Successful management of refractory lethal coronary spasm after off-pump coronary bypass grafting

Coronary artery spasm following on-pump coronary artery bypass grafting with 20 months follow-up

We report on a 69-year-old woman who demonstrated native coronary artery and grafted vessel spasm following on-pump coronary artery bypass grafting (CABG). Despite intraaortic balloon pump (IABP) insertion, electrocardiogram (ECG) abnormalities did not disappear. Emergency coronary angiography (CAG) was performed. The patient was successfully treated with systemic and intracoronary injection of vasodilator agents. ECG changes disappeared, with normalized and stable hemodynamic function. Intraaortic balloon pump was maintained for 48 h. The patient was discharged in good clinical condition. Coronary artery spasm (CAS) may result in life-threatening arrhythmias, circulatory collapse or death. The etiology of CAS is multifactorial and includes heart manipulation, exogenous vasoconstrictors, stress-related catecholamine release, hypoxia and oxidative stress. Postoperative CAS is most commonly manifested by ST-segment elevation and circulatory collapse without specific causes. The gold standard for revealing CAS is CAG. Infusion of vasodilators combined with IABP is adequate in most instances, but extracorporeal membrane oxygenation has been necessary for more extensive or resistant coronary spasm.

Postoperative coronary artery spasm after mitral valve replacement

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Coronary artery spasm occurred after mitral valve replacement in a patient with normal coronary arteries.

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The patient had ST changes and inferior wall hypokinesia.

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The diagnosis was established by urgent postoperative coronary angiography.

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The spasm responded to the intracoronary injection of nitrates.

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The remaining postoperative course was uneventful and the left ventricular function returned to normal.

Introduction

Postoperative coronary artery spasm is an infrequent life-threatening event after cardiac surgery which can occur without an underlying coronary disease

Presentation of case

We report a documented case of a 67-year-old man with normal coronary arteries submitted to mitral valve replacement. Immediately after surgery he had a ST elevation in the inferior leads, and an inferior wall hypokinesia at the trans-oesophageal echo. A coronary angiography demonstrated a focal spasm in the right coronary artery which was successfully treated by intracoronary injection of nitrates. The following postoperative course was uneventful and the left ventricular function returned to normal.

Discussion

A coronary artery spasm should be suspected whenever a postoperative infarction occurs after valvular surgery especially in absence of associated coronary artery disease. In this cases postoperative coronary angiography allows both the diagnosis and the treatment.

Conclusion

This case-report summarizes the findings of this rare and potentially life-threatening cause of early postoperative ischemia and highlights the role of early coronary angiography in the cases of suspected myocardial infarction after cardiac surgery

Coronary artery spasm following off-pump coronary artery bypass surgery

Coronary artery spasm after coronary artery bypass surgery may result in life-threatening arrhythmias, circulatory collapse, or death. We report two cases of coronary artery spasm after coronary artery bypass surgery, one of which developed ventricular fibrillation requiring extracorporeal membrane oxygenation support. Both patients were discharged in good condition and are currently followed as outpatients. Unexpected sudden hemodynamic compromise could be due to coronary vasospasm, and this should be considered as one of the possible differential diagnoses. We were able to prevent the lethal consequences seen with coronary artery spasm by early diagnosis and management.