Asian Cardiovasc Thorac Ann 2006;14:e21-e23
© 2006 Asia Publishing EXchange Ltd
Intracoronary Adenosine Triphosphate for Refractory Coronary Artery Spasm
Min-Ho Song, MD,
Koji Sakurai, MD,
Tomohiro Nakayama, MD,
Makoto Shirakawa, MD,
Hiroaki Hagiwara, MD,
Haruo Kamiya, MD1
Department of Cardiovascular Surgery
1 Department of Cardiology, The Japanese Red Cross Nagoya First Hospital Nagoya. Japan
For reprint information contact: Min-Ho Song, MD Tel: 81 57 222 5311 Fax: 81 57 225 1246 Email: songmhmd{at}yahoo.co.jp, Department of Cardiovascular Surgery, Gifu Prefectural Tajimi Hospital, 5-161 Maehata-cho, Tajimi-shi, Gifu 507-8522, Japan.
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ABSTRACT
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A 62-year-old woman underwent aortic valve replacement for aortic stenosis. Her hemodynamics deteriorated with ST-T depression 6 hours postoperatively. Emergency coronary catheterization showed diffuse right coronary artery spasm. The spasm persisted despite intracoronary infusion of nitrates and calcium antagonists. Intracoronary adenosine triphosphate infusion finally resolved the spasm and stabilized the cardiac function.
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INTRODUCTION
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Postoperative coronary artery spasm is one of the grave complications after open heart surgery. The mechanism remains to be determined, and there is no definitive treatment. As a result of its potentially lethal consequences, it must be treated immediately by spasmolytic agents once the diagnosis is made. In the prevention of spasm of a coronary artery, several types of medication have been used. Besides traditional nitrates, calcium antagonists such as diltiazem and verapamil have been shown to be effective by increasing cyclic guanosine monophosphate (cGMP) and opening the potassium channel. Phosphodiesterase inhibitors such as amrinone and milrinone are relatively new but have shown strong spasmolytic activity. Levosimendan, another new drug for left ventricular dysfunction, also sensitizes the myofilaments to calcium and opens the adenosine triphosphate-dependent potassium channels, and its usefulness has been proved for heart failure and stunned myocardium.1 Adenosine triphosphate (ATP) is known to have a cardioplegic effect due to increasing potassium influx into the cardiomyocyte. It is hypothesized that ATP has an anti-spasm effect via potassium ATP channel opening.
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CASE REPORT
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A 62-year-old woman with severe aortic stenosis was admitted for aortic valve surgery. She complained of dyspnea on exertion. Her physical examination was unremarkable except for a midsystolic murmur. Her medication comprised digoxin (0.125 mg·day–1) only. A preoperative coronary arteriogram and cardiac catheterization showed normal coronary arteries. At operation, non-pulsatile cardiopulmonary bypass with mild systemic hypothermia was instituted. Retrograde blood cardioplegia was used for myocardial preservation. In dissecting the aortic root to expose the right coronary artery (RCA), it was noted that the RCA was relatively small. The diseased aortic valve, which was markedly calcified in all three cusps, was replaced with a 21 mm mechanical prosthesis, using horizontal mattress sutures. After aortic declamping and rewarming, the heart regained normal sinus rhythm, and the patient was weaned from cardiopulmonary bypass with low doses of dopamine (9 mg·h–1 based on a body weight of 51.3 kg). Completing the procedure, she was transferred to the intensive care unit in a stable condition with the same 9 mg·h–1 dopamine infusion.
Although her blood gases and electrolytes were within normal limits, ventricular premature contraction was noted, which was treated with a lidocaine drip. Her body temperature remained at 35.6°C. Six hours after the operation, her blood pressure fell below 60 mm Hg and her pulmonary artery pressure rose above 40 mm Hg. The electrocardiogram monitor showed apparent ST-T depression in leads II, III, and aVF. An intra-aortic balloon pump was inserted and emergency coronary arteriography was performed, which revealed diffuse spasm of the RCA (Figure 1
). Despite administration every 10 min of intracoronary isosorbide dinitrate (total dose, 100 mg), verapamil (total dose, 10 mg), diltiazem (total dose, 10 mg), and nicorandil (total dose, 40 mg), the spasm was not completely reversed, especially in segments 1 and 4 (Figure 2). Twenty-five minutes after the last intracoronary infusion of nicorandil, it was decided to inject ATP (two doses of 0.05 mg), which adequately relieved the spasm (Figure 3). The patient’s hemodynamic parameters stabilized, her blood pressure increased to 124/68 mm Hg, and her pulmonary artery pressure decreased to 32/10 mm Hg. An intravenous drip of diltiazem and ATP was continued for 3 days postoperatively and she was converted to oral medication (diltiazem 200 mg·day–1 and nicorandil 15 mg·day–1). She recovered without complications and was discharged 2 weeks after the operation.
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DISCUSSION
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Several factors have been suggested as the possible mechanism of coronary artery spasm during the early postoperative period. These include sympathoadrenergic stimulation, respiratory alkalosis, cold, local trauma, release of vasoconstricting substances by platelets, high local concentration of potassium, and plasma vasopressin and histamine liberation due to allergic reactions to protamine and blood products.2–5 Another report suggests the importance of stabilizing hemodynamics as this leads to amelioration of the spasm.6 After aortic valve replacement, it might be possible that fragments of the calcified aortic valve and atheromatous debris from the aortic wall are involved in triggering local stimulation of a coronary artery, especially the RCA.6 In this case, the procedure of dissecting the aortic root around the RCA may have been the trigger for local stimulation of the RCA, but coronary artery spasm occurred postoperatively, not intraoperatively. Thus, we could not explain why this patient suffered RCA spasm 6 hours postoperatively.
In Japan, ATP (Adetphos®; Kowa Pharmaceuticals Co.) is available for injection in almost all hospitals. As ATP has been officially approved by the Ministry of Welfare and Labor in Japan for treatment of arrhythmia, Japanese physicians do not need to seek Institutional Review Board approval to use it. ATP has the pharmacological effect of reversal of coronary spasm by opening the potassium-ATP channel. Absence of potassium channel subtype Sur2 is known to cause episodic coronary artery vasospasm.7 Although the clinical usefulness of ATP as a vasorelaxing agent is not well documented, administration of ATP is a rational approach to treatment of intractable coronary spasm. In this case, ATP had a powerful effect after nitrates and calcium antagonists failed to reverse the spasm.
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REFERENCES
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- Sonntag S, Sundberg S, Lehtonen LA, Kleber FX. The calcium sensitizer levosimendan improves the function of stunned myocardium after percutaneous transluminal coronary angioplasty in acute myocardial ischemia. J Am Coll Cardiol 2004;43:2177–82.[Abstract/Free Full Text]
- Weber S, Genevray B, Pasquier G, Chapsal J, Bonnin A, Degeorges M. Severe coronary spasm during drug-induced immediate hypersensitivity reaction. Lancet 1982;2:821.[Medline]
- Wu W, Zbuzek VK, Bellevue C. Vasopressin release during cardiac operation. J Thorac Cardiovasc Surg 1980;79:83–90.[Medline]
- Perez JE, Saffitz JE, Gutierrez FA, Henry PD. Coronary artery spasm in intact dogs induced by potassium and serotonin. Circ Res 1983;52:423–31.[Abstract/Free Full Text]
- Shafei H, Bennett JG. Coronary artery spasm during mitral valve replacement. Eur J Cardiothorac Surg 1990;4:398–400.[Abstract]
- Tsuchida K, Takemura T, Kijima M, Matsumoto S. Coronary artery spasm after aortic valve replacement. Ann Thorac Surg 1993;56:170–3.[Abstract]
- Chutkow WA, Pu J, Wheeler MT, Wada T, Makielski JC, Burant CF, et al. Episodic coronary artery vasospasm and hypertension develop in the absence of Sur2 K(ATP) channels. J Clin Invest 2002;110:203–8.[Medline]
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ABSTRACT
INTRODUCTION
