, Then What?
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Wai‑Ching Sin1, Joy Melody Kwong1, Tiffany Cho‑Lam Wong1, Charlotte Kwong2, Carmen Chan3, Chung‑Wah Siu3
1
Departments of Adult Intensive Care Unit and 2Radiology, Queen Mary Hospital, 3Department of Medicine, Division of Cardiology, Li Ka Shing Faculty of Medicine,
The University of Hong Kong, Hong Kong, China

Abstract
ST‑segment elevation is well known for its diagnostic value for transmural myocardial infarction due to acute thrombotic occlusion of a
coronary artery and often requires emergency reperfusion therapy. However, ST‑segment is by no means pathognomonic for acute coronary
events. Here, we report a case of ST‑segment elevation after hepatectomy secondary to an unusual etiology.

Keywords: ST‑segment elevation, pneumomediastinum, pneumopericardium

Case Report The ST‑segment elevations resolved completely 5 days later

[Figure 1]. Repeated chest radiograph on day 7 showed no
A 22‑year‑old healthy man was transferred postoperatively
residual pneumomediastinum or pneumopericardium. The
to our Intensive Care Unit following elective hepatectomy of
patient was discharged 8 days after the operation.
the left and caudate lobes for live‑donor, liver transplantation.
The procedure was uneventful. On arrival, he had been
extubated and blood pressure was 98/62 mmHg and pulse Discussion
rate was 86 bpm. No inotropic support was required, and ST‑segment elevation is well known for its diagnostic value
routine electrocardiogram 8 h later revealed sinus rhythm at for transmural myocardial infarction due to acute thrombotic
a rate of 65 bpm. Nonetheless, there were new widespread occlusion of a coronary artery and often requires emergency
ST‑segment elevations over the inferior leads (II, III, and aVF) reperfusion therapy. Nonetheless, ST‑segment elevation is by
and anterolateral precordial leads (V2–V6) [Figure 1]. no means pathognomonic for ST‑segment elevation myocardial
infarction (STEMI); nonischemic ST‑segment elevation
PR‑segment depression was also noted over leads II, III, and
may be observed in a number of clinical conditions such as
aVF. He was asymptomatic and hemodynamically stable.
pericarditis [Table 1]. In our case, the diffuse ST‑segment
Echocardiogram showed normal systolic function with a left
elevations that involved multiple coronary territories, the
ventricular ejection fraction of 65%. There was no pericardial
normal left ventricular ejection fraction on echocardiography,
effusion or any regional wall motion abnormality. An initial
together with the disproportionally low troponin level favored
troponin I level of 0.03 ng/ml (normal range: <0.04 ng/ml)
an alternative diagnosis to STEMI. The clinical presentation
subsequently rose to 1.59 ng/ml. Chest radiograph in the
was consistent with that of pericarditis, but the short time
anteroposterior projection [Figure 2] revealed a radiolucent
period since surgery and the lack of pericardial effusion on
line at the left heart border. Computed tomography coronary
echocardiogram also made pericarditis an unlikely diagnosis.
angiogram was performed but showed no evidence of coronary
Albeit rare, pneumomediastinum and pneumopericardium
artery disease or pericardial effusion. Nonetheless, the presence
of air was confirmed in the mediastinal as well as the pericardial
Address for correspondence: Prof. Chung‑Wah Siu,
space [Figure 3]. The patient remained asymptomatic and Department of Medicine, The University of Hong Kong, Hong Kong, China.
hemodynamically stable; he was treated conservatively. E‑mail: [email protected]

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DOI: How to cite this article: Sin WC, Kwong JM, Wong TC, Kwong C, Chan C,
10.4103/2470-7511.248349 Siu CW. Postoperative ST-segment elevation: Not a blocked coronary artery,
then what? Cardiol Plus 2016;1:42-3.

42 © 2016 Cardiology Plus | Published by Wolters Kluwer - Medknow

 Sin, et al.: Postoperative ST‑segment elevation
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Figure 2: Chest radiograph (arrows indicate a radiolucency behind the

heart)

Table 1: Causes of ST‑segment elevation

Sites Causes
Myocardium ST‑segment elevation myocardial infarction
Takotsubo cardiomyopathy
Left ventricular hypertrophy
Chronic left ventricular aneurysm
Conductive Left bundle branch block
b system Early repolarization
Figure 1: Twelve‑lead electrocardiogram on day 1 (a) and day 5 (b) Pericardium Acute pericarditis
Pneumopericardium
Systemic causes Electrolyte disturbances: Hyperkalemia and
hypercalcemia

patient consent forms. In the form the patient(s) has/have

given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
a b and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Figure 3: Computed tomography of the thorax: (a) Coronal view and (b)
Sagittal view (arrows indicate air within mediastinum and pericardial Financial support and sponsorship
space) Nil.

have occasionally been reported due to blunt chest trauma, Conflicts of interest
barotrauma from mechanical ventilation, and laparoscopic There are no conflicts of interest.
procedures or other surgical procedures that breech the
integrity of the diaphragm.[1‑4] Review of our patient’s operative References
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throughout the operation, and the diaphragm had not been considered with electrocardiogram changes after blunt chest trauma:
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pneumopericardium could not be determined in our patient. A delayed case of tension pneumopericardium after total gastrectomy.
Nonetheless, this case demonstrates that these two uncommon J Clin Anesth 2014;26:58‑61.
3. Brearley WD Jr., Taylor L 3rd, Haley MW, Littmann L.
conditions may underlie postoperative ST‑segment elevation. Pneumomediastinum mimicking acute ST‑segment elevation myocardial
infarction. Int J Cardiol 2007;117:e73‑5.
Declaration of patient consent 4. Ko ML. Pneumopericardium and severe subcutaneous emphysema after
The authors certify that they have obtained all appropriate laparoscopic surgery. J Minim Invasive Gynecol 2010;17:531‑3.

Cardiology Plus ¦ Volume 1 ¦ Issue 1 ¦ January-March 2016 43