Late perioperative native coronary artery spasm following bypass grafting in a patient with anomalous aortic origin of the coronary artery

Abstract

Native right coronary artery (RCA) spasm is a less frequent early complication of perioperative coronary artery bypass grafting. Late presentation at 6 days postoperation is scarce and its relationship with an anomalous coronary artery is unknown. The optimal management and prevention remains controversial. In the case presented, the patient's anomalous left coronary artery originating from the right coronary cusp underwent ligation at its proximal segment at the time of bypass grafting. This ligation was preformed to prevent competitive flow. Six days postoperation, a refractory spasm of dominant native RCA occurred. The spasm resulted in right ventricular failure. Administration of intracoronary verapamil had a longer sustained vasodilatory effect and resolution of coronary spasm when compared with intracoronary nitroglycerine injection. An intra-aortic balloon pump, inotropic agents and low-dose nitroglycerine were used to maintain adequate haemodynamic support. Right ventricular systolic function recovery was noted within 2 days postintervention.

Keywords: cardiothoracic surgery; cardiovascular system; heart failure; interventional cardiology; ischaemic heart disease.

Figure 1

Regadenoson cardiac stress test with ECG (A) and nuclear imaging (B).

Figure 2

Preoperative cardiac catheterization, showing right coronary artery free of significant disease with no evidence of spasm (A); selective angiography of anomalous LAD with its septal perforators and diagonal branches (B).

Figure 3

Axial view of coronary CT angiography showing anomalous left coronary artery with intra-arterial course (A); dominant RCA without any evidence of stenosis (B); Cx with in-stent stenosis and delayed filling (C). RCA, right coronary artery.

Figure 4

Three-dimensional reconstruction CT with 45° rotational view between (A) and (B) to appreciate RCA and anomalous left coronary artery anatomy with separate but neighbouring ostia and their branches. RCA, right coronary artery.

Figure 5

Cardiac catheterization showing severe right coronary artery (RCA) spasm at distal segment with TIMI-2 flow (A); moderate improvement in spasm with intracoronary administration of nitroglycerine (B); marked improvement and sustained patency with intracoronary administration of verapamil (C). Transthoracic echocardiogram performed during active RCA spam showing severe dilation of right atrium and ventricle with basal right ventricular diameter of 4.20 cm (D); elevated right-sided pressure illustrated with dilated and non-collapsible inferior vena cava with diameter 2.40 cm (E).