Myocardial infarction with non-obstructive coronary arteries in a patient undergoing nephrectomy under general anesthesia

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an uncommon but clinically significant condition, particularly during the perioperative period. Its diagnosis is challenging under general anesthesia due to nonspecific signs and limited patient communication. However, few cases of perioperative MINOCA have been reported to date, and clinical awareness remains limited. A 56-year-old living-related kidney donor with no history of cardiovascular disease was scheduled to undergo nephrectomy under general anesthesia. The induction of anesthesia was uneventful. Electrocardiography (ECG) monitoring demonstratedF the presence of ST-segment elevation approximately 90 min after the start of the surgery. The heart rate (HR) was increased to 90–100 bpm, and despite the administration of a large dose of catecholamines, it remained difficult to maintain the systolic arterial blood pressure (ABP) over 90 mmHg. The patient was transferred to the intensive care unit (ICU) at the end of the surgery. Standard 12-lead ECG revealed aST-segment depression in v1–v4. Moreover, the cardiac troponin I (cTnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels had increased to critical values. Emergency coronary angiography revealed 40 % stenosis in the opening and proximal regions of the left anterior descending (LAD) artery; no stenosis was observed in the other branches of the coronary arteries. After ruling out perioperative anaphylaxis, hypovolemia, and pulmonary embolism, the patient was diagnosed with MINOCA intraoperatively. The patient was extubated 24 h postoperatively under stable hemodynamic conditions. The cTnI and NT-proBNP levels were also restored to the normal range nine days after the operation. Diagnosis of MINOCA indicates that an ischemic mechanism is responsible for the myocyte injury; however, its causes are complex and occult. Hemodynamics and ECG findings should be closely monitored intraoperatively as they play a crucial role in the early diagnosis of MINOCA. Prompt diagnosis and management may limit myocardial damage and improve outcomes.