[Intraoperative acute myocardial infarction during total gastrectomy under general anesthesia combined with thoracic epidural anesthesia].

A 61-year-old, 54-kg man with gastric cancer was scheduled for total gastrectomy under general anesthesia combined with thoracic epidural anesthesia. Approximately 20 minutes after the start of the operation, the patient developed sudden hypotension and ventricular fibrillation. The cardiac rhythm returned to normal after 38 minutes of cardiopulmonary resuscitation. The operation was discontinued and the patient was transferred to an intensive care unit. A 12-lead electrocardiogram (ECG) revealed complete right bundle branch block and elevation of the ST-segment from leads II, III, aVF, V1, and V2 which indicated an inferior myocardial infarction. Laboratory data showed elevated levels of enzymes such as glutamic oxaloacetic transaminase (495 IU.l-1), lactic dehydrogenase (1781 IU.l-1), and creatine kinase-MB (112 IU.l-1). The mildly elevated levels of the enzymes decreased around 10 hours after the termination of the operation, but they increased markedly again without any change in ECG on the second postoperative day. Elevation in serum myoglobin and glutamic pyruvic transaminase and decline in arterial ketone body ratio were also detected. Furthermore, renal failure developed with increase in blood urea nitrogen and creatinine. Because of hepatic failure and renal failure which might have been caused by rhabdomyolysis, the patient needed inotropic support with dopamine, dobutamine, and epinephrine to maintain the circulation. The patient died of reinfarction of the 20th postoperative day despite intensive care such as intraaortic balloon pumping, hemodiafiltration, and continuous intravenous infusion of prostaglandin E1.