Commentary

Authors describe a case of low cardiac output syndrome after coronary bypass surgery, which was related to the spasm of the radial arteries grafts.

Heart failure following bypass sur­gery is a major postoperative compli­cation. Coronary bypass or native coro­nary arteries spasm may be the case. Usually, postoperative percutaneous intervention confirms the diagnosis and at the same time provides the treatment by vasodilator application and direct vision intra-aortic balloon pump (IABP) insertion.

Sometimes the course of such a patient may be very dramatic causing a dilemma, if to go for the diagnosis to the cath-lab or if to run with the patient into the operating room? Hybrid room solves this problem.

Especially, if you deal with the refractory ventricular fibrillation (i.e. 30 minutes of heart massage with amio­darone and repeat defibrillations) which was the case in our resent practice, it is my recommendation to give the patient the bolus of trimecaine ( despite a fact that it is against the new guidelines) and/or nitroglycerine, despite his low blood pressure, which may solve the problem and avoid patient’s re-exploration.

Echocardiography should be performed in all patients, to exclude heart tamponade.

In the presented case it was wise to go the operating room at once, since there was no access for standard angiography and IABP insertion.

It is not clear however, what authors did to prevent or minimize the risk of further spasms (i.v. treatment)? What was the temperature of the patient? Why patient with good left ventricle function (45%) undergoing elective operation had in his postoperative course lactate of 16 mmol/l!?

There are also other issues which could be discussed like; if the chosen procedure was the best we can offer for a 70-year old gentleman, these days? Wouldn’t he profit more from the no-touch, composite arterial technique? Was it necessary, to graft the right coronary artery which has only 30% residual stenosis?

Authors should be congratulated for saving this patient’s life, however I have two major problems regarding their article:

Most of the text and both pictures (comparing ischemic changes, one should not present different leads: chest vs. arm) are irrelevant to the main topic – radial artery spasm causing heart failure.

What I missed most, was the point of view, which would make this common surgical problem interesting to the reader.