Correlation of Coronary Angiographic Findings and Hemodynamic Risk During General Anesthesia: A Case Report Case Study
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Keywords
surgical safety checklist, induction of anesthesia, cardiac anesthesia
Abstract
Introduction: The World Health Organization Safe Surgery Checklist requires confirmation that relevant imaging is available prior to surgery. In cardiac surgery, review of coronary angiography enhances clinicopathologic correlation and anticipatory management. This case study illustrates the importance of angiographic review to prevent refractory hypotension following anesthetic induction.
Methods: A single-patient case study was conducted involving a 71-year-old male with severe multi-vessel coronary artery disease undergoing beating-heart, pump-assisted coronary artery bypass grafting. Clinical presentation, intraoperative hemodynamics, echocardiographic findings, and vasoactive management were analyzed in the context of preoperative angiographic data.
Results: Following induction of anesthesia, the patient developed severe refractory hypotension (MAP 30 mmHg) and bradycardia (HR 48-55 BPM) despite phenylephrine administration. The diastolic blood pressure became inadequate to perfuse the left anterior descending (LAD) coronary artery, acutely compromising the myocardium. Escalation to epinephrine and norepinephrine provided transient stabilization. Transesophageal echocardiography revealed an acute reduction in left ventricular ejection fraction (LVEF) from 55-60% to 20%. Emergency sternotomy and initiation of cardiopulmonary bypass were required. Postoperative recovery was uneventful.
Conclusions: In high-risk coronary lesions, hypotension may precipitate myocardial failure refractory to vasopressors. Early inotropic support may be preferable to reflexive vasopressor escalation. Lesions involving the LAD coronary artery increase the risk of intraoperative myocardial ischemia. Adequate preoperative coronary angiogram review may have predicted the ischemia-induced low cardiac output state observed in this case. With this knowledge, patient safety and clinical decision-making would likely have improved, and emergent initiation of cardiopulmonary bypass may have been avoided.
References
2. Böhm F, Mogensen B, Engstrøm T, et al. FFR-guided complete or culprit-only PCI in patients with myocardial infarction. N Engl J Med. 2024;390(16):1481-1492.
3. Dangas G, Mehran R, Wallenstein S, et al. Correlation of Angiographic Morphology and Clinical Presentation in Unstable Angina. Journal of the American College of Cardiology. 1997;29(3):519-525. doi:https://doi.org/10.1016/s0735-1097(96)00560-8
4. Tørring B, Gittell JH, Laursen M, Rasmussen BS, Sørensen EE. Communication and relationship dynamics in surgical teams in the operating room: an ethnographic study. BMC Health Serv Res. 2019;19(1):528.
5. Okolo D, Ugorji WS, Gopep NS, Oragui CC, Ubajaka CC, Okobi OE. Perioperative Management of Anesthesia in Patients With Cardiovascular Disease: A Review of Current Guidelines in the United States. Cureus. Published online February 20, 2025. doi:https://doi.org/10.7759/cureus.79355
6. Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM. Association of Perioperative Myocardial Ischemia with Cardiac Morbidity and Mortality in Men Undergoing Noncardiac Surgery. The New England Journal of Medicine. 1990;323(26):1781-1788. doi:https://doi.org/10.1056/nejm199012273232601
7. Deng C, Bellomo R, Myles P. Systematic review and meta-analysis of the perioperative use of vasoactive drugs on postoperative outcomes after major abdominal surgery. Br J Anaesth. 2020;124(5):513-524.
8. van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017;136(16):232-268. doi:https://doi.org/10.1161/cir.0000000000000525
9. Jain U, Laflamme CJ, Aggarwal A, et al; Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Electrocardiographic and hemodynamic changes and their association with myocardial infarction during coronary artery bypass surgery: a multicenter study. Anesthesiology. 1997;86(3):576-591.
10. Smilowitz NR, Gupta N, Guo Y, Berger JS, Bangalore S. Perioperative acute myocardial infarction associated with non-cardiac surgery. Eur Heart J. 2017;38(31):2409-2417.
11. Lattanzi F, Picano E, Adamo E, Varga A. Dobutamine stress echocardiography: safety in diagnosing coronary artery disease. Drug Saf. 2000;22(4):251-262.
12. Stratmann HG, Kennedy HL. Evaluation of coronary artery disease in the patient unable to exercise: Alternatives to exercise stress testing. American Heart Journal. 1989;117(6):1344-1365. doi:https://doi.org/10.1016/0002-8703(89)90417-1
13. World Health Organisation. WHO surgical safety checklist. World Health Organisation. Published 2009. Accessed March 7, 2026. https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources
14. Sorgun MH, Rzayev S, Yilmaz V, Isıkay CT. Etiologic subtypes of watershed infarcts. J Stroke Cerebrovasc Dis. 2015;24(11):2478-2483.
15. Bloom JE, Chan W, Kaye DM, Stub D. State of Shock: Contemporary Vasopressor and Inotrope Use in Cardiogenic Shock. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease. 2023;12(15). doi:https://doi.org/10.1161/JAHA.123.029787
16. Riccardi M, Matteo Pagnesi, Ovidiu Chioncel, et al. Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors. European Journal of Heart Failure. 2024;26(2). doi:https://doi.org/10.1002/ejhf.3162
17. Levy B, Clere-Jehl R, Legras A, et al. Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. Journal of the American College of Cardiology. 2018;72(2):173-182. doi:https://doi.org/10.1016/j.jacc.2018.04.051
18. Madhavan S, Chan SP, Tan WC, et al. Cardiopulmonary bypass time: every minute counts. The Journal of Cardiovascular Surgery. 2018;59(2):274-281. doi:https://doi.org/10.23736/S0021-9509.17.09864-0
19. Li S, Nordick KV, Iván Murrieta-Álvarez, et al. Prolonged Cardiopulmonary Bypass Time-Induced Endothelial Dysfunction via Glypican-1 Shedding, Inflammation, and Matrix Metalloproteinase 9 in Patients Undergoing Cardiac Surgery. Biomedicines. 2024;13(1):33-33. doi:https://doi.org/10.3390/biomedicines13010033
20. Yang X, Lu N, Yang L, et al. Impact of prolonged cardiopulmonary bypass on gastrointestinal complications in cardiac surgery: a retrospective cohort study. Perioper Med (Lond). 2025;14(1):42.
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