Intraoperative cardiogenic shock induced by refractory coronary artery spasm in a patient with myasthenia gravis: A case report

BACKGROUND: Coronary artery spasm (CAS) is a rare but critical condition during surgery. Clinical manifestations can vary from only subtle electrocardiography change to sudden death. In this case report, we present the case of a patient with myasthenia gravis (MG) who developed refractory CAS-related cardiogenic shock during thymoma surgery.

CASE SUMMARY: A 61-year-old man had a history of cigarette smoking and coronary artery disease with a bare metal stent placed. Three months ago, he suffered from coronary spasms, with three vessels involved, after surgery for cervical spine injury. He started having progressive dysphagia 4 wk prior and was diagnosed with MG via serologic tests, and computed tomography declared a thymoma in the anterior mediastinum. After the symptoms of MG subsided, he was referred for thymectomy. The operation was uneventful until the closing of the sternal wound. Electrocardiography showed sudden onset ST elevation, followed by ventricular tachycardia and severe hypotension. Cardiopulmonary cerebral resuscitation was initiated immediately with electrical defibrillation, extracorporeal membrane oxygenation was performed due to refractory cardiogenic shock, and the patient was transferred to an angiography room. Angiography showed diffuse CAS with three vessels involved. Intracoronary isosorbide dinitrate and adenosine were administered, and then the patient was transferred to the intensive care unit.

CONCLUSION: Our case highlights the importance of being prepared for clinical situations such as the one described here and suggests the necessity of developing an appropriate anesthesia plan that includes proactive analgesia and preemptive coronary vasodilators.