Coronary artery spasm following mannitol administration during partial nephrectomy: A case report

Abstract

Rationale:Coronary vasospasm (CAS) is often triggered by autonomic imbalance and can lead to severe cardiac events, particularly in patients with undiagnosed variant angina. Mannitol, commonly used for renal protection, may inadvertently activate the sympathetic nervous system, potentially leading to CAS in susceptible patients. This rare case highlights the potential cardiac risks of mannitol-induced CAS during robotic-assisted surgery.Patient concerns:A 66-year-old male with no known cardiac history underwent robotic-assisted partial nephrectomy. Approximately 40 minutes after receiving a high-dose mannitol infusion (75 g), he developed frequent ventricular premature contractions followed by sudden ventricular fibrillation.Diagnoses:During the operation, post-resuscitation transthoracic echocardiography showed regional wall motion abnormalities. After the operation, emergent coronary angiography revealed no significant stenosis. A coronary spasm provocation test performed 10 days later confirmed the diagnosis of variant angina due to significant CAS.Interventions:In the operating room, prompt cardiopulmonary resuscitation and 3 rounds of defibrillation successfully restored circulation. Following emergent transthoracic echocardiography and coronary angiography, the patient was admitted to the intensive care unit for further evaluation and management.Outcomes:The patient recovered without neurologic sequelae. Calcium channel blocker therapy was initiated, and regular follow-up was arranged at the outpatient department.Lessons:This case underscores the potential cardiac risks associated with high-dose mannitol in patients with coronary hyperreactivity, highlighting the importance of personalized perioperative management and close cardiovascular monitoring. In high-risk patients, alternative strategies for renal protection should be considered to mitigate the risk of life-threatening cardiac events.