Author + information
- Received May 8, 2015
- Accepted May 23, 2015
- Published online October 1, 2015.
- Ajit Bhagwat, MD, DM∗ ( and )
- Sachin Mukhedkar, MD, DM
- ↵∗Reprint requests and correspondence:
Dr. Ajit Bhagwat, Kamalnayan Bajaj Hospital, Gut 43, Beed Bypass Road, Aurangabad, Maharashtra, India 431005.
A long-term smoker (45 years) presented with substernal chest pain on and off for 2 days. His coronary angiogram revealed the presence of a discrete 80% stenosis in mid-right coronary artery (RCA) (Figure 1A) and a normal left coronary system. Direct stenting with a 3.0 × 15-mm drug-eluting stent was performed at nominal pressure. Chest pain with ST-segment elevation occurred immediately. The angiogram showed severe coronary spasm involving the entire RCA before and after the stented segment, giving it a “threadlike” appearance (Figure 1B). Intracoronary injection of nitroglycerin (200 μg) had no effect, and a repeat angiogram showed no flow in the RCA (Figure 1C). Hypotension (systolic blood pressure, 40 mm Hg) and complete heart block ensued. Intravenous fluids and atropine were administered. Further administration of intracoronary vasodilators was deferred in view of hemodynamic instability. Ventricular fibrillation occurred that was cardioverted with a single DC shock. Immediate stenting of the ostioproximal segment of the RCA was performed with 3 × 18-mm drug-eluting stent to “break” the spasm. This resulted in restoration of flow in the artery, but persistent severe spasm of the nonstented segments of the artery was seen (Figure 1D). However, partial restoration of flow resulted in immediate hemodynamic improvement (systolic blood pressure, 70 mm Hg) and disappearance of the heart block. Two more intracoronary doses of nitroglycerin (200 μg each) were given without any angiographic improvement. Intracoronary diltiazem was then administered with relief of coronary spasm and Thrombolysis In Myocardial Infarction III flow in the artery (Figures 1E and 1F). Blood pressure was restored after 15 min, and the patient was moved to the cardiac care unit in a stable condition. He was discharged after 48 h on oral diltiazem along with dual antiplatelet therapy and a statin. He has been doing well during the 13 months after the procedure.
Life-threatening spasm of the coronary artery after stenting is very rare. Usually the spasm is restricted to a short segment at the edge of the stent and is generally responsive to intracoronary vasodilators. In this case, the spasm was resistant to drugs and caused serious arrhythmias and hemodynamic collapse. Mechanically breaking the spasm by stent implantation remains one of the quickest methods to tide over the crisis in a situation in which the spasm is responsible for life-threatening hemodynamic compromise.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 8, 2015.
- Accepted May 23, 2015.
- American College of Cardiology Foundation