ID:130 FC-D02-3 Successful Management of Refractory Bilateral Coronary Ostial Spasm with Repeated ECPR and Bilateral Thoracic Sympathectomy

Background: Refractory coronary artery spasm (CAS) may cause sudden hemodynamic collapse and cardiac arrest, and the optimal integration of ECPR, revascularization, and autonomic modulation is not well established. Clinical course/Activities: A 59-year-old man with prior syncope and paroxysmal atrioventricular block, who had experienced two previous episodes of collapse, suffered a third event presenting as out-of-hospital cardiac arrest. Venoarterial ECMO was initiated as ECPR within minutes under a predefined institutional protocol. Initial angiography showed non-obstructive coronary disease. After ECMO weaning and decannulation, he experienced a fourth episode of ventricular fibrillation, preceded by dynamic ischemic changes on continuous electrocardiographic monitoring, and again underwent rapid ECPR activation. Repeated angiography with ergonovine provocation demonstrated severe bilateral coronary ostial spasm (left main and right coronary artery). Multidisciplinary consensus led to bilateral ostial drug-eluting stent implantation, followed by bilateral uniportal VATS T2–T4 dorsal sympathectomy with concomitant ECMO decannulation. He subsequently received ICD implantation and was discharged neurologically intact. Discussion: This case underscores the value of a 24/7 protocolized ECPR program, immediate catheterization access, and close collaboration between cardiac surgery, cardiology, intensive care, and rehabilitation teams in managing refractory CAS. Conclusion: Rapid ECPR deployment combined with advanced coronary intervention and bilateral thoracic sympathectomy can yield excellent neurological and clinical outcomes in otherwise fatal refractory CAS.