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J Thorac Cardiovasc Surg 2007;134:1380-1381
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Severe vasospasm in off-pump coronary artery bypass surgery: A difficult clinical problem

Pankaj Saxena, MCh, DNB, Igor E. Konstantinov, MD, PhD, Mark A.J. Newman, FRACS

Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, Australia

To the Editor:

We read with interest the article published by Schena and associates.1Go They have highlighted the importance of vasospasm in the nongrafted right coronary artery (RCA) without any hemodynamically significant disease in a patient undergoing off-pump coronary artery bypass surgery (OPCAB) to the diseased left-sided vessels. We2Go have had a similar experience in which initially vasospasm developed in a normal RCA after OPCAB to the left anterior descending (LAD) and obtuse marginal arteries. The spasm was relieved by an intracoronary injection of vasodilators. Subsequently, severe vasospasm involving the left internal thoracic artery (LITA) and LAD developed. There was no improvement in myocardial ischemia despite use of intracoronary vasodilators and an intra-aortic balloon pump (IABP). This patient required a drug-eluting stent across the LITA-LAD anastomosis for relief of the spasm (Figure 1).


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  		Figure 1. Severe vasospasm involving LITA and LAD, including the anastomotic area (A). Result of stent placement across the anastomosis (B). Source: Saxena P, Konstantinov IK, Singh T, Koniuszko MD, Newman MAJ. Persistent severe vasospasm in off-pump coronary artery bypass surgery: the value of intraluminal stenting. J Thorac Cardiovasc Surg. 2006;131:237-8. Reproduced with permission of Elsevier Inc.

 
The incidence of persistent vasospasm requiring the use of intracoronary vasodilators, IABP, or stents in our experience with 677 OPCAB procedures was 0.33%.2Go If there is no improvement in myocardial ischemia despite standard measures or in the setting of recurrent myocardial ischemia after OPCAB surgery, intracoronary stents may have to be used. Coronary angiography should be performed promptly if unexplained myocardial ischemia occurs in the immediate postoperative period. An aggressive approach to this problem is associated with a satisfactory outcome.

We congratulate the authors on the successful management of a difficult case and emphasize that stenting can be an effective mode of treatment of persistent coronary artery and graft vasospasm.

References

  1. Schena S, Wildes T, Beardslee MA, Lasala JM, Damiano RJ, Lawton JS. Successful management of unremitting spasm of the nongrafted right coronary artery after off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2007;133:1649-1650.[Free Full Text]
  2. Saxena P, Konstantinov IE, Koniuszko M, Singh T, Newman MAJ. Persistent severe vasospasm in off-pump coronary artery bypass surgery: the value of intraluminal stenting. J Thorac Cardiovasc Surg 2006;131:237-238.[Free Full Text]




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Igor E. Konstantinov
Mark A.J. Newman
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