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Canadian Journal of Anesthesia 50:859-860 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Acute pulmonary edema in relation with single coronary ostium following acoustic neuroma surgery

Mijael Jativa, MD, Philippe Hantson, MD PhD, Olivier Gurné, MD PhD, Michel Van Boven, MD and Michel Gersdorff, MD PhD

Brussels, Belgium

To the Editor:

A 61-yr-old woman without risk factors for cardiovascular diseases underwent elective surgery for a right acoustic neuroma. Surgery lasted nine hours, a relative hypotension (around 80/50 mmHg) was tolerated throughout the surgical procedure and no cardiovascular event was recorded. Two hours after extubation in the intensive care unit, she suddenly developed acute respiratory distress with marked hypoxemia (pO2 52 mmHg, O2 saturation 73%, pCO2 69 mmHg). The chest x-ray was consistent with acute pulmonary edema; central venous pressure rose to 16 mmHg. The patient needed urgent re-intubation. The electrocardiogram showed ST-segment elevation in the anterior leads (V1–V3) and T-wave inversion in the lateral leads. Cardiac enzymes increased with creatine kinase (CK) 1615 IU•L-1, CK-MB 30.6 µg•L-1 (normal < 3.5 µg•L-1) and troponine I 0.48 ng•mL-1 (normal < 0.10). Cardiac echography showed severe impairment of left ventricular systolic function, with anterior, apical and septal akinesia; left ventricular ejection fraction was calculated at 30%. Cardiac index (CI) was 1.6 L•min-1•m2, and pulmonary capilllary wedge pressure 15 mmHg. Coronary angiography revealed a solitary ostium in the right aortic sinus, but the entire coronary system was free of any obstructive atherosclerotic lesions (FigureGo). The patient first received dobutamine 5 µg•kg-1•min-1 and thereafter milrinone 0.5 µg•kg-1•min-1, with a slight improvement in CI, but tachycardia developed. Infusion of glucose-insulin-potassium (GIK) was given over 72 hr. CI improved progressively. Extubation was possible 62 hr after the acute episode.



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  		FIGURE
 
A single coronary ostium is found in 0.2–1.4% of adult patients undergoing coronary arteriography.1,2 The mechanism leading to myocardial infarction in the present setting remains open to discussion: 1) myocardial ischemia has been described in patients with this anomaly in the absence of additional atherosclerotic disease. The pathophysiology is not completely understood.2–4 Impairment of coronary reserve (functional obstruction) is one among other hypotheses. Although a mild degree of hypotension was tolerated, there was no evidence of myocardial ischemia during surgery; 2) coronary vasospasm may have occured in the postoperative phase; 3) paradoxical air embolism causing an acute occlusion of the single coronary system should be considered after ENT surgery. The origin of the single coronary artery from the right aortic cusp together with the position of the patient during the procedure may have favoured air embolism.

In conclusion, this patient with a single coronary ostium but without heart disease, previously asymptomatic in daily life, suffered a myocardial infarction in the immediate postoperative period.5 Several explanations are likely. Whatever the exact mechanism, such individuals may be more prone to perioperative cardiac events.

References

1 Tricquet JY, Gurné O, Chenu P, Schroeder E, Marchandise B. Application of intracoronary flow velocity analysis in isolated congenital coronary artery. J Vasc Invest 1996; 2: 99–102.

2 Sharbaugh AH, White RS. Single coronary artery. Analysis of the anatomic variation, clinical importance, and report of five cases. JAMA 1974; 230: 243–6.[Medline]

3 Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements. Heart 1998; 80: 307–11.[Abstract/Free Full Text]

4 Brandt B III, Martins JB, Marcus ML. Anomalous origin of the right coronary artery from the left sinus of Valsalva. N Engl J Med 1983; 309: 596–8.[Medline]

5 Multz A, Scharf S. Pharmacology and ventilatory support of the circulation in critically ill patients. In: Dantzker D, Scharf S (Eds.) Cardiopulmonary Critical Care, 3rd ed. Philadelphia: WB Saunders Company; 1998: 329–47.





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