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Asian Cardiovasc Thorac Ann 2004;12:91
© 2004 Asia Publishing EXchange Ltd

IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY

Coronary Artery Spasm of a Non-Culprit Vessel During Off-Pump Bypass Surgery

On-Hng Kwok, FACC, Wing-Hing Chow, FRCP, Shui-Wah Chiu, FRCS1

Division of Cardiology, University Department of Medicine
1 Division of Cardiothoracic Surgery, University Department of Surgery, Grantham Hospital, Hong Kong

For reprint information contact: On-Hing Kwok, FACC Tel: 852 2518 2611 Fax: 852 2518 8558 Email: vohkwok{at}netvigator.com 5/F Kwok Tak Seng Heart Center, Grantham Hospital, 125 Wong Chuk Hang Road, Aberdeen, Hong Kong.

A 53-year-old man, with a history of single left anterior descending artery (LAD) disease and repeated percutaneous coronary interventions, was referred for off-pump bypass surgery. Right coronary artery (RCA) was normal on preoperative angiogram (Figure 1Go). Direct off-pump revascularization of the LAD with a saphenous vein graft was successful. However, the cardiac monitor revealed pronounced intermittent ST elevation over the inferior leads intraoperatively. Blood pressure was labile. Emergent coronary angiogram showed patent graft and multiple sites of severe coronary artery spasm over the RCA, involving the right ventricular branch (Figure 2Go). Boluses of intracoronary nitroglycerin, adenosine, verapamil and sodium nitroprusside were administered meticulously. The spasm was relieved and blood pressure increased (Figure 3Go). ST-elevation was resolved. Continuous intravenous infusion of nitroglycerin and diltiazem was started. Patient recovery was uneventful.



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  		Figure 1. Preoperative "normal" coronary angiogram

 


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  		Figure 2. Multiple sites of coronary spasm involving the right ventricular branch.

 


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  		Figure 3. Coronary spasm relieved by intracoronary vasodilators.

 
The exact etiology of the bystander coronary artery spasm was largely unknown. Severe target vessel spasm with ventricular fibrillation-arrest after multi-vessel off-pump bypass surgery has been reported. Instrumentation and attempt to stabilize the heart during off-pump surgery may predispose to coronary spasm. Endothelial dysfunction may be present in vessels with apparently "normal" angiogram. Anesthetic drugs, alpha-adrenergic agents, vasopressors and mechanical insult may all trigger an exaggerated vasomotor response.





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