同步體外震波碎石術及其對心臟的影響:手術期中發生ST段上升型心肌梗塞的病例報告

李一宏、林益聖、歐宴泉、許兆畬、童敏哲

童綜合醫院外科部泌尿科

Synchronized Extracorporeal Shockwave Lithotripsy and Its Cardiac Implications: A Case Report on Perioperative ST-Segment Elevation Myocardial Infarction

Yi Hong Li, Yi Sheng Lin, Yen Chuan Ou, Chao Yu Hsu, Min Che Tung

Division of Urology, Department of Surgery,

Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan

Introduction:

Extracorporeal shockwave lithotripsy (ESWL) is a leading non-invasive treatment for kidney and ureteral stones, valued for its outpatient procedure capability. However, even with its wide acceptance, the potential for significant complications, including cardiovascular events, necessitates careful patient selection and monitoring.

Case presentation:

A 45-year-old male with a medical history notable for recurrent kidney stones, type 2 diabetes, and controlled hypertension underwent ESWL for a right renal stone sized 10 mm × 6 mm. Despite being asymptomatic of coronary artery disease (CAD) and maintaining a relatively active lifestyle, his diabetes was suboptimally controlled (last HbA1c 8.9%), and he exhibited dyslipidemia.

During the ESWL procedure, performed under mild sedation, he experienced escalating right flank pain transitioning into acute chest discomfort. Initial vital signs were within normal limits, but the pain's progression prompted an EKG, which revealed ST-segment elevation indicative of an anterior wall myocardial infarction. Emergency coronary angiography identified critical stenosis in the LAD artery, necessitating immediate stenting. Post-procedure, the patient’s recovery was uneventful, with improvements in cardiac markers and discharge on the fourth day with a comprehensive cardiovascular and diabetes management plan.

Discussion:

The presented case highlights the intricate balance between the benefits of ESWL and its potential risks, particularly in patients with pre-existing metabolic syndromes such as diabetes and dyslipidemia. Several key insights emerge from this incident:

1. Preoperative Cardiovascular Screening: The occurrence of STEMI underscores the necessity for rigorous cardiovascular risk assessment prior to ESWL, especially in patients with metabolic syndrome. A thorough preoperative evaluation might identify individuals at elevated risk for adverse cardiac events, enabling preventative strategies or alternative treatment considerations.
2. Mechanism of Cardiac Injury: The direct or indirect mechanisms through which ESWL may precipitate myocardial injury warrant further investigation. While the procedure is designed to minimize direct tissue damage, the physiological stress of the procedure or the shockwaves themselves could potentially disrupt vulnerable plaque or induce cardiac arrhythmias in susceptible individuals.
3. Interplay Between Urolithiasis and Metabolic Syndrome: This case further illuminates the complex relationship between urolithiasis, metabolic syndrome, and cardiovascular risk. Understanding this connection is crucial for developing comprehensive treatment strategies that address both the urological condition and the patient's broader metabolic health.
4. Intraoperative Monitoring and Management: Enhanced intraoperative monitoring, including more sophisticated cardiac monitoring for patients at risk, may facilitate the early detection of adverse events. Additionally, optimizing control of metabolic conditions pre-procedure and considering the patient's overall cardiovascular risk profile could mitigate potential complications.

Conclusion:

This case report of a patient experiencing STEMI during ESWL treatment serves as a potent reminder of the cardiovascular risks associated with this otherwise low-risk procedure. It underscores the importance of a thorough preoperative evaluation, careful patient selection, and the need for heightened intraoperative monitoring. Future guidelines on ESWL may benefit from incorporating considerations for patients with metabolic syndrome, to enhance patient safety and treatment outcomes. Through a multidisciplinary approach, healthcare providers can better manage the risks associated with ESWL, ensuring a safer procedural course for patients with complex medical backgrounds.