Discussion
Coronary spasm after cardiac surgery is a rare entity that can be
associated to the development of arrythmias, both ventricular
fibrillation or ventricular tachycardia and bradycardia and
atrioventricular blocks3. It is defined as transient
total or subtotal coronary artery occlusion with angina and ischemic ECG
changes4. The underlying mechanism in this process is
still not clear and it results from the accumulation of multiple
triggers including endothelial dysfunction, coronary smooth muscle
calcium hypersensitivity, magnesium insufficiency, CBP related
inflammation and genetic susceptibility5. Recently,
coronary arteries hypersensitivity with vasospasm has been defined as
Kounis Syndrome6: anaphylactic response is supposed to
be the origin of a spectrum of coronary diseases resulting in
microvascular endothelial dysfunction and coronary spasm. Diagnosis may
be challenging without invasive examination, so certitude is obtained
only after coronary angiography. Anyway, coronary spasm should be
suspected in case of electrical instability after cardiac surgery: it
occurs especially after surgical myocardial revascularization, rarely
after valvular surgery, as reported in literature. Thus this syndrome is
unpredictable, promptness in diagnosis and treatment is fundamental.
Early recognition and immediate institution of specific treatment can be
performed in a hybrid theatre7: open-chest coronary
angiography allows evaluation and treatment of patients with early
cardiovascular collapse after cardiac surgery. Furthermore, the
consequent cardiac events such as coronary artery disease and acute
myocardial ischemia play crucial role in patient
survival8. Angioplasty (PCI) and coronary stenting are
not routinely indicated for patients with focal spasm and minimal artery
disease. Spasms may be due to the withdrawal of long-acting oral
nitrates or calcium channel blockers and are usually treated with
intracoronary nitrates, but it was not our case, for both, as the
patient had no therapy preoperatively and coronary spasms did not
respond to vasodilators nor to IABP. Moreover, when spasm is refractory
to conventional vasodilators, including nitrates, calcium channel
blockers, PCI turns out to be a valuable option 9.
Stent placement may be effective and moreover life-saving, once
hemodynamical instability has developed. Even if stent placement may be
a risk, as it may induce itself end-stent spasms10, in
our case, the decision of treatment was forced by the emergency
situation, as our patient could not be weaned from CBP. The binominal
interventional therapy and the opportunity to work in a hybrid setting
have a key role in the management and in the clinical consequences.
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