Asian Cardiovasc Thorac Ann 2006;14:158-160
© 2006 Asia Publishing EXchange Ltd
Vasodilator Resistant Lethal Spasm after Uncomplicated Off-Pump Coronary Surgery
Tetsuya Ueno, MD,
Kazuyuki Ikeda, MD,
Atsushi Nakashima, MD
Division of Cardiovascular Surgery, Ureshino National Hospital Saga, Japan
For reprint information contact: Tetsuya Ueno, MD Tel: 81 99 275 5368 Fax: 81 99 265 8177 Email: tueno{at}m.kufm.kagoshima-u.ac.jp, Department of Thoracic & Cardiovascular Surgery, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8520, Japan.
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ABSTRACT
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We report a case of lethal spasm of non-grafted coronary arteries after an uncomplicated off-pump coronary artery bypass grafting in a patient with no predisposing factors other than smoking. Transcatheter intraluminal injection of several vasodilators failed to relieve the spasm. The patient remained in profound cardiogenic shock due to broad acute myocardial infarction and died of multiple organ failure.
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INTRODUCTION
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Intra- and postoperative spasm of the native coronary arteries or bypass grafts is an uncommon but life-threatening complication.1 The etiology of perioperative coronary spasm is not fully understood.
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CASE REPORT
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A 72-year-old man with a history of smoking (20 per day) was transferred to our hospital with a diagnosis of anterior acute myocardial infarction, more than half a day after onset. Coronary angiography (CAG) showed occlusion of the left anterior descending artery (LAD) at its origin (Figure 1A
). The circumflex and right coronary arteries had mild (less than 25%) stenoses (Figure 1A and 1B). Because myocardial enzymes were already markedly elevated, catheter intervention was not performed. One month later, he underwent an uncomplicated off-pump coronary artery bypass grafting (OPCAB), in which the left internal thoracic artery (LITA) was grafted to the LAD.
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Figure 1. Preoperative coronary angiography. The left anterior descending artery was occluded at its origin (A). The circumflex and right coronary arteries had mild (< 25%) stenoses (A & B).
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About 10 minutes after extubation the patient suddenly went into shock, in association with ST elevation in leads II and III, and ventricular fibrillation (VF) on electrocardiogram (EKG). Coronary spasm of the right coronary artery was highly suspected. Intravenous administration of vasodilators, including nitroglycerin and calcium-channel blockers, did not improve these conditions. Echocardiography showed diffuse and severe hypokinesis in the posterolateral and inferior wall of the left ventricle. The patient underwent insertion of an intra-aortic balloon pump and was transferred to the catheter laboratory.
The CAG disclosed that the circumflex and right coronary arteries were in severe spasm throughout their whole lengths (Figure 2A and B). The proximal LAD was seen to have a 99% stenosis at its origin while its distal end exhibited a "to and fro" competitive flow pattern, which proved the LITA graft to be patent (Figure 2A). Intraluminal repeated infusion of nitroglycerin (4.5 mg in total), isosorbide dinitrate (22.5 mg), diltiazem (1 mg), verapamil hydrochloride (0.25 mg), nicorandil (2.4 mg), and papaverine hydrochloride (1.6 mg) provided little improvement of severe spasm on these un-grafted coronary arteries. The patient was placed on a percutaneous cardiopulmonary support (PCPS) system via the femoral artery and vein. The maximal value of creatinine phosphokinase was 4955 IU·L–1 and that of MB isozyme was 539 IU·L–1. The patient eventually died of multiple organ failure on the 13th postoperative day.
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Figure 2. Emergent postoperative coronary angiography. The circumflex and right coronary arteries were in severe and diffuse spasm (A & B). The proximal left anterior descending artery had 99% stenosis (A). Arrow = distal end of LAD with a "to and fro" pattern.
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DISCUSSION
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He and coworkers recommended that once coronary spasm is highly suspected, vasodilators should be infused selectively into the coronary arteries or bypass grafts in spasm — after other possible causes of unexplained hemodynamic deterioration have been excluded.2
According to the literature, the possible causes of coronary spasm are manipulation during operation, small coronary artery, coronary atherosclerosis, smoking, high endogenous or exogenous catecholamine levels, hypothermia, hypocapnea, and hypomagnesemia.1,3–5 Of these, light smoking was thought to be the only pertinent cause of coronary spasm in our case. Smoking has been reported to be a major risk factor for coronary spasm or vasospastic angina in the absence of significant coronary narrowing.4
Fatal events, including profound hypotension, hypoxia, and ventricular fibrillation, which might have triggered high endogenous catecholamine levels and required exogenous high-dose catecholamine infusion, have often occurred ahead of intra- or postoperative coronary spasm.1–3 However, fatal coronary spasm has occurred even in uncomplicated patients without these events, as in our case. According to anecdotal reports, supplemental infusion of magnesium sulfate during and after OPCAB totally eliminates sporadic occurrence of coronary spasm. In on-pump CABG, supplemental magnesium is one of the major components of the cardioplegia solution. In OPCAB, serum concentration of magnesium may be lowered by the rapid infusion of a large amount of extracellular type solution containing no magnesium. However, in our case, hypomagnesemia by dilution was unlikely to have occurred because the fluid balance during the operation was only +760 mL.
Lethal coronary artery spasm refractory to selective intraluminal injection of several vasodilators can occur after uneventful CABG, even in patients without apparent predisposing causes other than light smoking.
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REFERENCES
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- Paterson HS, Jones MW, Baird DK, Hughes CF. Lethal postoperative coronary artery spasm. Ann Thorac Surg 1998;65:1571–3.[Abstract/Free Full Text]
- He GW, Fan KY, Chiu SW, Chow WH. Injection of vasodilators into arterial grafts through cardiac catheter to relieve spasm. Ann Thorac Surg 2000;69:625–8.[Abstract/Free Full Text]
- Bittner HB. Coronary artery spasm and ventricular fibrillation after off-pump coronary surgery. Ann Thorac Surg 2002;73:297–300.[Abstract/Free Full Text]
- Sugiishi M, Takatsu F. Cigarette smoking is a major risk factor for coronary spasm. Circulation 1993;87:76–9.[Abstract/Free Full Text]
- Tanabe K, Osada N, Suzuki N, Nakayama M, Yokoyama Y, Yamamoto A, et al. Erythrocyte magnesium and prostaglandin dynamics in chronic sleep deprivation. Clin Cardiol 1997;20:265–8.[Medline]
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