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Treatment of acute right coronary artery occlusion during anesthesia

Toshiyuki Nakamura, MD^*, Yukio Hayashi, MD^*, Kiyokazu Kagawa, MD^*, Ikuto Yoshiya, MD^*, Nobuaki Hirata, MD and Hikaru Matsuda, MD

^* From the Department of Anesthesiology and
First Department of Surgery, Osaka Faculty of Medicine, Osaka, Japan

Address correspondence to: Yukio Hayashi MD, Department of Anesthesiology (D-7), Osaka University Faculty of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan. Phone:81-6-6879-3133; Fax:81-6-6879-3139; E-mail: yhayashi{at}anes.med.osaka-u.ac.jp

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.

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