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Ann Thorac Surg 2007;83:670-672
© 2007 The Society of Thoracic Surgeons
a Institute of Cardiac Surgery, Catholic University of Rome, Rome, Italy
b Institute of Cardiology, Catholic University of Rome, Rome, Italy
c Institute of Cardiac Anesthesia, Catholic University of Rome, Rome, Italy
Accepted for publication June 5, 2006.
* Address correspondence to Dr Altamura, Institute of Cardiology, Catholic University, Rome L.go F. Vito 1, Rome 00168, Italy. (Email: lucaaltamura{at}yahoo.com).
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Introduction |
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We report a case of coronary spasm soon after aortic valve replacement associated with hemodynamic and arrhythmic instability. The spasm was demonstrated at coronary angiography and was resolved with the intracoronary infusion of nitrates and antiarrhythmics.
A 65-year-old man with a history of angina on exertion and dyspnea was referred to the Department of Cardiovascular Disease of the Catholic University of Rome. An echocardiographic evaluation showed severe aortic regurgitation with normal left ventricular function. Cardiac catheterization confirmed severe aortic regurgitation and showed normal epicardial coronary arteries.
The patient was scheduled for aortic valve replacement, which was performed 10 months later with implantation of a Sorin Bicarbon n 23 valve (Sorin Biomedica Cardio S.p.A., Saluggia, Italy). The operation was performed under hypothermic cardiopulmonary bypass (30°), and continuous blood cardioplegia was delivered at the same temperature. At the end of cardiopulmonary bypass, after a period of hemodynamic stability, the patient presented ST segment depression (leads D2, D3 and aVF) and repeated ventricular fibrillation in the absence of apparent surgical causes.
Urgent coronary angiography demonstrated diffuse vasospasm of the entire coronary tree (Fig 1). During catheterization, the systemic pressure fell to 60/30 mm Hg. An intracoronary infusion of nitrates and verapamil promptly resolved the coronary spasm with immediate restoring of normal pressure values and normalization of ST segment (Fig 2). Amiodarone infusion was also started. Left ventricular failure needed inotropic support for 2 days after the intervention. Recovery was uneventful thereafter, and the patient was discharged home on the postoperative day 17.
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To date, few cases of coronary artery spasm have been reported in patients receiving isolated valve surgery [2–4]. In all patients, the preoperative coronary angiography showed normal coronary vessels. With the exception of the patient described by Shafei and Bennett [2], in whom spasm was evident when weaning from the extracorporeal circulation, the spasm caused a postoperative ST elevation in the corresponding electrocardiograph (ECG) leads, hemodynamic instability, and major ventricular arrhythmias requiring resuscitation in all cases and the use of an intraaortic balloon pump in some. ECG recovery and hemodynamic stabilization was obtained after intravenous or intracoronary injection of nitrates. Postoperative coronary angiography documenting the spasm was performed during the resuscitation maneuvers in 2 patients (including ours) [4] and at a distance in another [3]. In this latter patient, the intracoronary injection of ergonovine documented a spasm of the right coronary artery that corresponded to the clinical setting. In only 1 patient, the endothelial dysfunction was studied preoperatively by intracoronary injection of ergonovine, causing a spasm of the right coronary artery [2].
In the postoperative period coronary artery spasm must be differentiated from coronary artery embolism. Air embolism into the coronary artery occurs to some extent in all patients after removal of the aortic cross clamp. Its appearance is usually temporary, easily diagnosed, and self-limiting. In exceptional cases, the embolus is particulate. This can occur in relation to aortic valve decalcification or left atrial thrombectomy [6]. In these cases, however, the hemodynamic impairment and the ST anomalies are immediately evident when the coronary perfusion is restored and usually require a coronary artery bypass graft to reestablish a normal flow pattern.
Although a coronary artery spasm can be induced in about 33% [7] of healthy subjects by intracoronary injection of acetylcholine or ergonovine, its incidence in the postoperative period of valvular patients is rare and prevents the widespread use of these tests in patients undergoing cardiac surgery. Potassium chloride infused with cardioplegic solutions may also cause a coronary artery spasm in the presence of endothelial dysfunction [8]. When nitric oxide production by the endothelium is reduced, potassium chloride can induce contraction of the muscular cells in the media. This mechanism requires a lesion of the endothelium and is therefore rare in valvular patients with normal coronary arteries.
We are convinced that the routine use of continuous blood cardioplegia with normal potassium concentrations during the maintenance phase in contrast with classic cold crystalloid solutions, which renew the high potassium concentrations, may contribute to the prevention of the spasm by washing out the excess potassium. This also avoids the routine use of nitrates in the intraoperative and postoperative phases of the procedure. Furthermore, treatment of coronary spasm with intravenous vasodilators during episodes of severe hypotension may worsen the hemodynamic status and at the same time be ineffective, especially if systemic vasopressors have been used to sustain systolic blood pressure after recurrent cardiac arrests. The resolution of the spasm in such instances requires large doses of nitrates that can only be safely administered directly into the coronaries. This may be done either in the operative room or in the catheterization laboratory, as we did in the present case.
We suggest that in case of sudden postoperative ST elevation in valvular patients, an intravenous infusion of nitrates should be initiated, transesophageal echocardiography should be performed to confirm normal prosthetic function and to exclude aortic dissection, and the patient should be evaluated for coronary artery spasm. Instead of rushing the patient back to surgery, the evaluation should include postoperative angiography in case of hemodynamic failure or ventricular arrhythmias.
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