Coronary vasospasm during anesthesia induction: awareness, recognition, possible mechanisms, anesthetic factors, and treatment

Anesthetic Management of a Patient With Prinzmetal Angina

Prinzmetal angina (PA) is characterized by the development of reversible vasoconstriction of the coronary arteries, transient ischemic electrocardiographic changes in the ST segment, chest pain at rest, and prompt response to nitrates. Spasms of the coronary arteries can be precipitated during the perioperative period by an imbalance of vasodilator and vasoconstrictor factors of smooth muscle cells, which can lead to myocardial ischemia, cardiac arrhythmias, and death. Nevertheless, this is a relatively unrecognized topic, and literature is scarce about it. We present a case report detailing the successful anesthetic management of a patient diagnosed with PA and a documented nitrate allergy, who underwent bilateral ureterorenoscopy.

Successful Use of Continuous Erector Spinae Plane Blocks in a Patient With Variant Angina After Large Ventral Hernia Repair

Coronary artery spasm constitutes the primary underlying pathology of variant angina. Because provocation of coronary artery spasm may occur with both excess sympathetic and excess parasympathetic stimulation, patients with this disorder have extremely limited options for perioperative pain control. This is especially true for procedures involving extensive abdominal incision/manipulation. Whereas neuraxial analgesia might otherwise be appropriate in these cases, several studies have demonstrated that coronary artery spasm can occur as a result of epidural placement, and therefore, that this may not be an optimal choice for patients with variant angina. This report discusses the case of a patient with a preexisting diagnosis of variant angina who underwent an exploratory laparotomy with large ventral hernia repair and for whom continuous erector spinae plane blocks were successfully used as analgesic adjuncts without triggering coronary artery spasm.

Perioperative coronary artery spasm after off-pump coronary artery bypass grafting in the non-manipulated coronary artery

BACKGROUND

Perioperative coronary artery spasm (CAS) following coronary artery bypass grafting (CABG) is a severe or lethal condition that is rarely reported. In addition, rare cases with CAS following CABG in the non-manipulated coronary artery are angiographically documented in the perioperative period. We aimed to report our experiences on the diagnosis and treatment of a case with CAS following off-pump CABG in the non-manipulated coronary artery.

METHODS

A 57-year old male with coronary heart disease and unstable angina willing to undergo CABG was admitted to our department. CABG was recommended as he showed 90% stenosis in distal left anterior descending artery, 90% stenosis in intermediate branch, 90% stenosis in left circumflex coronary artery, as well as 50% stenosis in proximal right coronary artery (RCA).

RESULTS

After CABG, the patient showed Adams-Stokes syndrome and ST-segment elevation. Then CPR was conducted and coronary angiography indicated perioperative CAS in the non-manipulated posterior descending artery. For the treatment, the patient received nitroglycerin injection into the coronary artery by catheter and pumping of diltiazem. Finally, the patient was discharged on day 7 after surgery. A comprehensive literature search was conducted to summarize the studies focused on the diagnosis and treatment of such condition, which indicated that all of the CAS cases occurred in the manipulated vessels, except one study showing CAS in the untouched native coronary artery which was similar with our case.

CONCLUSIONS

Perioperative CAS in the non-manipulated coronary artery following CABG is a severe or lethal condition that is rarely reported, which deserves close attention by the clinicians in clinical practice.

Prinzmetal’s variant angina during laparoscopy: a case report of vasospasm in the context of cardiac arrest

We report the case of a 43-year-old male patient who experienced cardiac arrest during two elective laparoscopies for cholecystectomy. The first procedure was prematurely interrupted after the return of spontaneous circulation (ROSC) while the other was continued under intravenous (IV) perfusion of nitrates (isosorbide dinitrate). At each time, after a cycle of cardiopulmonary resuscitation (CPR) and injection of atropine 0.5 mg, sinus rhythm was restored. Only 3-lead electrocardiogram (ECG) outlines were recorded, showing ST-elevation in lead II. During the first incident, a coronary angiography was performed showing a vasospasm of the left anterior descending (LAD) coronary artery, reversible upon intracoronary injection of nitrates. ECG during catheterization showed ST-elevation in the anterior coronary territory. Calcium-channel blockers (CCB) were prescribed, and oral nitrates were added after the second episode. Cardiovascular prevention consisted in smoking cessation, aspirin and statins. Reporting this case seems to be relevant due to its unusual presentation: Prinzmetal’s angina is usually described as morning chest pains, and it rarely concerns Caucasian men. Moreover, the vasospasm was associated with cardiac arrest and ECG changes suggestive of ST-elevation myocardial infarction (STEMI). The final diagnosis was myocardial infarction with non-obstructive coronary arteries (MINOCA) due to coronary vasospasm, a few minutes after insufflation of pneumoperitoneum. So far, few cases have been described during non-cardiac surgery, and even fewer during laparoscopy. Sharing our experience seems important to attract attention to cardiovascular events that can occur under general anesthesia, especially when clinical presentation is rare.

Management of ischaemia with non-obstructive coronary arteries (INOCA)

Up to half of patients undergoing elective coronary angiography for the investigation of chest pain do not present with evidence of obstructive coronary artery disease. These patients are often discharged with a diagnosis of non-cardiac chest pain, yet many could have an ischaemic basis for their symptoms. This type of ischaemic chest pain in the absence of obstructive coronary artery disease is referred to as INOCA (ischaemia with non-obstructive coronary arteries). This comprehensive review of INOCA management looks at why these patients require treatment, who requires treatment based on diagnostic evaluation, what clinical treatment targets should be considered, how to treat patients using a personalised medicine approach, when to initiate treatment, and where future research is progressing.

Case Report: Perioperative Kounis Syndrome in an Adolescent With Congenital Glaucoma

A 12-year-old male patient suffering from congenital glaucoma developed bradycardia, left ventricular failure, and hypotension after induction of anesthesia. Electrocardiography and echocardiography revealed a complete normalization of ECG and a complete spontaneous recovery in the cardiac function 72 hours from the beginning of the clinical manifestations, while cardiac Magnetic Resonance Imaging was performed, and coronary Computed Tomography scan revealed a myocardial bridge of a tract of the left anterior descendent coronary artery. Diagnosis of Kounis syndrome (KS) was made, a relatively novel, under-recognized clinical condition, defined as the manifestation of an acute coronary syndrome accompanied by mast cell activation and platelet aggregation involving interrelated and interacting inflammatory cells in the setting of allergic, hypersensitivity, anaphylactic or anaphylactoid insults. We described one of the first pediatric cases of KS related to anesthetic medications. In children, this syndrome has been only described in isolated case reports or small case series. Thus, it appears critical to report new cases of KS in children to increase the awareness of this disease in pediatric healthcare workers so as to enhance its early recognition and optimal therapeutic strategy. Furthermore, it appears of paramount importance the implementation of universal guidelines accepted by allergology and cardiology societies, in order to standardize the management of pediatric and adult patients with KS. Finally, a close collaboration between pediatric allergists and cardiologists seems fundamental for an optimal multidisciplinary patient care.

Acute myocardial infarction in patient without cardiac risk factors during emergence from general anesthesia: a case report

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.

ST Elevations and Ventricular Tachycardia Secondary to Coronary Vasospasm upon Extubation

ST elevations (STE) in the perioperative setting can result from a number of different etiologies, the most common and feared being acute coronary syndrome (ACS). However, other causes should be considered, as treatment may differ depending on the diagnosis. Here, we describe a case of STE and ventricular tachycardia in a patient at high risk for ACS. The patient had a prior diagnosis of coronary vasospasm; however, given pre-existing risk factors, much consideration and deliberation occurred prior to electing conservative therapy. This report provides an overview of perioperative vasospasm and other causes of STE, which anesthesiologists should be aware of.

Sudden cardiac arrest due to coronary vasospasm in a patient with Wolff-Parkinson-White syndrome during brain surgery: a case report

Background

Wolff-Parkinson-White (WPW) syndrome has the risk of sudden cardiac death. Without appropriate treatment, coronary vasospasm is also a potentially fatal condition due to ischemia-induced ventricular fibrillation. A rare case of cardiac arrest due to coronary vasospasm during general anesthesia in a patient with pre-existing WPW syndrome is presented.

Case presentation

A 55-year-old man was scheduled for brain surgery under general anesthesia. During surgery, the ECG monitor showed ST segment elevation followed by sustained ventricular tachycardia and the patient’s blood pressure was unmeasurable. Since pseudo-VT with WPW syndrome was suspected, pilsicainide was administered. A few weeks later, a spasm provocation test with acetylcholine was performed, which showed complete spastic occlusion of the right coronary artery.

Conclusions

A rare case of cardiac arrest during surgery in a patient with WPW syndrome, possibly caused by coronary vasospasm, was described.

Coronary Vasospasm as an Unexpected Cause of Intraoperative Hemodynamic Instability and Cardiac Arrest

We present a case of intraoperative coronary artery vasospasm during thoracic surgery causing profound hemodynamic instability. A 68-year-old man undergoing completion right pneumonectomy exhibited intraoperative widespread ST elevation with associated hypotension. Transesophageal echocardiography performed by the anesthetist revealed hypokinetic apical and lateral walls, prompting transportation to the catheterization laboratory, with angiography demonstrating widespread coronary artery spasm. Intracoronary nitroglycerin relieved the vasospasm; however, heparin administration caused significant postoperative bleeding, resulting in cardiac arrest requiring resuscitation and return to the operating room. He ultimately recovered and was discharged to a rehabilitation facility 3 weeks later.

[Coronary vasospasm in general anaesthesia induction]

Coronary artery vasospasm in the induction of general anaesthesia is a rarely reported complication in our environment, owing to its low incidence or due to having disappeared. We present a case of a previously healthy woman, scheduled for shoulder arthroscopy, who in the anaesthetic induction had a ventricular tachycardia, which spontaneously reverted to sinus rhythm with ST elevation on the left side, and which was diagnosed and treated immediately by using angiography. The importance of the case is based on the lack of references found, and on being rarely reported in health patients during the induction of general anaesthesia, and with an immediate diagnosis and resolving using angiography.

Kounis syndrome or allergic coronary vasospasm in a two-year-old

Kounis syndrome is coronary vasospasm because of mast cell degranulation in the context of an allergic reaction. The syndrome has known associations with several drugs used during anesthesia, including rocuronium and isoflurane. In this case report, we discuss a 2-year-old patient who developed signs and symptoms of an acute coronary syndrome soon after anesthesia for atrial septal defect repair. A diagnostic angiography after the episode revealed diffusely small coronary arteries. Subsequent angiography after clinical improvement showed essentially normal coronary anatomy. We report the clinical course of this patient and postulate that Kounis syndrome was the explanation for his transient coronary vasospasm. To date, this is the youngest known patient with reported Kounis syndrome.

Coronary artery spasm occurring in the setting of the oculocardiac reflex

The oculocardiac reflex (OCR) occurs in up to 90% of ophthalmological surgeries. Several preventive and treatment strategies have been described. Coronary artery spasm (CAS) plays an important role in the pathogenesis of variant angina and myocardial infarction. We describe an unusual case of a perioperative myocardial infarction due to CAS that occurred in the setting of the treatment of the OCR. We offer insight aimed at minimizing the deleterious effects of the OCR and its management.