Diffuse Coronary Vasospasm Research Articles

Diffuse refractory coronary artery spasm after off-pump coronary artery bypass grafting: a case series

BackgroundDiffuse coronary artery spasm after coronary artery bypass grafting may cause disastrous circulatory collapse and death if not detected and managed promptly.Case presentationFour out of 387 patients who underwent uneventful off-pump coronary artery bypass grafting between January 2019 and December 2021 at our centre developed unexplained arrhythmias and hypotension within 2 to 6 h of the postoperative period. Coronary angiogram showed diffuse coronary vasospasm involving both grafted and ungrafted native coronary arteries. Vasospasm was refractory to intracoronary vasodilators in all these cases. All of the patients recovered completely with the use of intravenous verapamil infusion and intraaortic balloon pump support.ConclusionsCoronary artery spasm should remain in the differential diagnosis in patients developing unexplained arrhythmias and haemodynamic instability following coronary artery bypass grafting. Prompt diagnosis with coronary angiogram and proper management strategy using calcium channel blockers and intraaortic balloon pump can revert this deadly complication. Surgical intervention may delay precious time needed for therapeutic intervention.

Spontaneous, severe, and diffuse coronary vasospasm in a patient with COVID-19.

Spontaneous, severe, and diffuse coronary vasospasm in a patient with COVID-19.

Abstract 17500: A Crisis of the Heart

A 59 year old female with past medical history of metastatic neuroendocrine tumor without cardiac involvement was admitted for transarterial catheter embolization (TACE) procedure of liver lesions. During the TACE procedure, she developed hypertensive urgency treated with intravenous beta blocker therapy and continuous octreotide for carcinoid reaction. The following day she developed acute pulmonary edema and labile blood pressures requiring low dose norepinephrine. Octreotide infusion was up-titrated to 500 mcg/hour with concern for carcinoid crisis. On physical exam, she was tachycardic and regular without notable murmurs or extra cardiac sounds, no elevated jugular venous distension, and no lower extremity edema. She had bilateral crackles on pulmonary exam and was diaphoretic and delirious. There were sub-millimeter lateral ST- segment elevations on her electrocardiogram but her troponin levels were elevated to 14 ng/dL. Point of care cardiac ultrasound demonstrated severely impaired left ventricular systolic function without regional wall motion abnormalities. Coronary angiogram revealed diffuse coronary vasospasm and elevated left ventricular end-diastolic pressure. On right heart catheterization, she had elevated filling pressures, pulmonary arterial oxygen saturation of 25%, and cardiac index of 1.42 L/min/m2. Our patient was diagnosed with cardiogenic shock secondary to octreotide mediated coronary vasospasm causing diffuse myocardial injury. Continued multidisciplinary discussions were needed to determine appropriate vasopressor and inotropic agent use to support cardiac function without triggering further hormonal dysregulation during carcinoid crisis. Her cardiac function eventually improved with left ventricular Impella support and gradual down-titration of octreotide dose. Norepinephrine, epinephrine, and phenylephrine were avoided in favor of vasopressin, and dobutamine was switched to milrinone to prevent further sympathetic activation. She was able to wean off Impella and pressor support and had improvement of her left ventricular function on repeat echocardiography one month later. She has not had recurrence of heart failure symptoms and continues to follow up with oncology via tele-visits.

MON-LB041 Pheochromocytoma - Illusive Myriad of Symptoms

Background: Pheochromocytoma is a rare neuroendocrine neoplasm arising from the adrenal medullary chromaffin cells. It contributes to 80-85% of catecholamine secreting tumors. The annual incidence of pheochromocytoma is 0.8 cases per 100,000 person-years. It can be both sporadic or familial. The classic triad of headache, palpitations and diaphoresis is seen in only 4% of cases. Rare presentations include cardiomyopathy, stroke, diabetes mellitus, ventricular arrhythmias and myocardial infarction. Our patient presented concurrently with dilated cardiomyopathy, hypertensive emergency and new-onset diabetes mellitus (DM) followed by ischemic stroke within a week. Heart failure can present as takotsubo or dilated cardiomyopathy with an incidence of 10%. The underlying pathophysiology is catecholamine mediated myocardial stunning, diffuse coronary vasospasm, microvasculature dysfunction and fibrosis. DM is seen in 23% of pheochromocytoma and is due to catecholamine-induced impaired glucose tolerance, and insulin resistance. Cerebral ischemia has an incidence of 3%, and is secondary to severe hypertension and cerebral vasospasm. Clinical Case: A 47-year-old African American woman presented with a 1-week duration of worsening dyspnea, orthopnea, dizziness, and palpitations. Past medical history includes HTN, non-ischemic cardiomyopathy on carvedilol and pravastatin. Physical exam: BP 182/119, HR 120, mild pulmonary crackles. Labs: proBNP 3533 (1-150 pg/ml), HbA1c 13.1%. Echocardiogram: moderate global hypokinesis with left ventricle ejection fraction (LVEF) of 30-35%. On imaging, CT of chest revealed an incidental finding of 4.7 cm right adrenal adenoma. MRI abdomen confirmed heterogeneously enhancing 4.3 cm right adrenal mass. Further testing showed high plasma catecholamines of 9963 (242-1125 pg/ml), 24-hour urine catecholamines of 2125 (50-100 mcg), thus confirming the diagnosis of pheochromocytoma. Further, her clinical course was complicated by left-sided weakness. MRI brain reported an acute infarct in right corona radiata. Pre-operative blockade was done with phenoxybenzamine and metoprolol. Subsequently, she underwent right adrenalectomy and tissue diagnosis confirmed pheochromocytoma. On follow up visit, her symptoms resolved. Also noted normalized catecholamine levels, HbA1c of 5.4% and LVEF of 40- 45%. Conclusion: Pheochromocytoma can rarely present with multi-organ failure. It warrants a high index of suspicion in non-ischemic cardiomyopathy. As per recent Mayo Clinic criteria, diagnosis of takotsubo cardiomyopathy mandates ruling out pheochromocytoma. As seen in our patient, it is a reversible cause of left ventricular dysfunction, focal weakness and DM. Based on our knowledge, this is the only contingently diagnosed pheochromocytoma with varied clinical presentations. It has been aptly described as “The Great Masquerader”.

KILLER SPASM: A CASE OF RECURRENT CORONARY VASOSPASM

A 52 year old female presented after ventricular fibrillation (VF) cardiac arrest. Coronary angiography showed diffuse coronary vasospasm that resolved with intracoronary nitroglycerine. The patient had a history of hypertension, stroke and depression. Home medications included isosorbide,

Diffuse coronary vasospasm in a patient with hypothyroidism

Coronary vasospasm is an important etiology of ischemic heart disease. Sometimes thyroid disorders may be associated with cardiovascular disease. The major cardiovascular changes that occur in hypothyroidism include a decrease in cardiac output and cardiac contractility, a reduction in heart rate, and an increase in peripheral vascular resistance. There are also significant changes in modifiable atherosclerotic risk factors, including hypercholesterolemia, diastolic hypertension, carotid intimal media thickness, and endothelial derived relaxation factor (nitric oxide), which accompany overt hypothyroidism. Here, we present a case of diffuse coronary arterial vasospasm in a patient with hypothyroidism.

Postpartum coronary vasospasm with literature review.

Acute myocardial infarction during pregnancy or the postpartum period is rare. We report a case of a 39-year-old postpartum woman who developed non-ST-elevation myocardial infarction due to severe diffuse coronary vasospasm. To our knowledge, this is the first case of angiographically evidenced coronary vasospasm, in a postpartum woman, with resistance to intracoronary nitroglycerin.

Primary cardiac lymphoma causing coronary vasospasm

A 63-year-old woman with no significant medical history or risk factors presented with an acute coronary syndrome. It was her first episode of angina pectoris (AP). ECG showed ST-segment elevations in II, III, and aVF, and cardiac biomarkers were negative. Coronary angiography revealed a severe stenosis in the right coronary artery (RCA) ( Panel A ), which disappeared after intracoronary nitroglycerin infusion. Subsequent coronary vasomotility testing with the intracoronary infusion of acetylcholine induced diffuse coronary vasospasm, reproducing …

Diffuse coronary artery spasm treated by extracorporeal membrane oxygenation

Diffuse coronary vasospasm is an unpredictable and serious complication following coronary artery bypass surgery. The treatment of this emergency is dependent on patient suitability for angiography and direct injection of vasodilators into the affected vessels. In patients unable to proceed to angiography the diagnosis can only be suspected but treatment is nevertheless still towards reinstitution of coronary blood flow. We present one such case in which re-grafting and extracorporeal membranous oxygenation proved successful in restoring cardiac function in a patient with diffuse coronary artery spasm.

Severe diffuse coronary artery spasm in the early phase of cardiogenic shock

Coronary artery vasospasm rarely appears as a diffuse phenomenon that involves all the coronary tree. We present a clinical case of acute myocardial infarction complicated by ventricular fibrillation and cardiogenic shock. Urgent coronary angiography showed occlusion of proximal Circumflex coronary artery and a TIMI I flow in the left anterior descending artery due to severe, diffuse coronary vasospasm. Patient was successfully treated with intra-aortic balloon pump and intracoronary bolus of nitroglycerin with restoration of flow in left coronary branches and complete resolution of shock.

Why are arteries the size they are?

sones and shirey ([12][1]) performed the first coronary artery angiogram by accident in 1958. While injecting contrast material for a left ventricular angiogram, the catheter slipped out of the ventricle and into the right coronary artery. Sones immediately recognized the advantage of visualizing

Morphologic Differences of Vessel Wall at Sites of Focal and Diffuse Coronary Vasospasm by Intravascular Ultrasound(IVUS)

Background and Objectives:The coronary vasospasm has been shown to play an important role in the pathogenesis of not only variant angina but also ischemic heart disease in general, including other forms of angina pectoris, acute myocardial infarct, and sudden death. The angiographic features of a coronary vasospasm are focal and diffuse patterns in the clinical setting. We attempted to clarify the differences in the morphologic appearance of the vessel wall between the sites of focal and diffuse vasospasm by intravascular ultrasound (IVUS). Material and Methods:We studied 23 patients (32 segments) with variant angina in whom coronary angiograms were normal and coronary spasm was documented by intracoronary injection of acetylcholine. Coronary spasm was defined as a luminal diameter reduction of at least 90% of the baseline coronary artery diameter. Focal spasm was defined if the length of spastic narrowing was less than 10 mm. Using IVUS, we observed atheromatous plaques in 32 spasm segments with either focal or diffuse vasospasm. We measured the maximal intimal thickness, luminal cross-sectional area (CSA), and external elastic membrane-CSA in the spasm sites. Results:When comparing the maximal intimal thickness between the focal (n=15) and diffuse (n=17) vasospasm segments, the focal spasm segments were significantly thicker (1.21±0.36 mm vs. 0.70± 0.23 mm, p<0.001). The maximal plaque areas of the two groups were similar but tended to be greater in the focal spasm segments (6.03±2.06 mm vs. 4.92±2.59 mm, p=NS). When the circular shaped factor (CSF: standardized index of eccentricity) was compared, the focal spasm segments were greater than the diffuse spasm segments (0.89±0.06 vs. 0.97±0.02, p<0.001). The remodeling index was greater at the focal spasm segments than at the diffuse spasm segments (1.02±0.16 vs. 0.86±0.13, p<0.001). Conclusion:The focal spasm segments were more eccentric and had greater atheromatous plaque than the diffuse spasm segments. A positive remodeling pattern was observed at the segments of focal spasm, and a negative remodeling pattern was observed at the segments of diffuse spasm. There were morphologic differences in the vessel wall appearance between the focal and diffuse spasm sites.(Korean Circulation J 2001;31(8):749-756)

Morphologic differences of vessel wall at sites of focal and diffuse coronary vasospasm by Intravascular Ultrasound (IVUS)

Morphologic differences of vessel wall at sites of focal and diffuse coronary vasospasm by Intravascular Ultrasound (IVUS)

Comparison of vessel wall morphologic appearance a sites of focal and diffuse coronary vasospasm by intravascular ultrasound

Coronary vasospasm is manifested by either focal or diffuse pattern in clinical settings. To examine the differences in vessel wall morphologic appearance between the sites of focal and diffuse vasospasm, we studied 29 patients with chest pain at rest, during exertion, or both by intravascular ultrasound. By angiography, focal vasospasm with diameter reduction of 90% ± 3% (mean ± SD) was provoked by intracoronary ergonovine (0.01 to 0.04 mg) in 15 patients. Diffuse vasospasm with diameter reduction of 79% ± 5% (NS) was provoked in seven patients, and the remaining seven patients served as the control group. By ultrasonography, a significantly thickened intimal leading edge with sonolucent zone was observed in 55 sites from 22 coronary arteries with either focal or diffuse vasospasm (0.61 ± 0.32 mm), although these sites were normal or minimally narrowed by angiography. Seven segments from the control group exhibited a thin intimai leading edge with sonolucent zone (0.23 ± 0.08 mm, p < 0.01). When the thickness of the intimal leading edge with sonolucent zone was compared between the abnormal sites with focal and diffuse vasospasm, this was significantly greater at focal spasm, 1.01 ± 0.35 mm ( n = 15), than that at diffuse spasm, 0.46 ± 0.13 mm ( n = 40, p < 0.01). At the sites with diffuse spasm, some of the lesions lay scattered along the coronary vessels, although the lesions were localized at the sites of focal vasospasm. These results indicate that atherosclerosis is present at sites with both focal and diffuse vasospasm even in the absence of angiographically significant coronary artery disease. We suggest that the differences in severity of underlying atherosclerosis, disease distribution, or both can be related to the pattern of vasospasm in clinical settings.

Diffuse coronary vasospasm and accelerated atherosclerosis in a transplanted human heart

Coronary vasospasm is rare in transplanted hearts. We report a case of diffuse coronary vasospasm followed by rapidly progressive coronary atherosclerosis in a transplanted heart.