postoperative coronary artery spasm is an infrequent life - threatening event after cardiac surgery which can occur without an underlying coronary disease we report a documented case of a 67-year - old man with normal coronary arteries submitted to mitral valve replacement . immediately after surgery he had a st elevation in the inferior leads , and an inferior wall hypokinesia at the trans - oesophageal echo . a coronary angiography demonstrated a focal spasm in the right coronary artery which was successfully treated by intracoronary injection of nitrates . a coronary artery spasm should be suspected whenever a postoperative infarction occurs after valvular surgery especially in absence of associated coronary artery disease . in this cases postoperative this case - report summarizes the findings of this rare and potentially life - threatening cause of early postoperative ischemia and highlights the role of early coronary angiography in the cases of suspected myocardial infarction after cardiac surgery . the underlying mechanisms of spasm remain unclear , although an endothelial dysfunction seems to play a major role . all cardiac surgical procedures are associated with an imbalance of the homeostasis that may promote pocas , especially in association with coronary artery disease . occasionally the spasm occurs in patients with valve disease as in our patient who was submitted to a mitral valve replacement and had apparently normal coronary arteries . a 67-year - old man was admitted to hospital for the surgical treatment of a severe rheumatic mitral regurgitation . 1a ) the right coronary artery was dominant giving origin to large posterior descending and posterolateral arteries . in the left coronary system a single obtuse marginal originated from the circumflex artery which was of small caliber and exited the atrioventricular groove thereafter . the mitral valve was exposed through a vertical transeptal bilateral atriotomy and replaced with a bileaflets mechanical prosthesis . the operative course was uneventful and the patient was transferred to the intensive care unit ( icu ) on normal sinus rhythm and good cardiac function without inotropic support . upon arrival in the icu , a marked st elevation became evident in inferior leads , while hemodynamic conditions remained stable . a coronary angiogram was performed : a focal , subocclusive spasm was evident in the middle to distal segment of the right coronary artery ( fig . an intracoronary injection of nitrates resulted in a prompt resolution of the spasm ( fig . continuous intravenous infusion of nitroglycerin ( 4  mg / h ) and oral administration of diltiazem 60  mg twice a day were started . on postoperative day 2 , intravenous nitroglycerin was changed to transdermal patch ( 10  mg / day ) . subsequent postoperative course was uneventful and the patient was discharged in good clinical conditions on postoperative day 7 . supplementry material related to this article found , in the online version , at http://dx.doi.org/10.1016/j.ijscr.2015.01.049 . perioperative myocardial infarction is the first cause of early and log - term mortality after cardiac surgery . i although the most common cause of postoperative ischemia after mitral valve surgery is a iatrogenic lesion to the circumflex artery , a coronary spasm   should always be considered among the possible causes of postoperative ischemia . it may also occur with or without an underlying atheromatous coronary disease : intense oxidative stress , inflammation and changes in vascular reactivity all lead to an increased propensity to spasm . since 2006   we have adopted a policy of immediate postoperative coronary angiography in cases of hemodynamic instability or dubious ecg interpretation . this allows a prompt diagnosis as well as in most cases the treatment of any possible spontaneous or iatrogenic condition . however , in the last five years we could not observe any case of pocas . the most common presentation of pocas is upon arrival in the icu up to 6  h after surgery . usually it causes hemodynamic instability associated with ventricular arrhythmias and fibrillation . in some cases an extracorporeal membrane oxygenation ( ecmo ) support when the spasm is limited to right coronary artery the electrocardiographic alterations are those of an inferior infarction , but st changes can be subtle and difficult to interpret when the spasm is diffuse . , we could find 32 reports , including 7 small series , for a total number of 54 patients . in 9 of the reports a coronary angiography was not performed and the spasm was suspected as a result of the clinical presentation . some cases were considered intra - operative spasms , a condition that it is extremely difficult to ascertain . a recent case of intra - operative spasm occurred after the repair of a functional mitral regurgitation and was successfully detected and treated in a hybrid operating room by antevil et al . . the mortality in the 54 cases collected from the literature was 11% and its incidence can be underestimated by its apparent rarity and difficult diagnosis . on the other hand , once angiographically documented , the treatment of pocas is usually rapidly effective . devices to mechanically support the circulation ( intraortic ballon pump ; the ecmo or even a ventricular assist device ) were used in 10 cases . despite the high early mortality performed an angiographic control at 3 and 12 months   in five of the six patients who developed a pocas in his series . direct intracoronary injection of ergonovine provoked a focal spasm in the right coronary artery in only in one case . it was concluded that the spasm does not recur after surgery , although some patients may have a predisposition to its development . in conclusion , postoperative ischemia should prompt a coronary angiography to rule out the spasm and allow immediate therapy .
highlightscoronary artery spasm occurred after mitral valve replacement in a patient with normal coronary arteries.the patient had st changes and inferior wall hypokinesia.the diagnosis was established by urgent postoperative coronary angiography.the spasm responded to the intracoronary injection of nitrates.the remaining postoperative course was uneventful and the left ventricular function returned to normal .