Key result
Intracoronary acetylcholine testing under VA-ECMO support safely confirms severe vasospasm after VF arrest.
Why the study?
Coronary vasospasm is an important but under-recognized cause of ventricular fibrillation, especially when angiography reveals a nonocclusive fixed coronary lesion.
Case Report (n=1)
In cardiac arrest survivors where fixed coronary lesions do not fully explain refractory ventricular fibrillation, pharmacologic provocation testing under circulatory support (VA-ECMO) can safely unmask underlying coronary vasospasm and guide combined medical, device, and interventional therapy.
Answers are grounded in this paper and cite their sources.
Acetylcholine provocation under VA-ECMO may identify vasospasm in select VF arrest survivors with moderate lesions; leaves open broader diagnostic adoption pending prospective data.
BACKGROUND: A coronary vasospasm is an important but under-recognized cause of ventricular fibrillation, particularly when angiography shows a nonocclusive fixed coronary lesion. CASE SUMMARY: A previously healthy 36-year-old man presented with recurrent early-morning chest pain followed by refractory ventricular fibrillation requiring venoarterial extracorporeal membrane oxygenation. Coronary angiography showed moderate proximal left anterior descending artery stenosis with functionally significant ischemia. However, optical coherence tomography revealed no plaque rupture or thrombus. Because the coronary anatomy was discordant with the severity of presentation, acetylcholine provocation testing was performed under circulatory support and confirmed a severe coronary vasospasm. DISCUSSION: This case highlights the importance of a mechanism-based evaluation in survivors of malignant ventricular arrhythmias. TAKE-HOME MESSAGES: When fixed coronary findings do not fully explain the clinical presentation, a coronary vasospasm should be considered. In selected high-risk patients, carefully performed pharmacologic provocation testing under the appropriate hemodynamic support may be essential for establishing the diagnosis.
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Nishido et al. (2026) conducted a case report in Refractory ventricular fibrillation associated with coronary vasospasm and fixed moderate proximal left anterior descending artery stenosis (n=1). Intracoronary acetylcholine provocation testing under VA-ECMO support, calcium-channel blocker therapy, subcutaneous ICD implantation, and staged PCI was evaluated on Diagnosis of coronary vasospasm and resolution of anginal symptoms and recurrent ventricular arrhythmias. Intracoronary acetylcholine provocation testing under VA-ECMO support confirmed severe LAD vasospasm in a 36-year-old VF arrest survivor with moderate fixed stenosis.
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