Coronary-artery spasm after coronary artery bypass graft surgery without extracorporeal circulation: Diagnostic and management

CASE REPORT Rev Bras Cir Cardiovasc 2010; 25(3): 410-414 Coronary-artery spasm after coronary artery bypass graft surgery without extracorporeal circulation. Diagnostic and management Espasmo coronariano no pós-operatório de cirurgia de revacularização do miocárdio sem circulação extracorpórea. Diagnóstico e manejo Joaquim David CARNEIRO NETO1, José Antonio de LIMA NETO2, Rosa Maria da Costa SIMÕES3, Noedir Antonio Groppo STOLF4 RBCCV 44205-1206 Resumo O espasmo de artérias coronárias no perioperatório de cirurgia de revascularização do miocárdio é uma complicação grave, com elevada mortalidade. Paciente de 51 anos submetido à cirurgia de revascularização do miocárdio sem circulação extracorpórea. Apresentou no 1°dia de pós-operatório (PO) alteração enzimática e supradesnivelamento do segmento ST, evoluindo, em seguida, em fibrilação ventricular, com reanimação cardiopulmonar com sucesso. Cateterismo cardíaco demonstrou espasmo importante de todas as artérias coronárias e da anastomose entre artéria torácica interna esquerda com artéria interventricular anterior. Utilizados vasodilatadores intracoronarianos e intra-enxerto, com restabelecimento de seus calibres usuais, imediata melhora clínica e estabilidade hemodinâmica. Com evolução satisfatória, o paciente recebeu alta hospitalar no 13o PO. Abstract Coronary artery spasm in perioperative of coronary artery bypass graft surgery is a serious complication, with high rate mortality. Patient 51 years-old submitted to coronary artery bypass graft surgery without Extracorporeal Circulation. The patient evolved in 1st post operative (PO) day with enzymatic alteration and ST-elevation, developing soon afterwards in ventricular fibrillation, defibrillation with success. Cardiac catheterization showed important spasm of all coronary arteries and anastomosis between the left internal thoracic artery and the left anterior interventricular artery. Intracoronary Vasodilators and intra-graft, with re-establishment of their usual and immediate calibers to improve clinic and Hemodynamic stability was used. Satisfactory evolution, discharged at 13rd PO day. Descritores: Revascularização miocárdica. Ponte de artéria coronária. Vasoespasmo coronário. Cateterismo cardíaco. Descriptors: Myocardial revascularization. Coronary artery bypass. Coronary vasospasm. Heart catheterization. INTRODUCTION The spasm of coronary arteries (CAS) in the intraoperative and postoperative (PO) for coronary artery bypass grafting surgery is a rare complication with an incidence of 0.8% to 1.3%, which may bring catastrophic 1. Internship in Cardiology - Hospital Beneficência Portuguesa; Postgraduate in Hemodynamics - Hospital Beneficência Portuguesa. 2. Internship in Cardiology - Hospital Beneficência Portuguesa, Postgraduate Diploma in Clinical Cardiology - InCor. 3. Internship in Cardiology - Hospital Beneficência Portuguesa; Cardiologist Clinic - Prof. Eq. Dr. Noedir Stolf - Hospital Beneficência Portuguesa. 4. Professor of Cardiovascular Surgery, Faculty of Medicine, University of São Paulo, Chairman of the Board of InCor - HC-FMUSP. 410 consequences, with high mortality [1-3]. It presents itself as an important cause of myocardial ischemia, of multifactorial aspect, with sudden appearance and it may predispose to serious cardiac arrhythmia, cardiogenic shock and death during surgery for coronary artery bypass grafting [4-6]. Work performed at the Hospital Beneficência Portuguesa of São Paulo, São Paulo, Brazil. Correspondence address: Joaquim David Carneiro Neto Rua Francisco Gonçalves de Andrade Machado, 120 – Bela Vista – São Paulo, SP, Brazil – CEP: 01323-050. E-mail: davidc.neto @ gmail.com Article received on May 1st, 2010 Article accepted on June 25th, 2010 CARNEIRO NETO, JD ET AL - Coronary-artery spasm after coronary artery bypass graft surgery without extracorporeal circulation. Diagnostic and management Rev Bras Cir Cardiovasc 2010; 25(3): 410-414 The authors present the case of a patient undergoing coronary artery bypass grafting without cardiopulmonary bypass (CPB), which developed severe CAS diagnosed by cardiac catheterization after episode of ventricular fibrillation (VF) and cardiogenic shock. This patient agreed to this publication, signing a consent term. This study was submitted to the Research Ethics Committee at the Hospital Real e Benemérita Sociedade Portuguesa de Beneficência and it was approved under protocol 404-08. day for 35 years) hospitalized for a month due to unstable angina and discharged with anti-ischemic therapy and programming for coronary angiography. Cardiac catheterization revealed 80% obstruction of proximal left anterior interventricular artery (AIA) and other arteries free of lesions (Figure 1). Soon after the procedure, he developed a new episode of chest pain, and then he was referred to the Intensive Care Unit, where he received therapy for unstable angina and scheduled surgery for myocardial revascularization. Electrocardiogram showed extensive anterior ischemia (Figure 2) and values for troponin and CK-MB <0.01 and 12, respectively. The patient then underwent coronary artery bypass grafting with distal anastomosis of left internal thoracic artery (LITA) for AIA without CPB. The intraoperative and CASE REPORT Patient 51 years, male, untreated hypertensive patient and former smoker 3 years earlier (smoked 20 cigarettes per Fig. 1 - Preoperative coronary angiography showing a severe lesion in1/3 of the proximal of the AIA and CX without obstructive lesions in RAO (A) and LAO cranial (B). RC free of lesions (C) Fig. 2 - Pre-operative electrocardiogram: an extensive anterior ischemia 411 CARNEIRO NETO, JD ET AL - Coronary-artery spasm after coronary artery bypass graft surgery without extracorporeal circulation. Diagnostic and management Rev Bras Cir Cardiovasc 2010; 25(3): 410-414 immediate postoperative (IPO) were uneventful. Values of troponin and CK-MB 0.067 (normal: 0.010 ng/ml) and 22 (normal: 25 U/L), respectively. On the 1st postoperative day, the patient presented EKG with abnormal nonspecific repolarization in the anterior wall, without clinical signs and hemodynamic stability. Evolutionarily, onset of pain, sharp in the left hemithorax and in the insertion site of the pleural drain; being prescribed painkillers, performed electrocardiogram, which showed STsegment elevation of 1 mm in leads V2-V5 (Figure 3), and dosed troponin (0.099) and CK-MB (51). The patient had a cardiopulmonary arrest (CPA) in VF. He presented exams gasometry, sodium, potassium and magnesium within normal limits. Performed cardiopulmonary resuscitation (CPR) with tracheal intubation and defibrillation with two 360J shocks with reversion to sinus rhythm, and amiodarone 300 mg, however, the patient presented hemodynamic instability, requiring use of norepinephrine and dobutamine. Referred to the hemodynamic service for emergency cardiac catheterization. During the examination, presented a new CPA in VF, bei (...truncated)