Epinephrine-Induced Stemi Mimic Following Robotic-Assisted Bronchoscopy for Pulmonary Nodule Biopsy: A Two-Case...

Topical endobronchial epinephrine is widely used during bronchoscopy for the management of procedure-related bleeding and is generally considered a safe and effective hemostatic agent; however, systemic absorption may rarely result in significant cardiovascular complications. We report two patients who underwent robotic-assisted bronchoscopy with transbronchial biopsy and developed acute ST-segment elevation immediately after endobronchial epinephrine was administered for post-biopsy bleeding. In both cases, electrocardiographic and telemetry findings prompted emergent cardiology evaluation and coronary angiography for suspected ST-segment elevation myocardial infarction. Coronary angiography demonstrated no obstructive coronary artery disease, and the electrocardiographic abnormalities resolved spontaneously without coronary intervention or specific treatment for myocardial ischemia. Both patients recovered without persistent cardiovascular sequelae during the remainder of their hospitalization. The close temporal relationship between epinephrine administration and ischemic electrocardiographic changes, combined with normal coronary angiography, suggests that transient coronary vasospasm was the presumed mechanism, although other causes of transient ST-segment elevation cannot be completely excluded. Although uncommon, this complication has important implications as advanced bronchoscopic procedures increasingly rely on transbronchial sampling techniques that may require topical hemostatic agents. Phenylephrine represents a potentially safer alternative hemostatic agent because it provides local vasoconstriction without β-adrenergic stimulation, which may reduce the risk of arrhythmogenic and ischemic cardiovascular effects. Bronchoscopists should remain vigilant for cardiovascular complications following airway epinephrine administration, particularly in patients with underlying cardiovascular risk factors. Further studies are needed to compare the safety and efficacy of topical epinephrine and phenylephrine in the bronchoscopic setting.