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BACKGROUND: Cardiac biomarkers, such as high-sensitivity cardiac troponin (hs-cTn) and brain natriuretic peptide (BNP) or N­terminal prohormone of brain natriuretic peptide (NT-proBNP) are measured perioperatively to improve the prognosis and risk prediction. The European Society of Cardiology (ESC), European Society of Anesthesiology and Intensive Care (ESAIC) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI) have recently published guidelines on the use of cardiac biomarkers prior to surgery. OBJECTIVE/RESEARCH QUESTION: This article provides an overview of the available evidence on perioperative troponin and BNP/NT-proBNP measurements. Current guideline recommendations are presented and discussed. MATERIAL AND METHODS: MEDLINE, Cochrane and google.scholar were searched for relevant keywords. Titles and abstracts of identified papers were checked for relevance and published results were summarized. Guideline recommendations from the ESC, ESAIC and DGAI are presented, compared and evaluated based on the available literature. In addition, the significance of new perioperative cardiac biomarkers is discussed based on the existing evidence. RESULTS: The definitions, diagnosis and management of cardiovascular events in the perioperative context differ from those in the nonsurgical setting. The evidence for the measurement of hs-cTn and BNP/NT-proBNP is evaluated differently in the guidelines and the resulting recommendations are partly contradictory. In particular, recommendations for changes in perioperative management based on biomarker measurements diverge. The ESC guidelines propose an algorithm that uses preoperative biomarkers as the basis for additional cardiac investigations. In particular, invasive coronary angiography is recommended for patients with stable chronic coronary syndrome who have no preoperative cardiac symptoms but elevated biomarkers. In contrast, the ESAIC guidelines emphasize that the available evidence is not sufficient to use perioperative biomarker measurements as a basis for a change in perioperative management. DISCUSSION: Treating physicians should coordinate interdisciplinary (surgery, anesthesiology, cardiology) recommendations for clinical practice based on the aforementioned guidelines. If cardiac biomarkers are routinely determined in high-risk patients, this should be done in accordance with the ESC algorithm.

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Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.

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INTRODUCTION: Perioperative myocardial infarction (PMI) after CABG can contribute to in-hospital morbidity and mortality, however, its clinical significance on long-term outcome, remains inadequately addressed. We studied both 30-day mortality and long-term effects of PMI in Icelandic CABG-patients. MATERIALS AND METHODS: A retrospective nationwide-study on 1446 consecutive CABG-patients operated at Landspitali in Iceland 2002-2018 without evidence of preoperative myocardial infarction. PMI was defined as a tenfold elevetion in serum-CK-MB associated with new ECG changes or diagnostic imaging consistent with ischemia. Patients with PMI were compared to a reference group with uni- and multivariate analyses. Long-term and MACCE-free survival were estimated with the Kaplan-Meier method and logistic regression used to determine factors associated with PMI. The mean follow-up time was 8.3 years. RESULTS: Out of 1446 patients 78 (5.4%) were diagnosed with PMI (range: 0-15.5%) with a significant annual decline in the incidence of PMI (12.7%, p<0.001). Over the same period preoperative aspirin use increased by 22.3% (p<0.018). PMI patients had a higher rate of short-term complications and a 11.5% 30-day mortality rate compared to 0.4% for non-PMI patients. PMI was found to be a predictor of 30-day mortality (OR 15.44, 95% CI: 6.89-34.67). PMI patients had worse 5-year MACCE-free survival (69.2% vs. 84.7, p=0,01), although overall survival was comparable between the groups. CONCLUSIONS: Although PMI after CABG is associated with significantly higher rates of short-term complications and 30-day mortality, long-term survival was similar to the reference group. Therefore, the mortality risk attributable to PMI appears to diminish after the immediate postoperative period.

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Insufficient information is available regarding the administration of anticoagulants, specifically direct oral anticoagulants, in individuals with cirrhosis awaiting liver transplantation. In this report, we present a case of a 66-year-old male with atrial fibrillation treated with dabigatran who received idarucizumab prior to orthotopic liver transplantation. Hemostatic status was monitored throughout the procedure with both conventional hemostatic tests and point-of-care viscoelastic hemostatic assays. The patient suffered an intraoperative myocardial infarction, which could be related to the use of idarucizumab.

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Perioperative myocardial infarction is a complication of cardiac surgery, and the cause can be multifactorial. Injury of the left circumflex coronary artery has been described, particularly after mitral valve replacement. We present the case of a 72-year-old woman who underwent mitral valve replacement but developed a lesion in the proximal circumflex coronary artery related to partial mechanical kinking caused by a suture. The therapeutic options are surgical or percutaneous. In this patient, the percutaneous strategy was successful. Learning objective: • Percutaneous coronary intervention is an option in cases involving kinking of the left circumflex coronary artery after mitral valve replacement.• If unable to cross the lesion with a workhorse guide wire, one alternative is to use wires with good support properties and avoid very high tip loads to reduce the risk of perforation.In patients at high risk of bleeding, use of a drug-eluting stent and short-duration dual antiplatelet therapy is recommended.

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INTRODUCTION: The global healthcare burden associated with surgery is substantial, with many patients experiencing perioperative complications. Cardiac troponin I and T measured with high-sensitivity assays are cardiac specific biomarkers that associate closely with adverse outcomes in most patient populations. Perioperative physiological stress can induce troponin release from cardiomyocytes, a condition known as perioperative myocardial injury (PMI). PMI is associated with increased risk of poor short- and long-term outcomes, and current European guidelines recommend screening for PMI in at-risk individuals undergoing non-cardiac surgery. AREAS COVERED: In this review we summarize current knowledge of the prognostic attributes of cardiac troponins, as well as the challenges associated with their application as biomarkers in the perioperative phase. EXPERT OPINION: Measurement of circulating levels of cardiac troponins identify individuals at increased risk of poor postoperative outcomes. Systematic screening of at-risk individuals undergoing non-cardiac surgery will result in a large proportion of patients in need of further diagnostic workup to establish the exact nature of their PMI. The lack of concrete evidence of clinical benefit and the increased cost associated with such a strategy is concerning and underscore the need for further research.

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Intraoperative cardiac arrest (ICA) is a crucial property of morbidity and mortality for patients undergoing surgical operations. Spontaneous coronary artery dissection (SCAD) is an important cause of ICA and perioperative myocardial infarction, especially in young women. In this case report, we presented the successful management of SCAD-induced ICA in a 46-year-old female patient who underwent posterior spinal instrumentation in the prone position due to lumbar intervertebral disc extrusion.

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Postoperative coronary artery spasm occurs rarely after valve replacement surgery. We report the case of a 64-year-old man with normal coronary arteries who underwent aortic valve replacement. Nineteen hours postoperatively, his blood pressure plummeted with an elevated ST-segment. Coronary angiography demonstrated a 3-vessel diffuse coronary artery spasm, and direct intracoronary infusion therapy was performed with isosorbide nitrate, nicorandil and sodium nitroprusside hydrate within 1 h of onset. Nonetheless, there was no improvement, and the patient was resistant to treatment. The patient died due to prolonged low cardiac function and pneumonia complications. Prompt intracoronary vasodilator infusion is considered effective. However, this case was refractory to multi-drug intracoronary infusion therapy and was not salvageable.

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BACKGROUND: Early graft failure (EGF) after coronary artery bypass grafting (CABG) occurs in up to 12% of grafts, but is often clinically unapparent. EGF may result in perioperative myocardial infarction with consequently increased mortality. The aim of the present study was to analyze the incidence of clinically apparent EGF in patients undergoing CABG and the influence on mortality. METHODS: We analyzed outcomes of consecutive patients undergoing CABG from January 2015 to December 2018 with respect to postoperative emergency coronary angiography (CAG) due to suspected EGF and 30-day mortality. Patients with CAG-documented EGF were matched to patients without EGF to examine predictors of mortality. RESULTS: The analysis included 5638 patients undergoing CABG. Eighty-six patients (1.5%) underwent emergency CAG due to suspected EGF. Clinically apparent EGF was observed in 61 of these patients (70.9%), whereas 14 (16.3%) had a culprit lesion in a native coronary artery. The majority of patients (n = 45; 52.3%) were treated with percutaneous coronary intervention and 31 (36%) underwent re-do CABG. The remaining patients were treated conservatively. The 30-day mortality rate of suspected EGF patients undergoing CAG was 22.4% (n = 19), which was higher than the mortality rate of 2.8% overall (P<.001); this remained higher after matching the EGF patients with the control group (11 [20.4%] vs 2 [4.0%]; P=.02). CONCLUSION: Emergency CAG after CABG is rare and is primarily carried out in patients with EGF. The 30-day mortality rate of these patients is high, and EGF is an independent predictor of mortality. Perioperative CAG with subsequent treatment is mandatory in these patients.

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The new European Society of Cardiology (ESC) guidelines on the cardiovascular assessment and management of patients undergoing non-cardiac surgery were published in August 2022. In the preparation of the new document the previous guidelines published in 2014 were completely revised and the recommendations for action were adapted or renewed. Furthermore, the guidelines have been supplemented with some new chapters. The new and revised recommendations result in significant changes for the clinical practice. This particularly applies to the preoperative risk stratification, the perioperative risk management and the detection and management approaches in cases of perioperative and postoperative complications. Cardiovascular biomarkers play a special role in both the preoperative risk stratification and the detection of postoperative complications in combination with appropriate algorithms for action. The perioperative management of antithrombotic treatment (antiplatelet therapy or oral anticoagulation) is becoming increasingly individualized depending on the risk of ischemia or bleeding of the planned surgery. Particular attention is paid to the early detection of perioperative or postoperative myocardial infarctions based on determination of high-sensitivity (hs) cardiac troponin, not least because its association with high risk of morbidity and mortality. In patients with complex cardiovascular diseases, such as severe coronary artery disease, valvular heart diseases or those with ventricular support systems, the decision in an interdisciplinary team is highly recommended.

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Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.

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BACKGROUND AIMS: Early-phase cell therapy clinical trials depend on patient and physician involvement, yet barriers can impede their participation. METHODS: To optimize engagement for a planned cell therapy trial to prevent perioperative cardiac complications, the authors conducted semi-structured interviews with at-risk patients and physicians who could potentially be involved in the study. The authors used the theoretical domains framework to systematically identify potential barriers and enablers. RESULTS: Forty-one interviews were conducted to reach data saturation, and four overall potential barriers to participation (themes) were identified. Theme 1 emphasizes that patients and physicians need accessible information to better understand the benefits and risks of the novel therapy and trial procedures and to address misconceptions. Theme 2 underscores the need for clarity on whether the trial's primary purpose is safety or efficacy, as this may influence patient and physician decisions. Theme 3 recognizes the resource and logistic realities for patients (e.g., convenient follow-up appointments) and physicians (e.g., personnel to assist in trial procedures, competing priorities). Theme 4 describes the importance of social influences (e.g., physicians and family, peers/colleagues) that may affect decisions to participate and the importance of patient preferences (e.g., availability of physicians to discuss the trial, including caregivers in discussions). CONCLUSIONS: Prospectively addressing these issues may help optimize feasibility prior to conducting an expensive, resource-intensive trial.

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BACKGROUND: Although bilirubin is known to be an antioxidant, any relationship with coronary heart disease remains controversial. To the best of our knowledge, no previous study has investigated the association between bilirubin and perioperative myocardial infarction (PMI), including its long-term prognosis. AIM: To investigate the impact of bilirubin levels on PMI in patients undergoing percutaneous coronary intervention (PCI), and long-term prognosis in post-PMI patients. METHODS: Between January 2014 and September 2018, 10236 patients undergoing elective PCI were enrolled in the present study. Total bilirubin (TB) and cardiac troponin I (cTnI) levels were measured prior to PCI and cTnI at further time-points, 8, 16 and 24 h after PCI. Participants were stratified by pre-PCI TB levels and divided into three groups: < 10.2; 10.2-14.4 and > 14.4 µmol/L. PMI was defined as producing a post-procedural cTnI level of > 5 × upper limit of normal (ULN) with normal baseline cTnI. Major adverse cardiovascular events (MACEs) included cardiac death, MI, stroke and revascularization during a maximum 5-year follow-up. RESULTS: PMI was detected in 526 (15.3%), 431 (12.7%) and 424 (12.5%) of patients with pre-PCI TB levels of < 10.2, 10.2-14.4 and > 14.4 µmol/L (P = 0.001), respectively. Multivariate logistical analysis indicated that patients with TB 10.2-14.4 and > 14.4 µmol/L had a lower incidence of PMI [TB 10.2-14.4 µmol/L: Odds ratio (OR): 0.854; 95% confidence interval (CI): 0.739-0.987; P = 0.032; TB > 14.4 µmol/L: OR: 0.846; 95%CI: 0.735-0.975; P = 0.021] compared with patients with TB < 10.2 µmol/L. Construction of a Kaplan-Meier curve demonstrated a higher MACE-free survival time for patients with higher TB than for those with lower TB (log-rank P = 0.022). After adjustment for cardiovascular risk factors and angiographic characteristics, multivariate Cox analysis showed that a TB level > 14.4 µmol/L was associated with a reduced risk of MACEs compared with a TB level < 10.2 µmol/L (hazard ratio 0. 667; 95%CI: 0.485-0.918; P = 0.013). CONCLUSION: Bilirubin was a protective factor in PMI prediction. For post-PMI patients, elevated bilirubin levels were independently associated with a reduced risk of MACEs during long-term follow-up.

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BACKGROUND: Perioperative myocardial infarction/injury (PMI) is a frequent, often missed and incompletely understood complication of noncardiac surgery. The aim of this study was to evaluate whether patient- or procedure-related factors are more strongly associated to the development of PMI in patients undergoing repeated noncardiac surgery. METHODS: In this prospective observational study, patient- and procedure-related factors were evaluated for contribution to PMI using: 1) logistic regression modelling with PMI as primary endpoint, 2) evaluation of concordance of PMI occurrence in the first and the second noncardiac surgery (surgery 1 and 2). and 3) the correlation of the extent of cardiomyocyte injury quantified by high-sensitivity cardiac troponin T between surgery 1 and 2. The secondary endpoint was all-cause mortality associated with PMI reoccurrence in surgery 2. RESULTS: Among 784 patients undergoing repeated noncardiac surgery (in total 1'923 surgical procedures), 116 patients (14.8%) experienced PMI during surgery 1. Among these, PMI occurred again in surgery 2 in 35/116 (30.2%) patients. However, the vast majority of patients developing PMI during surgery 2 (96/131, 73.3%) had not developed PMI during surgery 1 (phi-coefficient 0.150, p < 0.001). The correlation between the extent of cardiomyocyte injury occurring during surgery 1 and 2 was 0.153. All-cause mortality following a second PMI in surgery 2 was dependent on time since surgery (adjusted hazard ratio 5.6 within 30 days and 2.4 within 360 days). CONCLUSIONS: In high-risk patients, procedural factors are more strongly associated with occurrence of PMI than patient factors, but patient factors are also contributors to the occurrence of PMI.

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Background and Aims: The impact of obstructive sleep apnea (OSA) on perioperative myocardial infarction (PMI) following coronary artery bypass grafting (CABG) remains unclear. Off-pump CABG (OPCABG) has become a common practice for CABG in China. The present study investigated mainly the correlation between OSA and PMI following OPCABG. Methods: In this prospective observational single-center study, consecutive eligible patients listed for elective OPCABG underwent cardiorespiratory polygraphy before surgery between January 2019 and June 2020. OSA was defined as an apnea-hypopnea index (AHI) ≥15 events/h. The primary end point was perioperative myocardial infarction (PMI) following OPCABG (type 5 MI). Results: Patients with OSA accounted for 42.2% (62/147) of the cohort. Twenty-four patients (16.3%) met the protocol criteria for PMI: 17 (27.4%) in the OSA group and 7 (8.2%) in the non-OSA group (P = 0.002). Multivariate logistic regression analysis revealed that AHI (OR = 1.115, 95% CI 1.066 to 1.166, P < 0.001), high-sensitivity c-reactive protein (hs-CRP) (OR = 1.080, 95% CI 1.025 to 1.138, P = 0.004), and SYNTAX score (OR = 1.098, 95% CI 1.056 to 1.141, P < 0.001) were associated with PMI incidence. Furthermore, ROC analysis revealed that the AHI (AUC = 0.766, 95% CI 0.689 to 0.832, P < 0.001) and SYNTAX score (AUC = 0.789, 95% CI 0.715 to 0.852, P < 0.001) had predictive value for PMI. In addition, multiple linear regression analysis showed that the AHI was an independent influencing factor of hs-CRP (B = 0.176, 95% CI 0.090 to 0.263, P < 0.001) and the SYNTAX score (B = 0.553, 95% CI 0.397 to 0.709, P < 0.001). Conclusions: OSA was independently associated with a higher incidence of PMI following OPCABG, and the formation of severe coronary atherosclerotic lesions aggravated by an enhanced inflammatory response might be the potential mechanism. The efficacy of CPAP treatment for improving prognosis after CABG remains to be further investigated.

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Annually, up to 850 000 coronary aortic bypass graft operations are performed worldwide. Despite modern technical equipment ensuring a high level of safety of the procedure, currently important remains a problem related to intraoperative myocardial damage in using artificial circulation. Early detection and clinical assessment of myocardial ischaemia often present a difficult task. This article deals with clinical, instrumental and laboratory methods of diagnosis, aimed at verification of an intraoperative cardiac lesion associated with graft dysfunction in coronary artery bypass grafting. Isolated electrocardiographic and echocardiographic signs of myocardial ischaemia between the comparison groups did not differ significantly. Analysing the markers of myocardial lesions, statistically significant differences were obtained only after 48 hours which, from the point of view of saving viable myocardium, is an utterly long-term interval. Studying the findings of intraoperative flowmetry showed statistically significant dependence between velocity characteristics, pulse index of shunts and their patency on angiographic examination. Thus, only combination of diagnostic parameters makes it possible to detect myocardial damage related to shunt dysfunction. This enables early determination of indications for performing bypass angiography and selection of the required therapeutic policy. Timely coronary artery angiography makes it possible to reveal defects of shunts and to timely perform surgical correction, preventing myocardial infarction.

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PURPOSE: The Canadian Cardiovascular Society (CCS) guidelines for patients undergoing non-cardiac surgery address the lack of standardized management for patients at risk of perioperative cardiovascular complications. Our interdisciplinary group evaluated the implementation of these guidelines. METHODS: We used an interrupted time series design to evaluate the effect of implementation of the CCS guidelines, using routinely collected hospital data. The study population consisted of elective, non-cardiac surgery patients who were: i) inpatients following surgery and ii) age ≥ 65 or age 45-64 yr with a Revised Cardiac Risk Index ≥ 1. Outcomes included adherence to troponin I (TnI) monitoring (primary) and adherence to appropriate consultant care for patients with elevated TnI (secondary). Exploratory outcomes included cost measures and clinical outcomes such as length of stay. RESULTS: We included 1,421 patients (706 pre- and 715 post-implementation). We observed a 67% absolute increase (95% confidence interval, 55 to 80; P < 0.001) in adherence to TnI testing following the implementation of the guidelines. In patients who had elevated TnI following guideline implementation (n = 64), the majority (85%) received appropriate follow-up care in the form of a general medicine or cardiology consult, all received at least one electrocardiogram, and half received at least one advanced cardiac test (e.g., cardiac perfusion scan, or percutaneous intervention). CONCLUSIONS: Our study showed the ability to implement and adhere to the CCS guidelines. Large-scale multicentre evaluations of CCS guideline implementation are needed to gain a better understanding of potential effects on clinically relevant outcomes.

RéSUMé: OBJECTIF: Les lignes directrices de la Société canadienne de cardiologie (SCC) concernant les patients subissant une chirurgie non cardiaque ont été conçues pour pallier l'absence de standardisation dans la prise en charge des patients à risque de complications cardiovasculaires périopératoires. Notre groupe interdisciplinaire a évalué la mise en œuvre de ces lignes directrices. MéTHODE: Nous avons utilisé une méthodologie de série chronologique interrompue pour évaluer l'effet de la mise en œuvre des lignes directrices de la SCC, à l'aide des données hospitalières habituellement recueillies. La population à l'étude se composait de patients de chirurgies non cardiaques non urgentes qui étaient : i) hospitalisés après leur chirurgie et ii) âgés de ≥ 65 ans ou de 45 à 64 ans avec un Indice de risque cardiaque révisé ≥ 1. Les critères d'évaluation comprenaient l'observance du monitorage de la troponine I (TnI) (critère d'évaluation primaire) et l'observance des soins spécialisés appropriés aux patients présentant un taux élevé de TnI (critère secondaire). Les critères exploratoires comprenaient des mesures de coûts et des résultats cliniques tels que la durée de séjour. RéSULTATS: Nous avons inclus 1421 patients (706 avant et 715 après la mise en œuvre). Nous avons observé une augmentation absolue de 67 % (intervalle de confiance de 95 %, 55 à 80; P < 0,001) de l'observance des tests de la TnI suite à la mise en œuvre des lignes directrices. Parmi les patients présentant un taux élevé de TnI suite à la mise en œuvre des lignes directrices (n = 64), la majorité (85%) a reçu des soins de suivi appropriés sous la forme d'une consultation en médecine générale ou en cardiologie; tous ont subi au moins un électrocardiogramme, et la moitié ont passé au moins un examen cardiaque subséquent (p. ex., évaluation de la perfusion myocardique par scintigraphie ou cathétérisme percutané). CONCLUSION: Notre étude a montré qu'il est possible de mettre en œuvre et d'adhérer aux nouvelles lignes directrices de la SCC. Des évaluations multicentriques à grande échelle portant sur la mise en œuvre des lignes directrices de la SCC sont nécessaires pour mieux comprendre ses effets potentiels sur les devenirs cliniquement pertinents.

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INTRODUCTION: The relationship between the distance from the mitral annulus to the left circumflex coronary artery (LCX) and iatrogenic LCX injury has been questioned. This study was designed to determine the high-risk sites of LCX injury with an anatomical approach using multiple detector-computed tomography (MDCT) scanning taken before mitral valve annuloplasty (MVA). The purpose of this study is to prevent LCX injury in patients unable to receive MDCT before mitral valve surgery. METHODS: In 2018, we performed MVA on 59 patients, 52 of whom had undergone preoperative MDCT scanning. We retrospectively analyzed the MDCT images of these 52 patients and measured the shortest distance from the mitral annulus to the LCX in three dimensions. Also, we divided the mitral annulus into 12 clockwise areas (A0-A11) to identify the exact location. RESULTS: The site of closest proximity and their numbers of patients were as follows: A6, 1 patient; A8, 2 patients; A9, 32 patients; and A10, 17 patients. Nine (17.3%) of the 52 patients had the shortest distance of less than 2 mm. The shortest distance according to the dominance of coronary artery showed no significant difference (p = 0.81). CONCLUSION: The site of closest proximity from the mitral annulus to the LCX was concentrated on the A8 to A10 areas and it is an interesting result that as many as 17% of patients have their coronary arteries less than 2 mm away from the annulus.

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BACKGROUND: Perioperative myocardial infarction is a rare but highly fatal complication, which often occurs in patients with poor preoperative cardiac conditions undergoing high-risk surgery. We report a case of acute myocardial infarction in a patient without cardiac risk factors during emergence from general anesthesia for removal of spinal screws. CASE PRESENTATION: A 37-year-old, 60 kg, and 160 cm man, who had no history of cardiovascular diseases, underwent removal of loosen spinal plug screws at L4-L5. The preoperative investigations revealed no abnormality and the patient was ASA I. The surgery was uneventful. During aspiration of the endotracheal tube, the patient suddenly experienced paroxysmal atrial fibrillation and ST segment elevation in DII lead. He was treated with oxygenation, optimal hemodynamics, minimize cardiac work, antiarrhythmias, and anticoagulation. The clinical conditions improved. Sinus rhythm was regained after 24 h and discharged without complications. CONCLUSIONS: Myocardial infarction can occur suddenly and unexpectedly in patients without risk factors after a low-risk surgery in any period of general anesthesia. Close monitoring and prompt treatment with this condition is important for improving outcomes.