Case report: venoarterial extracorporeal membrane oxygenation supported severe coronary vasospasm with recurrent cardiac arrest.

Background: Coronary vasospasm is a known cause of transient myocardial ischaemia with non-acute significant occlusive atherosclerotic coronary lesions. Most of them are often effectively managed with oral vasodilators but a few seem to have recurrent episodes despite good adherence to treatment. Case summary: Here, we report a case of a 54-year-old woman with optimal guideline medical treatment due to known coronary vasospasm. During admission, despite several intravenous vasodilators, she presented recurrent severe coronary vasospasm episodes with subsequent cardiac arrests that required venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. After stabilization, oral vasodilators followed by stellate ganglion block and thoracic sympathectomy were done to avoid new episodes. Discussion: This case reflects a wide range of treatment possibilities for recurrent coronary vasospasm although optimal medical treatment, including circulatory support with VA-ECMO during the hyperacute phase, which provided significant benefit in the context of recurrent witnessed cardiac arrest due to pulseless electrical activity. Long-acting vasodilators (molsidomine, nicorandil), alongside less commonly used treatments (magnesium, fluvastatin), may be useful in patients with refractory vasospasm. Lastly, it seems reasonable to consider transient stellate ganglion ablation and thoracic sympathectomy as the final step of treatment if severe episodes persist. Nevertheless, stronger evidence is needed for the aforementioned strategies.