[Case of coronary spasm during thoracic surgery under combined epidural-general anesthesia]

A 70-year-old woman, who had neither complication nor risk factors of ischemic heart disease, was scheduled for a partial resection of the left lung. After an epidural catheter was placed at the T7-8 interspace, general anesthesia was induced and maintained with propofol and fentanyl. Once stable vital signs had been confirmed, 3 ml of 0.5% ropivacaine was given through the epidural catheter. Bradycardia with hypotension progressively developed and continued despite the intravenous administration of phenylephrine, ephedrine, and atropine. Fourteen minutes after the injection of ropivacaine, the electrocardiogram showed an elevation of the ST segment. One minute later, the heart rhythm changed to a 2:1-type second degree block. Although a bolus of 1 mg epinephrine was injected intravenously, severe hypotension and bradycardia persisted, leading to the complete block and paroxysmal ventricular tachycardia. Continuous infusion of nitroglycerin as well as cardiopulmonary resuscitation was started. The sinus rhythm with normal ST segment was eventually restored with subsequent hemodynamic stability. Intraoperative transesophageal echocardiography indicated a satisfactory cardiac wall motion. Coronary spasm was suspected because of the transient ST segment elevation and the absence of wall motion abnormality after the recovery. The clinical course of the A-V block appearing shortly after ST segment elevation suggested that the right coronary artery, perfusing the A-V node areas, was involved.