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Program

Anesthesiology

Training Level

Resident PGY 1

Institution

Henry Ford Hospital

Abstract

MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) is a syndrome defined as MI with normal or near normal coronary arteries on angiography. Although the prevalence is estimated to be between 1-14%, its incidence in patients undergoing non-cardiac surgery, is not established. Etiologies such as coronary artery vasospasm, acute thrombosis at site of a non-obstructive eccentric plaque thrombus, takotsubo cardiomyopathy, coronary microvascular dysfunction, viral myocarditis, thrombophilia, and coronary artery embolism, have been identified as culprits for MINOCA. We present a case of a 65-year-old male, with past medical history significant for esophageal adenocarcinoma, COPD, 45 year pack tobacco history, and obesity, who developed MINOCA secondary to coronary artery vasospasm postoperatively. Patient underwent esophagectomy at an outside hospital, which was complicated by an anastomotic leak. He was transferred to our institution, for further interventions. Here patient underwent a redo thoracotomy with pulmonary decortication, complete gastrectomy and creation of esophagostomy. On postoperative day 0, patient developed transient ST elevations followed by ventricular tachycardia and then atrial fibrillation. Differential diagnosis included acute coronary syndrome, coronary vasospasm, coronary plaque rupture and recanalization secondary to pericarditis. Echocardiogram after the event showed normal LV systolic function globally with ejection fraction (EF) 70%. On postoperative day 5, patient developed transient bradycardia without hypotension or changes in mental status. EKG significant for ST elevations in the inferior leads with reciprocal ST depressions, transient AV Type II block with 1:2 and 1:3 conduction variance. Within few minutes, patient self-converted to atrial fibrillation with RVR without ST elevations. Patient underwent a left heart catherization, which was negative for obstructive coronary artery disease, but significant for moderate hypokinesis of the apical and periapical wall with reduced EF. In view of continued suspicion for RCA vasospasm as the etiology for these episodes, it was recommended to start patient on diltiazem, amiodarone, and low dose ASA 81mg. Unfortunately, patient was unable to tolerate diltiazem secondary to hypotension. He was started on nitroglycerin infusion and eventually transitioned to isordil without issue. He remained in atrial fibrillation, which was rate controlled, without any further episodes of coronary vasospasm. Mediastinal infection secondary to anastomotic leak post esophagectomy, can lead to pericarditis, which in turn can present as MINOCA.

Presentation Date

5-2020

Right coronary artery spasm following anastomotic leak status post-esophagectomy

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