ST segment elevation for diagnosis of pericardial local blood clots after coronary artery bypass grafting: a case report

ST segment elevation for diagnosis of pericardial local blood clots after coronary artery bypass grafting: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report ST segment elevation for diagnosis of pericardial local blood clots after coronary artery bypass grafting: a case report aiwen wang, Zhuo Yuan, Shuzhen Bi, Huanzhen Chen, Xingpeng Bo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4074031/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Backgroud : Local blood clots in the pericardium are a common complication after coronary artery bypass grafting (CABG). However, it is very rare to clinical present with persistent ST-segment elevation. To date, there have been no reported cases. Case presentation : A 54-year-old male was admitted due to exertional angina. Three-vessel coronary artery disease was initially diagnosed based on Coronary angiography. The patient underwent a selective three coronary artery bypass graft (CABG) and extracted the tube the next day. But, on the second postoperative day, type I respiratory failure and type 5 myocardial infarction were diagnosed based on elevated ST segment, high-sensitivity troponin T and decreased P02 (55mmHg). The patient was given intravenous nitroglycerin and invasive mechanical ventilation. Despite these interventions, the patient's condition deteriorated on the third postoperative day. Cardiac tamponade was diagnosed based on clinical presentation and echocardiography. He underwent an emergency procedure for retrograde pericardial effusion drainage, which led to a rapid improvement in his clinical symptoms. Unfortunately, the patient subsequently developed acute hepatic and renal failure. A rethoracotomy was performed on the fifth postoperative day, which showed a large amount of blood clots on the pericardial surface and partial occlusion of the inferior vena cava reflux. The patient 's condition improved significantly and the elevated ST segment returned to normal after the surgery. On the tenth day after reoperation, laboratory tests such as liver function, renal function, and troponin T returned to normal. The patient was discharged fourteen days after the reoperation. Conclusion : P ersistent ST-segment elevation as a rare but easily detectable clinical presentation of of pericardial local blood clots after CABG. Coronary Artery Bypass Graft Persistent ST-segment elevation Pericardial Local Blood Clot Cardiac Tamponade Figures Figure 1 Figure 2 Backgroud Pericardial effusion is a common complication after CABG, and 1–3% of them require timely intervention [ 1 , 2 ]. Encapsulated pericardial effusion is often secondary to local clots on the pericardium after CABG and can cause life-threatening cardiac tamponade [ 3 ]. It poses a significant challenge to the clinical and ultrasonic diagnosis of cardiac tamponade due to changes in anatomy and irregular accumulation of blood clots around the pericardium after CABG [ 2 , 5 ]. Transesophageal echocardiography has a high specificity for cardiac tamponade [ 4 , 5 ]. However, it has yet to be widely popularized due to clinical conditions. Therefore, finding a method that can detect pericardial blood clots early and predict the development of cardiac tamponade later is necessary. Persistent ST-segment elevation following CABG is often associated with adverse cardiovascular events [ 6 , 7 ]. Previous studies have demonstrated that acute myocardial infarction(AMI) or acute pericarditis after CABG can manifest as persistent ST-segment elevation[ 7 ]. However, persistent ST-segment elevation presenting as a localized blood clot in the pericardium following CABG has rarely been reported. In this case study, we explore a case of persistent ST-segment elevation after CABG. This case underscores the significance of postoperative persistent ST-segment elevation as a potential early indicator of local blood clots in the pericardium. Case presentation A 54-year-old male was admitted due to exertional angina. Three-vessel coronary artery disease was initially diagnosed based on Coronary angiography. The patient underwent a selective three coronary artery bypass graft (CABG) and extracted the tube the next day. Liver and renal function tests were regular after CABG ( Table 2 ) . ECG showed no ST segment abnormality ( Figs. 1 A ) . Pericardial drainage tube drainage was unobstructed. Table 1 Blood gas analysis during the critical period and after improvement. Before CABG 2 hours after CABG 1days after CABG/before tracheal tube removal 2days after CABG/Before re-intubation 2days after CABG/2 hours after re-intubation Day 3 after second surgery Reference Range PH, mmHg 7.40 7.38 7.35 7.24 7.36 7.42 7.35–7.45 P02, mmHg 136.00 158 84 58 67 72 70–110 PC02, mmol/L 34.5 36 40 30 33 35 35–45 HC03-, mmol/L 21.2 22 22.8 -12.7 18.5 22.6 18–23 Lac, mmol/L 1.8 0.5 0.7 6.6 2.4 1.3 < 2 Table 2 Laboratory data during the critical period and after improvement. Day of operation The second day after CABG Three days after CABG Four days after CABG Day of reoperation day The first day after the reoperation Second day after reoperation Six days after the reoperation Ten days after reoperation Reference Range Hs-TNT(pg/ml) 127.2 508.3 844.1 499.4 419.4.4 467.4 375.4 80.1 13 0–14 ALT(U/L) 38 583 2848 2141 299 43 9–50 AST(U/L) 26 11055 4042 3274 263 35 15–40 TBIL(umol/L) 45.1 58.8 69.8 79.4 60.9 18 0–26 DBIL(umol/L) 15.3 39.9 49.9 64.2 51.5 5.3 1.7–6.8 IBIL(umol/L) 29.8 18.9 19.9 15.2 9.4 12.7 2-13.7 PT(s) 13.5 20.3 18.7 18.9 15.4 14.3 12.4 13.7 10–14 APTT(s) 35.1 68.1 60.5 59.7 37.7 36.9 24 26.9 23.8–38.8 INR 1.18 1.8 1.65 1.67 1.35 1.25 1.08 1.2 0.8–1.2 SCr(umol/L) 56.7 196 206 196 184 335 109 82 57–97 Abbreviation Hs-TNT : high-sensitivity cardiac troponin ALT : alanine amino transferase AST : aspartate transaminase TBIL : totalbilirubin DBIL : direct Bilirubin IBIL : indirect Bilirubin PT : prothrombin time APTT : activated partial thromboplastin time INR: i nternational normalized ratio SCr : serum creatinine However, the patient developed dyspnea without fever, heart murmur or pericardial friction rub on the second day after CABG. An arterial blood gas analysis revealed PH 724, PO2 58mmHg, PCO2 30mmHg, HCO3 − 12.7mmol/L ( Table 1 ) . His high-sensitivity troponin T levels increased from 127.2pg/ml at 2 hours after CABG to 508.3pg/ml ( Table 2 ) . Electrocardiography showed ST segment significant elevation in I、AVL、II、V2-6 compared to the previous ECG ( Figs. 1 B ) . Cardiac ultrasound showed a well-defined hypoechogenicity of about 3.9*2.7cm at the left atrial base (Video 1) . In line with the 2018 fourth edition of the universal definition of myocardial infarction, the causes of ST-segment elevation were considered: could this be a type 5 myocardial infarction and pericardial local blood clot? The patient was treated with intravenous nitroglycerin, subcutaneous low molecular weight heparin, and invasive mechanical ventilation. Unfortunately, this patient failed to undergo a second thoracotomy in time due to the new coronavirus epidemic. However, these conservative treatments led to an improvement in the patient's oxygen saturation. Nevertheless, the patient's condition deteriorated on the third postoperative day. He presented with manifestations of cardiac tamponade, such as moderate jugular distention (CVP 18cmH20), systolic blood pressure of 75mmHg, and oliguria. Echocardiography showed that posterior pericardial effusion 1.09 cm and diastolic collapse were observed in the right atrium and right ventricle, no segmental motion abnormality and EF 59% ( Figs. 2 E ) . Acute cardiac tamponade was considered based on Clinical presentation and cardiac ultrasound. Under aseptic conditions, retrograde into the pericardial drainage tube and about 140ml of bloody fluid was extracted. Subsequently, the patient's hemodynamics were stabilized with trace norepinephrine support. But, the patient developed acute hepatic failure and renal failure. A Laboratory tests showed aspartate transaminase (AST) 4042U/L, alanine amino transferase (ALT) 2848U/L, totalbilirubin (TBil) 69.8umol/L, International normalized ratio(INR)1.67, blood urea nitrogen (BUN)16mmol/L, serum creatinine(SCr)206umol/L ( Table 2 ) . The patient received hepatoprotective drugs and underwent bedside renal replacement therapy. On the fifth postoperative day, a rethoracotomy was conducted, revealing massive blood clots on the pericardial surface and partial occlusion of the inferior vena cava reflux ( Figs. 2 F ) . Watchable, when these clots were surgically cleared ( Figs. 2 G ) , the patient's spontaneous urine output recovered, and vasoactive drugs were discontinued. ECG showed elevated ST segment complete resolution in leads I AVL II V2-6 and bidirectional or inverted T waves in leads V2-6 ( Figs. 1 C ) . CRRT and ventilator were withdrawn on the first and third day after reoperation. By the third day post-reoperation, the electrocardiogram showed complete normalization of the original abnormal ST segment and T waves and no new pathological Q waves ( Figs. 1 D ) . Laboratory tests, such as liver function, renal function, and high-sensitivity troponin T, gradually returned to normal by the tenth day following reoperation. The patient was discharged 14 days after reoperation. After two years of follow-up, the patient had no major adverse cardiovascular events. Discussion The clinical implications of transient ST-segment changes on the electrocardiogram following CABG remain debatable. Generally, these changes are considered non-specific and not associated with long-term prognosis [ 6 ]. However, persistent ST-segment elevation after cardiac surgery is usually considered to be associated with adverse cardiovascular events [ 6 , 7 ]. The causes of ST-segment elevation after CABG are complex and include intraoperative damage to the pericardium and myocardium, postoperative inflammatory changes, myocarditis, pericarditis and coronary spasm[ 6 ]. Hyperkalemia and hypothermia can also lead to ST-segment elevation but can be determined by clinical and laboratory results [ 8 ]. Pericardial effusion is a common complication after CABG), with 1–3% of them requiring timely intervention [ 1 , 2 ]. Encapsulated pericardial effusion, often resulting from local clots on the pericardium following CABG, can cause life-threatening cardiac tamponade [ 3 ]. Patients are usually treated with substantial sedation, ventilation, and inotropes; typical signs of tamponade are generally absent, such as hypotension and paradoxical pulse [ 4 ]. It poses a significant challenge to the clinical and ultrasonic diagnosis of cardiac tamponade due to anatomical distortions, residual air in the thoracic cavity, the presence of surgical dressings or scars, and irregular accumulation of blood clots around the pericardium after CABG [ 2 , 5 ]. Transesophageal echocardiography has a high specificity for cardiac tamponade [ 4 , 5 ]. However, it has yet to be widely popularized due to clinical conditions. Therefore, it is necessary to find a method to predict the occurrence of cardiac tamponade in patients at a later stage. It is difficult to distinguish true ischemia, pericardial inflammation, or blood clots on the pericardial surface based on ST-segment elevation. However, delayed identification of the cause of ST-segment elevation can cause malignant events such as acute myocardial infarction and acute cardiac tamponade. Clinicians should remain highly vigilant and suspicious. Emergency transesophageal ultrasound should be employed promptly for early detection in cases of high clinical suspicion for pericardial clot formation. When necessary, timely surgical intervention should be executed to enhance the likelihood of a successful outcome. Abbreviations CABG: coronary artery bypass grafting AMI: acute myocardial infarction BUN: blood urea nitrogen Hs-TNT: high-sensitivity cardiac troponin ALT: alanine amino transferase AST: aspartate transaminase TBIL: totalbilirubin DBIL: direct Bilirubin IBIL: indirect Bilirubin PT：prothrombin time APTT：activated partial thromboplastin time INR: international normalized ratio SCr：serum creatinine Declarations Acknowledgements Not applicable. Authors’ Contributors: Liang Zong and Huanzhen Chen designed the study and supervised the overall project. Zhuo Yuan and Xingpeng Bo participated in collecting data, and Aiwen Wang participated in data collecting and analysis. Aiwen Wang, Shuzhen Bi and Huanzhen Chen, provided the statistical analysis and wrote the manuscript. Funding Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article. Ethics approval and consent to participate Written informed consent was obtained from the patient’s daughter for publication of this case report. Consent for publication Written informed consent for publication was obtained from the patient’s daughter, and a copy of the consent form is available upon request to review. Competing interests The authors declare that they have no competing interests References Ashikhmina, E. A.; Schaff, H. V.; Sinak, L. J.; Li, Z.; Dearani, J. A.; Suri, R. M.; Park, S. J.; Orszulak, T. A.; Sundt, T. M., Pericardial effusion after cardiac surgery: risk factors, patient profiles, and contemporary management. Ann Thorac Surg 2010, 89 (1), 112-118. Kuvin, J. T.; Harati, N. A.; Pandian, N. G.; Bojar, R. M.; Khabbaz, K. R., Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg 2002, 74 (4), 1148-1153. Adi O, Ahmad AH, Fong CP, Ranga A, Panebianco N. Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade. Ultrasound J. 2021;13(1):22. Published 2021 Apr 15. doi:10.1186/s13089-021-00225-7 Lehto J, Kiviniemi T. Postpericardiotomy syndrome after cardiac surgery. Ann Med. 2020;52(6):243-264. doi:10.1080/07853890.2020.1758339 Imren, Y.; Tasoglu, I.; Oktar, G. L.; Benson, A.; Naseem, T.; Cheema, F. H.; Unal, Y., The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery. J Card Surg 2008, 23 (5), 450-453. Liu, J.; Birnbaum, Y., ST segment elevation following coronary artery bypass surgery. J Electrocardiol 2019, 57, 128-131. Lockerman, Z. S.; Rose, D. M.; Cunningham, J. N.; Lichstein, E., Postoperative ST-segment elevation in coronary artery bypass surgery. Chest 1986, 89 (5), 647-651. Loeb HS, Gunnar WP, Thomas DD. Is new ST-segment elevation after coronary artery bypass of clinical importance in the absence of perioperative myocardial infarction?. J Electrocardiol. 2007;40(3):276-281. doi:10.1016/j.jelectrocard.2006.08.098 Additional Declarations No competing interests reported. Supplementary Files Video.pptx Video legend. Cardiac ultrasound showed a well-defined hypoechogenicity of about 3.9 * 2.7 cm at the left atrial base. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4074031","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":288723446,"identity":"5d9f7953-84da-4aaf-a030-a75077d455f9","order_by":0,"name":"aiwen wang","email":"","orcid":"","institution":"Changzhi People's Hospital, The Affiliated Hospital of Changzhi Medical College","correspondingAuthor":false,"prefix":"","firstName":"aiwen","middleName":"","lastName":"wang","suffix":""},{"id":288723447,"identity":"24c4946d-22a2-46bf-b9a4-253e774a1dc9","order_by":1,"name":"Zhuo Yuan","email":"","orcid":"","institution":"Changzhi People's Hospital, 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12:49:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4074031/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4074031/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54371947,"identity":"9ec33d9a-1809-4a83-bc7c-5c17172477a6","added_by":"auto","created_at":"2024-04-09 13:17:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1145021,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA. \u0026nbsp;\u003c/strong\u003eAt 2 hours post- CABG, no significant ST segment in all leads.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. \u0026nbsp;\u003c/strong\u003eOn day 3 post-CABG, significant ST-segment elevation in leads I, II, aVL, V2 to V6 with ST-segment depression in the lead III and AVR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC. \u0026nbsp;\u003c/strong\u003eAt 2 hours post-reoperation, the original ST elevation returned to normal and T waves in leads V2 – V6 were bidirectional or inverted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD. \u0026nbsp;\u003c/strong\u003eOn day 3 post-reoperation, T waves in leads V2-4 returned to normal and there were no new pathological Q waves.\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4074031/v1/c986d60c597888de0ae22ed0.png"},{"id":54371940,"identity":"693a5044-4600-4a37-9b7c-85635945c852","added_by":"auto","created_at":"2024-04-09 13:17:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":545131,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eE. \u0026nbsp;\u003c/strong\u003eCardiac ultrasound showed pericardial effusion\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF. \u0026nbsp;\u003c/strong\u003eA lot of blood clots on pericardial surface found during rethoracotomy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eG.\u003c/strong\u003e \u0026nbsp;Blood clot dissected from pericardial surface during rethoracotomy\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4074031/v1/9de5cc4640de0ecce5b31100.png"},{"id":57226736,"identity":"14d4e8ee-8c7e-4fba-bd5b-395adc0c2610","added_by":"auto","created_at":"2024-05-27 18:16:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2833154,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4074031/v1/b4e11f21-b35c-4353-8cbe-e1f14a4d6a57.pdf"},{"id":54371939,"identity":"18c3f930-7bf1-4d82-a228-1b7c6810ae46","added_by":"auto","created_at":"2024-04-09 13:17:10","extension":"pptx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":629572,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo legend. \u003c/strong\u003e\u0026nbsp;Cardiac ultrasound showed a well-defined hypoechogenicity of about 3.9 * 2.7 cm at the left atrial base.\u003c/p\u003e","description":"","filename":"Video.pptx","url":"https://assets-eu.researchsquare.com/files/rs-4074031/v1/fcdc19659a620aafa6ccd3f5.pptx"}],"financialInterests":"No competing interests reported.","formattedTitle":"ST segment elevation for diagnosis of pericardial local blood clots after coronary artery bypass grafting: a case report","fulltext":[{"header":"Backgroud","content":"\u003cp\u003ePericardial effusion is a common complication after CABG, and 1\u0026ndash;3% of them require timely intervention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEncapsulated pericardial effusion is often secondary to local clots on the pericardium after CABG and can cause life-threatening cardiac tamponade [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It poses a significant challenge to the clinical and ultrasonic diagnosis of cardiac tamponade due to changes in anatomy and irregular accumulation of blood clots around the pericardium after CABG [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTransesophageal echocardiography has a high specificity for cardiac tamponade [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, it has yet to be widely popularized due to clinical conditions. Therefore, finding a method that can detect pericardial blood clots early and predict the development of cardiac tamponade later is necessary.\u003c/p\u003e \u003cp\u003ePersistent ST-segment elevation following CABG is often associated with adverse cardiovascular events [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Previous studies have demonstrated that acute myocardial infarction(AMI) or acute pericarditis after CABG can manifest as persistent ST-segment elevation[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, persistent ST-segment elevation presenting as a localized blood clot in the pericardium following CABG has rarely been reported.\u003c/p\u003e \u003cp\u003eIn this case study, we explore a case of persistent ST-segment elevation after CABG. This case underscores the significance of postoperative persistent ST-segment elevation as a potential early indicator of local blood clots in the pericardium.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 54-year-old male was admitted due to exertional angina. Three-vessel coronary artery disease was initially diagnosed based on Coronary angiography. The patient underwent a selective three coronary artery bypass graft (CABG) and extracted the tube the next day. Liver and renal function tests were regular after CABG \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. ECG showed no ST segment abnormality \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003eA\u003cstrong\u003e)\u003c/strong\u003e. Pericardial drainage tube drainage was unobstructed.\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBlood gas analysis during the critical period and after improvement.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003cp\u003eCABG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2 hours after CABG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1days after CABG/before tracheal tube removal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2days after CABG/Before re-intubation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2days after CABG/2 hours after re-intubation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDay 3 after second surgery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePH, mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.35\u0026ndash;7.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP02, mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e136.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70\u0026ndash;110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePC02, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHC03-, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLac, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eLaboratory data during the critical period and after improvement.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"11\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDay of operation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThe second day after CABG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThree days after CABG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFour days after CABG\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDay of reoperation day\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThe first day after the reoperation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSecond day after reoperation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSix days after the reoperation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTen days after reoperation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHs-TNT(pg/ml)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e127.2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e508.3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e844.1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e499.4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e419.4.4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e467.4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e375.4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e80.1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0\u0026ndash;14\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eALT(U/L)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e583\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2848\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2141\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e299\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e9\u0026ndash;50\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAST(U/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e11055\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e4042\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3274\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e263\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e35\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u0026ndash;40\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBIL(umol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e45.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e58.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e69.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e79.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e60.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u0026ndash;26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDBIL(umol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e39.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e49.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e64.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e51.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.7\u0026ndash;6.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIBIL(umol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e29.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e18.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e19.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e9.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2-13.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePT(s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e20.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e18.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e18.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u0026ndash;14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAPTT(s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e35.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e68.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e60.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e59.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e37.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e36.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e26.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e23.8\u0026ndash;38.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eINR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.65\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.67\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.35\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.25\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.8\u0026ndash;1.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCr(umol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e56.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e196\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e206\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e196\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e184\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e335\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e109\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e82\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e57\u0026ndash;97\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eHs-TNT\u003c/strong\u003e: high-sensitivity cardiac troponin\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eALT\u003c/strong\u003e: alanine amino transferase\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eAST\u003c/strong\u003e: aspartate transaminase\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eTBIL\u003c/strong\u003e: totalbilirubin\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eDBIL\u003c/strong\u003e: direct Bilirubin\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eIBIL\u003c/strong\u003e: indirect Bilirubin\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003ePT\u003c/strong\u003e: prothrombin time\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eAPTT\u003c/strong\u003e: activated partial thromboplastin time\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eINR: i\u003c/strong\u003enternational normalized ratio\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003e\u003cstrong\u003eSCr\u003c/strong\u003e: serum creatinine\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eHowever, the patient developed dyspnea without fever, heart murmur or pericardial friction rub on the second day after CABG. An arterial blood gas analysis revealed PH 724, PO2 58mmHg, PCO2 30mmHg, HCO3\u0026thinsp;\u0026minus;\u0026thinsp;12.7mmol/L\u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. His high-sensitivity troponin T levels increased from 127.2pg/ml at 2 hours after CABG to 508.3pg/ml \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Electrocardiography showed ST segment significant elevation in I、AVL、II、V2-6 compared to the previous ECG \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003eB\u003cstrong\u003e)\u003c/strong\u003e. Cardiac ultrasound showed a well-defined hypoechogenicity of about 3.9*2.7cm at the left atrial base \u003cstrong\u003e(Video 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cdiv\u003e\n \u003cbr\u003e\n\u003c/div\u003e\n\u003cp\u003eIn line with the 2018 fourth edition of the universal definition of myocardial infarction, the causes of ST-segment elevation were considered: could this be a type 5 myocardial infarction and pericardial local blood clot? The patient was treated with intravenous nitroglycerin, subcutaneous low molecular weight heparin, and invasive mechanical ventilation. Unfortunately, this patient failed to undergo a second thoracotomy in time due to the new coronavirus epidemic. However, these conservative treatments led to an improvement in the patient\u0026apos;s oxygen saturation.\u003c/p\u003e\n\u003cp\u003eNevertheless, the patient\u0026apos;s condition deteriorated on the third postoperative day. He presented with manifestations of cardiac tamponade, such as moderate jugular distention (CVP 18cmH20), systolic blood pressure of 75mmHg, and oliguria. Echocardiography showed that posterior pericardial effusion 1.09 cm and diastolic collapse were observed in the right atrium and right ventricle, no segmental motion abnormality and EF 59% \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003eE\u003cstrong\u003e)\u003c/strong\u003e. Acute cardiac tamponade was considered based on Clinical presentation and cardiac ultrasound. Under aseptic conditions, retrograde into the pericardial drainage tube and about 140ml of bloody fluid was extracted. Subsequently, the patient\u0026apos;s hemodynamics were stabilized with trace norepinephrine support. But, the patient developed acute hepatic failure and renal failure. A Laboratory tests showed aspartate transaminase (AST) 4042U/L, alanine amino transferase (ALT) 2848U/L, totalbilirubin (TBil) 69.8umol/L, International normalized ratio(INR)1.67, blood urea nitrogen (BUN)16mmol/L, serum creatinine(SCr)206umol/L \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. The patient received hepatoprotective drugs and underwent bedside renal replacement therapy.\u003c/p\u003e\n\u003cp\u003eOn the fifth postoperative day, a rethoracotomy was conducted, revealing massive blood clots on the pericardial surface and partial occlusion of the inferior vena cava reflux \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003eF\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eWatchable, when these clots were surgically cleared \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003eG\u003cstrong\u003e)\u003c/strong\u003e, the patient\u0026apos;s spontaneous urine output recovered, and vasoactive drugs were discontinued. ECG showed elevated ST segment complete resolution in leads I AVL II V2-6 and bidirectional or inverted T waves in leads V2-6 \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003eC\u003cstrong\u003e)\u003c/strong\u003e. CRRT and ventilator were withdrawn on the first and third day after reoperation. By the third day post-reoperation, the electrocardiogram showed complete normalization of the original abnormal ST segment and T waves and no new pathological Q waves \u003cstrong\u003e(\u003c/strong\u003eFigs.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003eD\u003cstrong\u003e)\u003c/strong\u003e. Laboratory tests, such as liver function, renal function, and high-sensitivity troponin T, gradually returned to normal by the tenth day following reoperation.\u003c/p\u003e\n\u003cp\u003eThe patient was discharged 14 days after reoperation. After two years of follow-up, the patient had no major adverse cardiovascular events.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe clinical implications of transient ST-segment changes on the electrocardiogram following CABG remain debatable. Generally, these changes are considered non-specific and not associated with long-term prognosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, persistent ST-segment elevation after cardiac surgery is usually considered to be associated with adverse cardiovascular events [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe causes of ST-segment elevation after CABG are complex and include intraoperative damage to the pericardium and myocardium, postoperative inflammatory changes, myocarditis, pericarditis and coronary spasm[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hyperkalemia and hypothermia can also lead to ST-segment elevation but can be determined by clinical and laboratory results [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePericardial effusion is a common complication after CABG), with 1\u0026ndash;3% of them requiring timely intervention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Encapsulated pericardial effusion, often resulting from local clots on the pericardium following CABG, can cause life-threatening cardiac tamponade [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Patients are usually treated with substantial sedation, ventilation, and inotropes; typical signs of tamponade are generally absent, such as hypotension and paradoxical pulse [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It poses a significant challenge to the clinical and ultrasonic diagnosis of cardiac tamponade due to anatomical distortions, residual air in the thoracic cavity, the presence of surgical dressings or scars, and irregular accumulation of blood clots around the pericardium after CABG [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTransesophageal echocardiography has a high specificity for cardiac tamponade [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, it has yet to be widely popularized due to clinical conditions. Therefore, it is necessary to find a method to predict the occurrence of cardiac tamponade in patients at a later stage.\u003c/p\u003e \u003cp\u003eIt is difficult to distinguish true ischemia, pericardial inflammation, or blood clots on the pericardial surface based on ST-segment elevation. However, delayed identification of the cause of ST-segment elevation can cause malignant events such as acute myocardial infarction and acute cardiac tamponade. Clinicians should remain highly vigilant and suspicious. Emergency transesophageal ultrasound should be employed promptly for early detection in cases of high clinical suspicion for pericardial clot formation. When necessary, timely surgical intervention should be executed to enhance the likelihood of a successful outcome.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCABG: coronary artery bypass grafting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAMI: acute myocardial infarction\u003c/p\u003e\n\u003cp\u003eBUN: blood urea nitrogen\u003c/p\u003e\n\u003cp\u003eHs-TNT: high-sensitivity cardiac troponin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eALT: alanine amino transferase \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAST: aspartate transaminase\u003c/p\u003e\n\u003cp\u003eTBIL: totalbilirubin\u003c/p\u003e\n\u003cp\u003eDBIL: direct Bilirubin\u003c/p\u003e\n\u003cp\u003eIBIL: indirect Bilirubin\u003c/p\u003e\n\u003cp\u003ePT：prothrombin time\u003c/p\u003e\n\u003cp\u003eAPTT：activated partial thromboplastin time\u003c/p\u003e\n\u003cp\u003eINR: international normalized ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSCr：serum creatinine\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributors:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiang Zong and Huanzhen Chen designed the study and supervised the overall project. \u0026nbsp;Zhuo Yuan and Xingpeng Bo participated in collecting data, and Aiwen Wang participated in data collecting and analysis. Aiwen Wang, Shuzhen Bi and Huanzhen Chen, provided the statistical analysis and wrote the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s daughter for publication of this case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient\u0026rsquo;s daughter, and a copy of the consent form is available upon request to review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAshikhmina, E. A.; Schaff, H. V.; Sinak, L. J.; Li, Z.; Dearani, J. A.; Suri, R. M.; Park, S. J.; Orszulak, T. A.; Sundt, T. M., Pericardial effusion after cardiac surgery: risk factors, patient profiles, and contemporary management. Ann Thorac Surg 2010, 89 (1), 112-118.\u003c/li\u003e\n\u003cli\u003eKuvin, J. T.; Harati, N. A.; Pandian, N. G.; Bojar, R. M.; Khabbaz, K. R., Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg 2002, 74 (4), 1148-1153.\u003c/li\u003e\n\u003cli\u003eAdi O, Ahmad AH, Fong CP, Ranga A, Panebianco N. Resuscitative transesophageal echocardiography in the diagnosis of post-CABG loculated pericardial clot causing cardiac tamponade. Ultrasound J. 2021;13(1):22. Published 2021 Apr 15. doi:10.1186/s13089-021-00225-7\u003c/li\u003e\n\u003cli\u003eLehto J, Kiviniemi T. Postpericardiotomy syndrome after cardiac surgery. Ann Med. 2020;52(6):243-264. doi:10.1080/07853890.2020.1758339\u003c/li\u003e\n\u003cli\u003eImren, Y.; Tasoglu, I.; Oktar, G. L.; Benson, A.; Naseem, T.; Cheema, F. H.; Unal, Y., The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery. J Card Surg 2008, 23 (5), 450-453.\u003c/li\u003e\n\u003cli\u003eLiu, J.; Birnbaum, Y., ST segment elevation following coronary artery bypass surgery. J Electrocardiol 2019, 57, 128-131.\u003c/li\u003e\n\u003cli\u003eLockerman, Z. S.; Rose, D. M.; Cunningham, J. N.; Lichstein, E., Postoperative ST-segment elevation in coronary artery bypass surgery. Chest 1986, 89 (5), 647-651.\u003c/li\u003e\n\u003cli\u003eLoeb HS, Gunnar WP, Thomas DD. Is new ST-segment elevation after coronary artery bypass of clinical importance in the absence of perioperative myocardial infarction?. J Electrocardiol. 2007;40(3):276-281. doi:10.1016/j.jelectrocard.2006.08.098\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Coronary Artery Bypass Graft, Persistent ST-segment elevation, Pericardial Local Blood Clot, Cardiac Tamponade","lastPublishedDoi":"10.21203/rs.3.rs-4074031/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4074031/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackgroud\u003c/b\u003e: Local blood clots in the pericardium are a common complication after coronary artery bypass grafting (CABG). However, it is very rare to clinical present with persistent ST-segment elevation. To date, there have been no reported cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCase presentation\u003c/b\u003e: A 54-year-old male was admitted due to exertional angina. Three-vessel coronary artery disease was initially diagnosed based on Coronary angiography. The patient underwent a selective three coronary artery bypass graft (CABG) and extracted the tube the next day. But, on the second postoperative day, type I respiratory failure and type 5 myocardial infarction were diagnosed based on elevated ST segment, high-sensitivity troponin T and decreased P02 (55mmHg). The patient was given intravenous nitroglycerin and invasive mechanical ventilation. Despite these interventions, the patient's condition deteriorated on the third postoperative day. Cardiac tamponade was diagnosed based on clinical presentation and echocardiography. He underwent an emergency procedure for retrograde pericardial effusion drainage, which led to a rapid improvement in his clinical symptoms. Unfortunately, the patient subsequently developed acute hepatic and renal failure. A rethoracotomy was performed on the fifth postoperative day, which showed a large amount of blood clots on the pericardial surface and partial occlusion of the inferior vena cava reflux. The patient 's condition improved significantly and the elevated ST segment returned to normal after the surgery. On the tenth day after reoperation, laboratory tests such as liver function, renal function, and troponin T returned to normal. The patient was discharged fourteen days after the reoperation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: \u003cem\u003eP\u003c/em\u003eersistent ST-segment elevation as a rare but easily detectable clinical presentation of of pericardial local blood clots after CABG.\u003c/p\u003e","manuscriptTitle":"ST segment elevation for diagnosis of pericardial local blood clots after coronary artery bypass grafting: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-09 13:15:59","doi":"10.21203/rs.3.rs-4074031/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da09427c-2a75-4c1e-bff0-95719051b2d1","owner":[],"postedDate":"April 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-27T18:08:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-09 13:15:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4074031","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4074031","identity":"rs-4074031","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}