Coronary artery spasm in a neonate with transposition of great arteries: a rare complication and reason for heart transplant.

Arterial switch operation has become the standard of care for d-transposition of great arteries and has excellent short- and long-term outcomes. We report the case of a newborn with a diagnosis of d-transposition of great arteries with intact ventricular septum and a low-risk coronary artery anatomy who developed coronary artery vasospasm while coming off bypass following arterial switch operation in the operating room. The coronary artery spasm led to severe biventricular dysfunction and need for extracorporeal membranous oxygenation support. Despite extracorporeal membranous oxygenation and inotropic support, there was no improvement in the left ventricular function, and cardiac transplantation was performed after 8 days. The explanted heart showed extensive infarction of both ventricles. Both the coronary ostei were patent with no evidence of thrombus, suggesting coronary artery vasospasm rather than embolus or thrombus formation. This is the first case of coronary artery vasospasm in a neonate with d-transposition of great arteries leading to cardiac transplantation. We speculate that early identification of patients who are at a high risk for coronary vasospasm and prophylactic or timely infusion of papaverine directly into the coronary arteries may be beneficial in this condition.

Coronary Vasospasm and Bowel Ischemia in a Patient with Metastatic Gastrointestinal Carcinoid.

We describe a case of a 60-year-old female with a history of metastatic carcinoid disease with liver involvement who developed coronary vasospasm and mesenteric ischemia. The carcinoid syndrome is known for its cardiac involvement most well characterized by fibrous tissue deposits on the endocardium.(1,2) Case reports of coronary artery vasospasm have been previously described and hypothesized to be mediated by vasoactive amines and polypeptides synthesized by the tumor.(3-9) Intestinal ischemia is another reported complication of the carcinoid syndrome and is hypothesized to have a similar mechanism to that of the coronary vasospasm.(10-17) We have reviewed the literature and describe a case of coronary vasospasm and mesenteric ischemia in a patient on octreotide therapy. This is the first case in which we have identified concurrent coronary vasospasm and mesenteric ischemia in a patient with carcinoid disease.

Exercise-induced vasospastic angina after left atrial catheter ablation: a case report.

INTRODUCTION: Left atrial catheter ablation (LACA) is routinely used in the management of recurrent atrial fibrillation. CASE PRESENTATION: We report a patient suffering from vasospastic angina 2 months after a LACA procedure. Typical clinical symptoms, ST-segment changes during exercise test and successful treatment with nicorandil led to the diagnosis. According to our hypothesis, destruction of autonomic ganglia in the left atrium and resulting autonomic nerve tone imbalance might be the main determinants that have caused this phenomenon. CONCLUSION: Coronary spasms even weeks after LACA should draw attention to a possible association with the procedure.

Intraoperative administration of clevidipine to prevent vasospasm after radial and internal mammary artery grafts during coronary artery bypass grafting.

During coronary artery bypass graft surgery, various arterial and venous conduits have been used to carry blood flow from the aorta to the coronary vasculature. Arterial conduits provide certain advantages over the saphenous vein, including superior long-term patency, relative resistance to the development of atherosclerosis, and greater endothelium-dependent relaxation. However, the perioperative release of catecholamines and thromboxane A, mechanical manipulation, and underlying endothelial cell dysfunction may result in vasoconstriction or vasospasm of the arterial conduit and a compromise of myocardial perfusion. Given these issues, pharmacologic therapy is frequently initiated intraoperatively to prevent vasospasm. Clevidipine is a rapidly acting calcium channel antagonist. Like nicardipine, it is a member of the dihydropyridine subgroup. Its rapid metabolism by tissue and plasma esterases results in an effective half-life of 1 to 3 minutes. We report, for the first time, the perioperative use of clevidipine to prevent vasospasm after coronary artery bypass graft surgery with the use of internal mammary artery and bilateral radial artery conduits. Its potential application in this scenario and advantages when compared with other commonly used agents is discussed.

Perioperative coronary artery spasms in patients undergoing catheter ablation of atrial fibrillation.

PURPOSE: Catheter ablation (CA) is an established treatment for atrial fibrillation (AF). Although coronary artery spasms (CAS) during or after ablation procedures have been described as a rare complication in some case reports, the incidence and characteristics of this complication have not been fully elucidated. The present observational study aimed to clarify the CAS in a large number of patients experiencing AF ablation. METHODS: A total of 2913 consecutive patients (male: 78%, mean 66 ± 10 years) who underwent catheter ablation of AF were enrolled. RESULTS: Nine patients (0.31%, mean 66 ± 10 years, 7 males) had transient ST-T elevation (STE). Eight out of the 9 patients had STE in the inferior leads. STE occurred after the transseptal puncture in 7 patients, after the sheath was pulled out of the left atrium in 1, and 2 h after the ablation procedure in 1. Six patients had definite angiographic CAS without any sign of an air embolization on the emergent coronary angiography. In the3 other patients, the STE improved either directly after an infusion of nitroglycerin or spontaneously before the CAG. The patients with CAS had a higher frequency of a smoking habit (89% vs. 53%; P = .04), smaller left atrial diameter (36 ± 6 vs. 40 ± 7; P = .07), and lower CHADS2 score (0.6 ± 0.5 vs. 1.3 ± 1.1; P = .004) than those without. CONCLUSIONS: Although the incidence was rare (0.31%), CAS should be kept in mind as a potentially life-threatening complication throughout an AF ablation procedure especially performed under conscious sedation.

A case of intraoperative coronary artery spasm in a patient with vascular disease.

A 66-year-old man with a history of longtime smoking, untreated hypertension, hyperlipidemia, and impaired glucose tolerance but no history of myocardial infarction or angina pectoris was scheduled for right aortofemoral bypass and thromboembolectomy for arteriosclerosis obliterans with right common iliac and right popliteal arterial thrombus. Epidural anesthesia and general anesthesia were administered without obvious ECG changes. Just after skin incision, ST elevation in leads II and V5 and a short run of ventricular tachycardia with frequent premature ventricular contractions (PVCs) were recorded on the ECG monitor, and the patient's blood pressure suddenly decreased within a few seconds. On noticing these changes, we suspected coronary artery spasm (CAS) and rapidly administered vasodilators and vasopressors to stabilize hemodynamics and ECG changes. Transesophageal echocardiography (TEE) showed basal to mid- and anteroseptal to inferior wall motion hypokinesis that gradually returned to normal during observation. Even in patients without coronary disease but with systemic arteriosclerosis, it is important to consider the possibility of perioperative CAS and not to overlook ECG changes. Immediate diagnosis and treatment are essential.

[Case of coronary vasospasm during lumbar discectomy in prone position].

A 62-year-old man with hypertension was scheduled for discectomy at L4-5 in prone position. Anesthesia was induced with propofol 70 mg, fentanyl 0.75 mg and rocuronium 40 mg and maintained with sevoflurane 0.8-2.0% in oxygen 2 l x min(-1) and nitrous oxide 2 l x min(-1). Just before the end of surgery, ST elevation with hypotension on the ECG was observed for only a few seconds, followed by ventricular fibrillation (Vf). Immediately, lidocaine 50 mg, nitroglycerine 0.5 mg and methoxamine 6 mg were administered intravenously, and sinus rhythm and normal blood pressure returned from Vf within one minute. This case achieved a complete response to quick administration of the coronary vasodilator and antiarrhythmic agent, in this case whose coronary spasm was suspected on the basis of ST elevation in the first place. We have to be careful of various initiating factors for coronary spasm each time during anesthesia as it is difficult to assess its clinical risk, especially in prone position because actual coronary flow is much lower and cardiac resuscitation is difficult in a sudden cardiac complication.

[Coronary artery spasm during neurosurgical anesthesia].

We experienced a case of coronary artery spasm during neurosurgical anesthesia. A 69-year-old man was scheduled for craniotomy for cerebello-pontine angle meningioma. He had a history of cigarette smoking, but no history or evidence of ischemic heart disease. After the dura mater was opened, marked ST elevation on the ECG monitor followed by ventricular fibrillation was noticed. After successful resuscitation, the surgery was cancelled. Because the coronary angiography, immediately after surgery, demonstrated normal coronary arteries, coronary artery spasm was considered to be the cause of the ECG change. Possible triggering factor in this case was vagal stimulation due to surgical manipulation. Careful anesthetic management is required to prevent intraoperative coronary artery spasm even in patients without a history of ischemic heart disease during neurosurgery.

Multiple Life-threatening Coronary Artery Spasms after Percutaneous Coronary Intervention for Acute Coronary Syndrome.

A 69-year-old man who had been hospitalized with acute coronary syndrome (ACS), underwent urgent percutaneous coronary intervention. In the subacute phase, he developed sudden chest pain and hemodynamic deterioration, and urgent coronary angiogram showed multiple coronary artery spasms. The discontinuation of beta-blocker treatment and the administration of a calcium antagonist helped prevent angina attacks. In Japanese patients who tend to have coronary artery spasm, the routine administration of beta-blockers for post-ACS patients with a preserved left ventricular systolic function should be considered carefully.

Hyperthyroidism-associated coronary vasospasm with myocardial infarction and subsequent euthyroid angina.

A 40-year-old African-American woman presented with atypical chest pain, an acute non-ST segment elevation myocardial infarction, and angiographic evidence for severe ostial vasospasm of the left main and right coronary arteries. Subsequently, she was diagnosed with hyperthyroidism and treated with antithyroid therapy and oral nitrates. Repeat angiography revealed resolution of the vasospasm; however, the chest pain recurred in the euthyroid state. Hyperthyroidism-associated coronary vasospasm is a rare disorder that characteristically causes angina in young Asian women and resolves with correction of hyperthyroidism. We present an atypical case of an African-American woman presenting with a myocardial infarction who developed recurrent angina while euthyroid.

Very late coronary spasm inducing acute myocardial infarction in a heart transplant recipient.

: We report coronary angio findings of very late (10-year) coronary spasm inducing acute myocardial infarction with typical chest pain in a heart transplant recipient. Coronary spasm was promptly relieved by intra-coronary infusion of nitrates.

Coronary vasospasm as a cause of angina following interventional recanalization.

Angina following a coronary intervention may be due to vasospasm rather than restenosis. Two cases of angina following a previously successful recanalization are described. In both cases vasospasm was documented as the cause of angina, determined in one case by using an ergonovine provocative test and in the other by using lesion response to nitroglycerine. Rather than another intervention, vasodilator treatment was instituted, with effective symptom amelioration.