Soliman Dina, Castillo-Rodriguez Cristian, Cruz Diego, Abdelmalek John
Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
Catheter Cardiovasc Interv. 2025 Jul;106(1):557-562. doi: 10.1002/ccd.31584. Epub 2025 May 12.
Coronary artery vasospasm following coronary artery bypass grafting (CABG) is a rare but potentially life-threatening complication that can lead to myocardial ischemia, arrhythmias, and cardiogenic shock. Nitroglycerin-resistant vasospasm, particularly involving the left main coronary artery (LMCA), poses significant diagnostic and therapeutic challenges.
We report the case of a 47-year-old female with a history of hypertension, hyperlipidemia, and ADHD on dextroamphetamine-amphetamine, who presented with chest pain and was found to have a suspected severe LMCA lesion. Coronary angiography revealed a 95% LMCA stenosis that was unresponsive to intracoronary nitroglycerin, raising concern for catheter-induced vasospasm versus true stenosis. The patient underwent urgent CABG. Intraoperatively and postoperatively, she experienced recurrent, diffuse coronary vasospasm refractory to nitroglycerin, necessitating multiple interventions including mechanical circulatory support with intra-aortic balloon pump and percutaneous ventricular assist device. Coronary angiography confirmed severe diffuse coronary and peripheral vasospasm. The patient was managed with intravenous vasodilators, vasopressors, and supportive care, and eventually recovered with restoration of cardiac function and discharge to cardiac rehabilitation.
This case underscores the difficulty in differentiating vasospasm from true atherosclerotic disease in the LMCA, the potential for nitroglycerin resistance, and the risk of severe complications during CABG. The use of adjunctive imaging modalities, vasodilators beyond nitroglycerin, and early mechanical circulatory support may be critical in managing such complex cases.
Nitroglycerin-resistant coronary vasospasm, especially in the LMCA, can mimic fixed stenosis and lead to inappropriate surgical intervention and life-threatening complications. A multidisciplinary, imaging-guided approach is essential for accurate diagnosis and optimal management.
冠状动脉旁路移植术（CABG）后发生冠状动脉痉挛是一种罕见但可能危及生命的并发症，可导致心肌缺血、心律失常和心源性休克。对硝酸甘油耐药的血管痉挛，尤其是累及左主干冠状动脉（LMCA）的情况，带来了重大的诊断和治疗挑战。
我们报告了一名47岁女性的病例，她有高血压、高脂血症病史，正在服用右苯丙胺 - 苯丙胺治疗注意力缺陷多动障碍（ADHD），因胸痛就诊，检查发现疑似严重的LMCA病变。冠状动脉造影显示LMCA狭窄95%，对冠状动脉内硝酸甘油无反应，这引发了对导管诱导的血管痉挛与真性狭窄的担忧。该患者接受了紧急CABG。术中及术后，她反复出现弥漫性冠状动脉痉挛，对硝酸甘油难治，需要多次干预，包括使用主动脉内球囊泵和经皮心室辅助装置进行机械循环支持。冠状动脉造影证实存在严重的弥漫性冠状动脉和外周血管痉挛。患者接受了静脉血管扩张剂、血管加压药及支持治疗，最终心脏功能恢复，出院接受心脏康复治疗。
该病例凸显了在LMCA中区分血管痉挛与真性动脉粥样硬化疾病的困难、硝酸甘油耐药的可能性以及CABG期间发生严重并发症的风险。使用辅助成像方式、硝酸甘油以外的血管扩张剂以及早期机械循环支持对于处理此类复杂病例可能至关重要。
对硝酸甘油耐药的冠状动脉痉挛，尤其是在LMCA中，可模拟固定狭窄并导致不适当的手术干预和危及生命的并发症。多学科、影像引导的方法对于准确诊断和优化管理至关重要。
