ROPIVACAINE-INDUCED CORONARY ARTERY VASOSPASM

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Ropivacaine is a frequently used nerve block for orthopedic procedures. Few cases have been reported in which the amides have caused coronary artery spasm (CAS). We present a case of CAS after ropivacaine administration. CASE PRESENTATION: An 85-year-old male with coronary artery disease, status post 4-vessel coronary artery bypass grafting 11 years prior, peripheral arterial disease, and hypertension, underwent an interscalene nerve block with 0.5% Ropivacaine prior to an orthopedic procedure. Two hours later, the patient developed ventricular fibrillation arrest. He was defibrillated 3 times, received amiodarone, epinephrine, magnesium, and an intralipid emulsion for radical binding of ropivacaine prior to return of spontaneous circulation. Patient had not received any inciting medications and his labs were unremarkable prior to the event. His only prescribed medications included low dose aspirin, clopidogrel, metoprolol, and ramipril. Bedside echocardiogram showed an ejection fraction of 20%; apical anteroseptal and anterolateral akinesis was present; electrocardiogram was remarkable for sinus tachycardia with ST segment elevation in leads V1-V6; his initial troponin T was 3.3 ng/dL. Aspirin, ticagrelor, and heparin infusion were administered, and the patient was rushed to coronary angiography. Angiography demonstrated patent bypass grafts. However, during the investigation of the Left Internal Mammary (LIMA) graft-to-Left Anterior Descending artery (LAD) anastomosis, the LAD had no flow (TIMI 1/0) beyond the LIMA anastomosis. Inframammary nitroglycerin was injected and immediately resolved the diffuse stenosis, suggesting coronary vasospasm. His other coronary arteries demonstrated stable disease related to his chronic CAD. Given the timing of cardiac arrest in relation to the nerve block, coronary vasospasm was presumed secondary to Ropivacaine injection. DISCUSSION: Ropivacaine is a highly potent, lipid soluble amide local anesthetic frequently used as an interscalene nerve block for orthopedic procedures involving the arm or hand. In addition to its arrhythmogenic properties, there have been few cases reported in which the amides have caused coronary artery spasm (CAS), relieved with calcium channel blockers. These cases were reported in individuals with and without underlying coronary artery disease, before, during, and after surgery; these reports are limited as diagnosis of CAS was not directly visualized with coronary angiography. Diagnosis was based upon relief in the setting of calcium channel blockers and nitroglycerin CONCLUSIONS: Our case is unique in that we present a patient who experienced ventricular fibrillation most likely secondary to CAS associated myocardial infarction after the interscalene administration of ropivacaine. This case is even more unique in that CAS reversal with intracoronary nitroglycerin was visualized and documented with cardiac catheterization. Reference #1: Mutlak M1, Nikolsky E. Severe coronary artery spasm induced by epidural injection of bupivacaine hydrochloride: a case report. Acute Card Care. 2011 Sep;13(3):155-8. https://doi.org/10.3109/17482941.2011.567286. Epub 2011 Apr 25. DISCLOSURES: no disclosure on file for Shahyar Gharacholou; No relevant relationships by Alexander Heckman, source=Web Response