In January 2005, a 9-year-old boy who had undergone heart transplantation as an infant presented for surveillance biopsy and coronary angiography. Prior surveillance coronary angiography had shown no evidence of vasculopathy. At the time of the procedure, the patient had no cardiac symptoms, and echocardiography immediately before the procedure had shown normal graft function.
The patient weighed 39.8 kg. After sedation, right femoral arterial access was obtained and a 5F sheath placed. The left main coronary artery was cannulated with a 5F 2.5 Judkins left coronary catheter. Approximately 3 cc of undiluted contrast agent was injected by hand. Thereupon, the left main coronary artery appeared normal, but the left anterior descending and circumflex coronary arteries were diffusely narrow and the transit time was prolonged (). Marked ST-segment elevation occurred, and the patient became hypotensive. He developed ventricular tachycardia and further reduction in systolic pressure as measured via the arterial sheath. Cardiopulmonary resuscitation was initiated immediately, and lidocaine infusion and cardioversion enabled the resumption of sinus rhythm, accompanied by the normalization of ST segments and blood pressure. An echocardiogram obtained immediately thereafter showed normal graft systolic function. The patient recovered uneventfully and was discharged from the hospital on the following day.
Fig. 1 Left coronary injection of contrast agent (long axial view) shows coronary spasm.
Review of the angiograms led us to consider whether the patient had graft vascular disease or had experienced coronary artery vasospasm. We decided to perform another coronary angiographic procedure, preceded by the intracoronary administration of nitroglycerin.
Therefore, approximately 1 month after the original procedure, the patient underwent repeat coronary angiography. After sedation, a 5F sheath was placed in the right femoral artery. A 5F 2.5 Judkins catheter was placed in the orifice of the left coronary artery. We injected 50 μg of nitroglycerin and flushed it with 2 cc of normal saline. We injected 3 cc of contrast agent by hand. There were no changes in ST segments, cardiac rhythm, or blood pressure. The caliber of the left main coronary artery again appeared normal. The left anterior descending and circumflex coronary arteries appeared to have improved (). The patient recovered uneventfully and was discharged from the hospital later the same day. After 5 years and subsequent coronary angiography (preceded in each instance by intracoronary nitroglycerin administration), he remained well and free of angiographically apparent graft vasculopathy.
Fig. 2 Left coronary injection of contrast agent (lateral view) after intracoronary nitroglycerin injection shows increased vascular diameter and improved opacification of distal branches.