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Published on: April 4, 2022
A Rare Case of Nitroglycerin Resistant Coronary Arterial Vasospasm During Coronary Artery Bypass Surgery
Dina Soliman1, Cristian Castillo-Rodriguez1, Diego Cruz1
1Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
Insights
Coronary artery vasospasm after bypass surgery can mimic true blockages and resist standard treatment. Early diagnosis and advanced support are key for managing this rare, life-threatening condition.
Area of Science:
- Cardiology
- Vascular Surgery
Background:
- Coronary artery bypass grafting (CABG) can be complicated by rare but severe coronary artery vasospasm.
- Vasospasm resistant to nitroglycerin, particularly in the left main coronary artery (LMCA), presents diagnostic and therapeutic challenges.
Observation:
- A patient with suspected LMCA stenosis unresponsive to nitroglycerin underwent CABG.
- Postoperatively, the patient experienced recurrent, diffuse vasospasm refractory to nitroglycerin, requiring mechanical circulatory support.
Findings:
- Differentiating vasospasm from true LMCA stenosis is difficult.
- Nitroglycerin-resistant vasospasm can mimic fixed lesions, leading to potential misdiagnosis and severe complications during CABG.
- Diffuse coronary and peripheral vasospasm was confirmed by angiography.
Implications:
- Adjunctive imaging, alternative vasodilators, and early mechanical circulatory support are crucial for managing refractory vasospasm.
- A multidisciplinary, imaging-guided approach is essential for accurate diagnosis and optimal patient outcomes.
Background:
Coronary artery vasospasm following coronary artery bypass grafting (CABG) is a rare but potentially life-threatening complication that can lead to myocardial ischemia, arrhythmias, and cardiogenic shock. Nitroglycerin-resistant vasospasm, particularly involving the left main coronary artery (LMCA), poses significant diagnostic and therapeutic challenges.
Case Presentation:
We report the case of a 47-year-old female with a history of hypertension, hyperlipidemia, and ADHD on dextroamphetamine-amphetamine, who presented with chest pain and was found to have a suspected severe LMCA lesion. Coronary angiography revealed a 95% LMCA stenosis that was unresponsive to intracoronary nitroglycerin, raising concern for catheter-induced vasospasm versus true stenosis. The patient underwent urgent CABG. Intraoperatively and postoperatively, she experienced recurrent, diffuse coronary vasospasm refractory to nitroglycerin, necessitating multiple interventions including mechanical circulatory support with intra-aortic balloon pump and percutaneous ventricular assist device. Coronary angiography confirmed severe diffuse coronary and peripheral vasospasm. The patient was managed with intravenous vasodilators, vasopressors, and supportive care, and eventually recovered with restoration of cardiac function and discharge to cardiac rehabilitation.
Discussion:
This case underscores the difficulty in differentiating vasospasm from true atherosclerotic disease in the LMCA, the potential for nitroglycerin resistance, and the risk of severe complications during CABG. The use of adjunctive imaging modalities, vasodilators beyond nitroglycerin, and early mechanical circulatory support may be critical in managing such complex cases.
Conclusion:
Nitroglycerin-resistant coronary vasospasm, especially in the LMCA, can mimic fixed stenosis and lead to inappropriate surgical intervention and life-threatening complications. A multidisciplinary, imaging-guided approach is essential for accurate diagnosis and optimal management.
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