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Interact CardioVasc Thorac Surg 2007;6:387-388. doi:10.1510/icvts.2006.145474 © 2007 European Association of Cardio-Thoracic Surgery
Coronary artery spasm following aortic valve replacementDepartment of Cardiology and Centre of Cardiothoracic Surgery, S. João Hospital, Porto, Portugal Received 22 September 2006; received in revised form 19 February 2007; accepted 20 February 2007
*Corresponding author: Serviço de Cirurgia Torácica, Hospital de São João, Alameda Prof. Hernâni Monteiro, 4202-451 Porto, Portugal Tel.: +351-225502417.
The authors present a clinical case of coronary artery spasm in a 62-year-old woman undergoing elective aortic valve replacement surgery for aortic regurgitation. On admission at ICU, the patient developed marked hemodynamic and electrical instability. Emergent coronary angiography demonstrated a pronounced spasm of the distal portion of the right coronary artery, apparently related to compression of this vessel by a chest drain tube.
Key Words: Aortic valve replacement; Coronary artery spasm; Chest drain tube
Coronary artery spasm is defined as a reversible coronary stenosis that limits coronary blood flow. Per-operative coronary spasm is a potentially life-threatening complication of cardiac surgery. Most published cases occurred following coronary artery bypass surgery, its occurrence after valve replacement is uncommon [1, 2]. We report a case of right coronary artery vasospasm, with profound electrical and hemodynamic instability, after aortic valve replacement (AVR).
A 62-year-old woman with symptomatic severe aortic regurgitation (NYHA class III) was admitted for elective AVR. There was no history of angina pectoris or of any other important clinical problem in the past. Preoperative cardiac catheterization confirmed important aortic regurgitation with normal left ventricular function. Coronary angiography showed no lesions. Aortic valve was replaced by a 19-mm mechanical prosthesis (St Jude Medical); thoracic aorta cross-clamping lasted 60 min. On admission at ICU, ST segment elevation occurred and was followed by transitory complete A-V block, pronounced hemodynamic instability and ventricular fibrillation. Percutaneous cardiopulmonary support was immediately started and an emergent transesophageal echocardiography (TEE) showed no signs of mechanical prosthesis dysfunction or evidence of myocardial impairment. Since marked hemodynamic and electrical instability persisted, coronary angiography was done that showed a pronounced spasm of the distal portion of the dominant right coronary artery. Intracoronary isossorbide dinitrate was promptly administered. Concomitantly, compression of the vessel wall by a chest drain tube was observed (Fig. 1a). The pericardial drainage tube was removed with relief of coronary vasospasm (Fig. 1b). Intra-aortic balloon counterpulsation was started and intravenous isossorbide dinitrate was maintained for 48 h.
The remainder of the postoperative course was uneventful. There was no evidence of myocardial infarction (EKG, Enzymes). Pre discharge evaluation (TEE, coronary angiography) showed normal aortic prosthesis, left ventricular functions and coronary perfusion (Fig. 2). The patient was discharged on the 11th postoperative day under nitrates and calcium-channel blocker. Two-year follow-up evolved without angina or cardiovascular events.
Coronary artery spasm is an abnormal transient contraction of a segment of an epicardial artery resulting in myocardial ischemia. The mechanism of spasm remains uncertain, but is considered to be multifactorial including the autonomic nervous system, platelet aggregation, vascular endothelium, among others. Endothelin and nitric oxide have been implicated in the control of vascular tone, and their activity seems to be impaired in the coronary arteries of patients who develop spasm. Recently, some genetic factors have been implicated [3]. Postoperative coronary arterial spasm has been associated to coronary artery trauma during surgical manipulation, compression by chest drain tubes, alkalosis, low body temperature and release of vasospastic factors by platelets damage during cardiopulmonary bypass [4]. The manifestations of spasm range from asymptomatic ST elevation to hypotension and circulatory collapse, related to arrhythmias or myocardial injury. Most cases have been reported in Japanese patients and during coronary artery bypass graft. Previous reports of postoperative coronary spasm after valve replacement procedure are rare [5, 6]. It must be considered in the differential diagnosis of acute postoperative circulatory instability because rapid recognition and specific therapy may be life saving [4]. In this case, emergency coronary angiography was performed since hemodynamic instability was not apparently related to mechanical prosthesis dysfunction or worsened ventricular function, and right coronary artery spasm was evidenced. We speculate that the focal trauma due to external compression of the vessel wall by a chest drain tube may have had some influence in the development of spasm. Indeed, the diffuse and severe nature of the observed coronary spasm suggests that this represents a true vasospasm and not only a simple case of focal compression of the vessel wall. According to this, intracoronary nitrates were immediately infused and almost simultaneously the drain tube was removed with clinical improvement. In conclusion, this case shows that coronary spasm should be considered as a cause of unexplained electrical or hemodynamic instability after cardiac surgery and adequate attitudes should be promptly undertaken.
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Abstract
1. Introduction
