Subendocardial infarction on recovery from anesthesia]

A 57-year-old man without any history of coronary artery disease underwent total hip replacement for which a continuous lumbar epidural analgesia combined with general anesthesia was used. During the recovery from anesthesia, the patient developed sudden hypotension and ventricular fibrillation (Vf), followed by ST elevation (I, II, III, aVF and V2-V6) on ECG. A coronary angiography, which was performed 30 min after the onset of Vf, revealed both the total occlusion of proximal left anterior descending artery (LAD) and 25% stenosis of proximal right coronary artery. It seemed that coronary artery spasm had occurred during the emergence from anesthesia, and then the coronary spasm ceased in a minute or two, while thrombus was produced in proximal LAD. The patient recovered from the episode of myocardial ischemia after percutaneous transluminal coronary recanalization and intraaortic balloon pumping. This patient was operated again on 4th and 8th postoperative days uneventfully under general anesthesia (enflurane and nitrous oxide in oxygen).     

A case of cardiac arrest with coronary artery spasm during lumbar epidural anesthesia

A 61-year-old man underwent arthroscopic surgery for internal derangement of the knee joint under epidural anesthesia. Epidural catheterization was performed at the L 2-3 interspace. Operation was started with 10 ml of 1.5% lidocaine. Then 12 ml of 0.375% bupivacaine was added to epidural space. Twenty minutes thereafter, electrocardiogram demonstrated marked elevation of ST segment and atrio-ventricular dissociation, followed by cardiac arrest. Cardiopulmonary resuscitation was started immediately and after 25 minutes normal sinus rhythm was restored. The patient recovered with no neurological sequelae. Coronary angiogram examination was performed but no significant stenosis of coronary artery was observed. Coronary artery spasm caused by lumbar epidural anesthesia was suspected.     

Coronary artery spasm during neurosurgical anesthesia

We experienced a case of coronary artery spasm during neurosurgical anesthesia. A 69-year-old man was scheduled for craniotomy for cerebello-pontine angle meningioma. He had a history of cigarette smoking, but no history or evidence of ischemic heart disease. After the dura mater was opened, marked ST elevation on the ECG monitor followed by ventricular fibrillation was noticed. After successful resuscitation, the surgery was cancelled. Because the coronary angiography, immediately after surgery, demonstrated normal coronary arteries, coronary artery spasm was considered to be the cause of the ECG change. Possible triggering factor in this case was vagal stimulation due to surgical manipulation. Careful anesthetic management is required to prevent intraoperative coronary artery spasm even in patients without a history of ischemic heart disease during neurosurgery.     

Anesthetic management of concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy

This case report describes an anesthetic management of a patient who received successful concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy. A 66-year-old man presented for left lower lobectomy. His medical history included angina pectoris under control with isosorbide and nifedipine. Preoperative coronary angiography revealed multiple stenosis [100% at right coronary artery (# 2), 99% at left anterodescending artery (# 7) and 90% at left circumflex artery (# 11)]. Concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy were scheduled. Anesthesia was maintained with combined total intravenous anesthesia (propofol and fentanyl) and continuous thoracic epidural anesthesia. Postoperative pain was well controlled with continuous epidural analgesia (TEA) and patient control analgesia (PCA). There were no signs of postoperative respiratory complications and myocardial ischemia. Combined total intravenous and continuous thoracic epidural anesthesia has multiple benefits for concomitant coronary artery bypass grafting without cardiopulmonary bypass and left lower lobectomy.     

Anterior spinal artery syndrome after minimally invasive direct coronary artery bypass grafting under general combined epidural anesthesia

A 65-year-old patient with ischemic heart disease and severe diabetes mellitus underwent minimally invasive direct coronary artery bypass grafting under general combined with epidural anesthesia. Paraplegia developed after surgery and the diagnosis of anterior spinal artery syndrome was made based on the patient s neurological condition and magnetic resonance imaging findings. Paraplegia following epidural anesthesia is a rare but recognized complication and this complication should be taken into account, especially in patients at risk, when considering epidural analgesia techniques in the minimally invasive cardiac surgery.     

Coronary artery spasm under thoracic epidural anesthesia

Three paroxysmal episodes of ST-segment elevation in lead II of ECG were observed during bullectomy and chest closing under epidural anesthesia supplemented with enflurane in compressed air in a patient who had history of variant angina with 50% obstruction of right coronary artery. The first and the third episodes were followed by ventricular tachycardia, complete A-V block and hypotension. These attacks were preceded by decreases in heart rate and blood pressure. It was suspected that coronary artery spasm developed with increased vagal tone under thoracic epidural block. The first and the second attacks were successfully treated with intravenous injection of nitroglycerin and lidocaine. The third attack needed additional treatments which included intravenous administrations of atropine, epinephrine, isoproterenol and phenylephrine and direct heart massage through the thoracic incision. Postoperative serial examinations of ECG showed inverted T in lead V1-V4, and serum enzymes (GOT, GPT, LDH, CPK, CPK-MB) were elevated. However ratio of CPK-MB to total CPK was only 1.5%. The patient was discharged two weeks after the operation with normal ECG and serum enzymes. It is speculated that coronary artery spasm was induced by hypotension and vagal stimulation under epidural anesthesia which blocks cardiac sympathetic nerves.     

Recurrent ST-segment elevations in a patient without significant coronary disease

We report a case of recurrent ST-segment elevations totaling 7 times over 3 hours during subtotal gastrectomy and the early postoperative period in a patient with no history of coronary artery disease. Possible contributing factors include cold stimulus, epidural anesthesia, and inadequate depth of anesthesia. The first episode almost resulted in cardiac arrest and was treated with intravenous epinephrine. The second episode was associated with ventricular fibrillation, which was treated with defibrillation and intravenous verapamil. The third to the seventh episodes were successfully treated with intravenous nitrate. The electrocardiographic changes and postoperative coronary angiography were consistent with a clinical diagnosis of coronary artery spasm. This case suggests that coronary artery spasm is capable of occurring repeatedly in a cyclic pattern during perioperative periods.     

Ischemia, myocardial infarction and epidural anesthesia in patients with coronary disease

In patients with coronary artery disease, the beneficial effects of epidural anesthesia are well known and often emphasized. Thus, several studies have shown a decrease in the determinants of myocardial oxygen consumption, and an improvement in regional and global left ventricular performance. The disadvantages of epidural anesthesia in patients with coronary artery disease are also well known, however, rarely reported. These detrimental effects are dominated by a decrease in arterial pressure which in turn may compromise the coronary perfusion pressure and induce myocardial ischemia. These 2 case reports illustrate the occurrence of myocardial complications in relation to epidural anesthesia. These case reports contrast with data from the literature showing a beneficial influence of epidural anesthesia on the myocardium. However, the severity of the coronary artery disease in these 2 reported patients may explain this discrepancy. These case reports pointed out that the decrease in arterial pressure is not the exclusive mechanism by which myocardial ischemia may be observed during epidural anesthesia since an hemodynamically-unrelated ischemic episode is described. The treatment of myocardial ischemia during epidural anesthesia is illustrated by these 2 case reports. A relationship between myocardial ischemia and myocardial infarction is discussed from these observations.     

Coronary artery spasm immediately after the long-standing operation for cancer of the tongue]

A 72-year-old male underwent radical operation for cancer of the tongue. Anesthesia was maintained with the combination of enflurane-N2O-vecuronium and cervical epidural block. Five minutes after the cessation of the longstanding operation, VT and circulatory collapse occurred. After administration of lidocaine and ephedrine, VPC and ST elevation were noted, followed by VT and Vf. Cardioversion successfully restored sinus rhythm with no ST change, suggesting an episode of coronary artery spasm. The possible inducing factors in this case were hypotension and acute imbalance in autonomic nervous systems caused by hypovolemia, hypothermia, insufficient anesthetic depth, loss of surgical stress, neostigmine and epidural block. The authors reviewed case reports on coronary spasm, especially looking for possible inducing factors of coronary artery spasm during anesthesia.     

A case of coronary artery spasm during epidural anesthesia with continuous infusion of propofol

A 50-year-old male patient was scheduled for left partial pulmonary resection and biopsy. The patient had neither complication nor history of ischemic heart disease. After arriving in the operation room, an epidural catheter was inserted into the epidural space at the T 4-5 intervertebral space. Anesthesia was induced with intravenous propofol 100 mg, fentanyl 100 microgram and vecuronium 6 mg and then a double lumen endotracheal tube was inserted. Anesthesia was maintained with O2 and air (FIO2 0.3-1.0), continuous infusion of propofol, intermittent intravenous administration of fentanyl and epidural injection of 1% lidocaine. Forty-five minutes after the start of operation, ECG showed an elevation of ST segment and soon it passed into ventricular tachycardia and ventricular fibrillation. The patient was treated with cardiopulmonary resuscitation. Fifteen minutes later, ECG returned to sinus rhythm but the elevation of ST segment remained. We considered that these cardiac events were due to coronary spasm, and started continuous infusion of nitroglycerin and nicorandil. One hour later, ST segment returned to normal. The possible inducing factors in this case were altered balance between sympathetic and parasympathetic nervous activity caused by infusion of propofol and epidural block, and alpha-stimulation caused by ephedrine.     

Case of coronary spasm during thoracic surgery under combined epidural-general anesthesia

A 70-year-old woman, who had neither complication nor risk factors of ischemic heart disease, was scheduled for a partial resection of the left lung. After an epidural catheter was placed at the T7-8 interspace, general anesthesia was induced and maintained with propofol and fentanyl. Once stable vital signs had been confirmed, 3 ml of 0.5% ropivacaine was given through the epidural catheter. Bradycardia with hypotension progressively developed and continued despite the intravenous administration of phenylephrine, ephedrine, and atropine. Fourteen minutes after the injection of ropivacaine, the electrocardiogram showed an elevation of the ST segment. One minute later, the heart rhythm changed to a 2:1-type second degree block. Although a bolus of 1 mg epinephrine was injected intravenously, severe hypotension and bradycardia persisted, leading to the complete block and paroxysmal ventricular tachycardia. Continuous infusion of nitroglycerin as well as cardiopulmonary resuscitation was started. The sinus rhythm with normal ST segment was eventually restored with subsequent hemodynamic stability. Intraoperative transesophageal echocardiography indicated a satisfactory cardiac wall motion. Coronary spasm was suspected because of the transient ST segment elevation and the absence of wall motion abnormality after the recovery. The clinical course of the A-V block appearing shortly after ST segment elevation suggested that the right coronary artery, perfusing the A-V node areas, was involved.     

Case of cardiac arrest due to coronary spasm during laparoscopic distal gastrectomy

We describe a 50-year-old man who developed ventricular arrhythmia followed by cardiac arrest during laparoscopic distal gastrectomy. Preoperatively, there were no findings suggesting an ischemic heart disease. Anesthesia was maintained using sevoflurane combined with epidural anesthesia. His blood pressure, heart rate, and ECG waves were stable during the initial stage of laparoscopic procedure. After establishment of small laparotomy for stomach resection, the blood pressure decreased to before 60 mmHg without remarkable ST change on lead II. Administration of intravenous ephedrine was not effective and a short run appeared. Then persistent ventricular tachycardia followed by ventricular standstill developed. Chest compression and intravenous adrenalin restored sinus rhythm, and thereafter the patient remained hemodynamically stable with intravenous nitroglycerine and nicorandil. The operation was completed and the patient awoke without neurological deficits. Postoperatively the coronary angiography showed no stenosis of coronary arteries; however, when acetylcholine test was attempted on right coronary artery, paroxysmal ventricular fibrillation in accordance with spasm of #1 segmental coronary artery developed. In the case of abrupt onset of lethal arrhythmia, coronary vasospasm should be suspected even when ST changes are not recognized with routine ECG monitor.     

Epidural anesthesia for coronary revascularization in the conscious patient

Thoracic epidural anesthesia has been widely used to complement general anesthesia in coronary artery bypass grafting. The main advantages of the combination are excellent pain control and a less pronounced stress response to surgery. The invasiveness of surgery to treat ischemic heart disease has been attenuated thanks to the use of the mini-sternotomy and coronary anastomosis without extracorporeal circulation. In 4 patients, coronary artery revascularization was carried out via a mini-sternotomy, grafting the anterior descending artery to the left internal thoracic artery under high thoracic epidural anesthesia (block of segments T1-T8) with a perfusion of 0.75% ropivacaine and fentanyl in a conscious patient. There were no hemodynamic or respiratory complications during surgery. The mean duration of stay in the intensive care unit was less than 18 hours and the mean hospital stay was less than 5 days. Postoperative coronary arteriograms demonstrated the patency of all grafts and all patients were asymptomatic at 1 month. Our initial experience suggests that the use of only high thoracic epidural anesthesia is feasible in coronary revascularization in selected, cooperative patients who require a single coronary bypass graft.     

Coronary spasm during laryngoplasty

A 63-yr-old man weighing 56kg was scheduled for pharyngoplasty under general anesthesia. The patient had no history of ischemic heart disease. Preoperative ECG showed incomplete right branch block. We administered thiopental and succinylcholine for intubation. Anesthesia was maintained with enflurane, nitrous oxide, oxygen and pancuronium bromide. Thirty minutes after the start of incision, the patient developed a severe hypotension and ECG revealed ST elevation and complete AV block. We administered ephedrine hydrochloride, phenylephrine hydrochloride and atropine sulfate. The ECG returned to sinus rhythm but ST segment was depressed this time. We considered it due to coronary spasm, so we started continuous intravenous administration of nitroglycerin (0.5 microgram. kg-1. min-1). One hour later, ST segment returned to normal. ECG showed no remarkable changes and no symptoms were seen after the operation. We found it important to suspect coronary spasm when ECG showed PVC-like abnormal waves with ST elevation. We consider that continuous administration of nitroglycerin at a rate of 0.5 microgram. kg-1. min-1 was effective for the treatment of coronary spasm in this case.     

Treatment of acute right coronary artery occlusion during anesthesia

PURPOSE: Perioperative coronary artery occlusion is a potentially dangerous complication causing myocardial infarction and circulatory collapse. We report a case showing severe ST segment depression in leads II and V5 during anesthesia. Diltiazem and nifedipine, but not nitroglycerine, partially improved the ST changes which were normalized by a percutaneous cardiopulmonary system (PCPS). CLINICAL FEATURES: A 71-yr-old man with cerebrovascular disease was scheduled for coronary artery bypass grafting (CABG). Past medical history included myocardial infarction due to right coronary artery (RCA) occlusion. Both the femoral artery and vein were cannulated percutaneously before operation and the PCPS was prepared as a back-up system. Depression of the ST segments in leads V5 and II was observed following heparinization. Although hemodynamic stability was maintained with continuous infusion of catecholamines, the ST changes were not improved by intravenous nitroglycerine. Intravenous diltiazem followed by nasal nifedipine partially improved the ST changes. The changes were normalized after induction of PCPS. No neurological complications were observed. The postoperative coronary angiography confirmed the total occlusion of RCA. CONCLUSION: Calcium channel blockers were more effective than nitroglycerine in treating perioperative ST depression. However, none of them produced complete reversal of the ischemic changes which were normalized with PCPS.     

Awake heart valve surgery in a patient with severe pulmonary disease

Cardiac operations may be performed in a conscious, spontaneously breathing patient, but it is difficult to justify an awake technique in patients undergoing coronary artery procedures with low operative risk. We describe an elderly patient with severe chronic obstructive pulmonary disease in whom general anesthesia was contraindicated. A valve procedure was performed under thoracic epidural anesthesia alone, thus avoiding intubation and mechanical ventilation. The patient had an uneventful postoperative course and excellent recovery.     

Coronary artery spasm during low flow anesthesia]

A 70-year-old man, without history of angina pectoris, was scheduled for aorto-femoral bypass graft surgery under epidural anesthesia supplemented with nitrous oxide and sevoflurane. At the beginning of operation, twenty minutes after the start of low flow anesthesia (2 l.min-1), ECG showed an elevation of the ST segment during hypotension. Rising blood pressure and bolus injection of nitroglycerin relieved the elevation and his circulation became stable. It was suspected that a coronary spasm attack was induced by hypotension, as well as vagal stimulation from an inadequate amount of anesthesia. For prevention of intraoperative coronary spasm, it is important to maintain anesthesia at sufficient levels using monitors.     

Anesthetic management of combined lung volume reduction surgery and off-pump coronary artery bypass grafting

A 54-year-old man with severe emphysema and stenosis of coronary artery was scheduled for combined surgery of lung volume reduction and an off-pump coronary artery bypass grafting. His FEV1.0 was 600 ml and %FEV1.0 was 18%. Coronary angiography showed 99% stenosis of the left anterior descending artery. Anesthesia was induced with propofol, fentanyl and vecuronium, and was maintained with sevoflurane and continuous epidural anesthesia. In order to avoid high airway pressure, a pressure-controlled ventilation (less than 15 cmH2O) was carried out. A laryngeal mask airway was replaced with an endotracheal tube after surgery to avoid bucking during extubation, and this was removed after recovery from anesthesia successfully. No complications were observed during anesthesia. Lung volume reduction surgery after coronary reconstruction by off-pump coronary artery bypass grafting may be beneficial for patients with emphysema and ischemic heart disease.     

Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia

Background: Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia, most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences. This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease.

Methods: Four hundred twenty-three patients, between 1988 and 1991, were randomly assigned to receive general (n = 138), epidural (n = 149), or spinal anesthesia (n = 136) for femoral to distal artery bypass surgery. All patients were monitored with radial artery and pulmonary artery catheters. Postoperatively, patients were in a monitored setting for 48-72 h and had daily electrocardiograms for 4-5 days and creatine phosphokinase/isoenzymes every 8 h x 3, then daily for 4 days. Cardiac outcomes recorded were myocardial infarction, angina, and congestive heart failure.

Results: Baseline clinical characteristics were not different between anesthetic groups. Overall, the patient population included 86% who were diabetic, 69% with hypertension, 36% with a history of a prior myocardial infarction, and 41% with a history of smoking. Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received. In the intention to treat analysis, incidences of cardiac event or death for general, spinal, and epidural groups were 16.7%, 21.3%, and 15.4%, respectively. The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was -1.6% (95% confidence interval -9.2%, 6.1%) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia.     

Intraoperative coronary artery vasospasm: a twist in the tale!

The cause of variant angina is localized hyperresponsiveness of the vascular smooth muscle cells caused by non-specific stimuli of vasoconstriction. Autonomic imbalance can be one of the mechanisms of spontaneous vasospasm, and sympathetic or parasympathetic stimulation can induce Coronary Artery Spasm (CAS). Although various reports of CAS events have been described, episodes associated with untwisting or manipulation of a visceral structure remains unique. We report one such case of CAS in association with intraoperative untwisting of a torted ovarian cyst treated with intracoronary nitroglycerine in the catheterization laboratory. Vasospastic or variant angina is a well known clinical condition first described by prinzmetal and colleagues, characterized by CAS in normal and diseased coronary arteries. General anesthesia can be a triggering event. This case demonstrates unique etiology in that spasm was provoked by surgical manipulation of a torted ovarian cyst. CAS has been implicated as a cause of sudden, unexpected circulatory collapse and death during surgery, cardiopulmonary bypass, and other non-cardiac surgical procedures. There are few reports of coronary vasospasm during regional anesthesia and neuroaxial block. Many factors are involved in the occurrences of perioperative CAS including activated sympathetic activity, activated parasympathetic activity, cocaine, alkalosis, hypercalcemia, magnesium deficiency, succinylcholine, vasopressors, essential hypertension, Hyperthyroidism, epidural anesthesia, spinal anesthesia, smoking, lipid metabolic disorder, coronary artery aneurysm, commercial weight loss products. We describe a rare case of CAS during general anesthesia, in a patient with no past history of coronary artery disease, possibly provoked by surgical manipulation ofa torted ovarian cyst, which was diagnosed and treated promptly via cardiac catheterization. Intraoperative coronary artery vasospasm: a twist in the tale!