Results of coronary artery spasm treatment after cardiac surgery procedures
Tungusov D.S., Chernov I.I., Tarasov D.G., Pavlov A.V., Kondratyev D.A., Urtaev R.A.
Per-operative coronary spasm is a potentially life-threatening complication of
cardiac surgery. Most published cases of coronary artery spasm (CAS) occurred
following coronary artery bypass surgery, its occurrence after valve surgery is rare.
During an operation or in post operative period almost every surgeon faced with
the persistent ischemic signs, including ST-segment changes, hypotension, severe
global hypokinesia and ventricle heart arrhythmias. Besides surgically caused abnormal
coronary blood flow, ischemic condition may be developed due to CAS. Making a
decision we have to always suspect CAS.
According to published data an injection of nitrates into coronary arteries is
considered to be the most effective method of CAS treatment as compare to
intravenous delivery.
The method mentioned above has limitations which is impossible to overcome in
some cases. To perform coronary angiography we need to have a hybrid operation
theater or need to a transfer patient into an angio lab. Sometimes we are disabled to
execute it due to hemodynamics instability of a patient.
Two years ago we suggested an alternative method to cure this condition (patent
2552892 RU Tungusov D). We cross clamp aorta for a short time and inject nitrates into
aortic root in case of CAS suspicion. It enables to deliver nitrates especially into
coronary arteries intraoperatively. We cross clamp aorta for 10 – 15 seconds and inject
into aortic root 4 ml of nitrates solution (1 mg in 1 ml).
The purpose of the study was to compare two methods of CAS treatment.
During 2013 – 2014 we performed 3452 open heart procedures in our institution. Into
the 1st group we included patients who had underwent postoperative CAG with nitrates
injection into coronary arteries. Into the 2nd group we included patients who had
underwent cross-clamping of aorta and an injection of nitrates into aortic root. The 1st
group collected 22 patients and the second group 38 patients. Selection of method of
CAS treatment was based on the surgeons decision.
In general incidence of CAS was 1.7%. More often CAS have been registered
after CABG with correction of ischemic MV insufficiency and left ventricle reconstruction
in both groups.
The incidence of myocardial infarction was significantly higher in the 1 st group.
59% versus 15.8%/ In Six cases from the 2nd group in which myocardial infarction had
been developed coronary angiography has been performed. CAS, thrombosis or kingking of grafts have not been revealed. So we may suppose CAS to be cured
intraoperatively. In the first group 2 (9,1%) patients died. In the second group no
mortality was observed.
We would like to present algorithm of CAS treatment. We suggest to inject
nitrates in to aortic root on short time cross clamp of aorta in case of CAS suspicion. If
the estimated result wouldn’t be achieved CAG should be performed. In case of a
positive effect but doubts of potential technical problems with coronary blood flow CAG
also should be performed. If there are no evident technical problems and no ischemic
signs by EKG and Echo an operation may be finished.
The method mentioned above to have 2 contradictions such as porcelain aorta
and aortic valve procedures with aortic wall thinness.
In the conclusion we would like to say that intraoperative coronary artery spasm
treatment enables significantly decrease incidence of myocardial infarction, mortality,
ICU and hospital stay. The two compared methods do not exclude each other and
should be used together in order to ensure safety for a patient.