Case presentation
The patient was a 22-year-old woman (height: 165 cm; weight: 86.5 kg;
BMI: 31.8 kg/m2). She was scheduled to undergo
endometrial ablation for endometrial hyperplasia. Regarding her medical
history, she experienced a cardiopulmonary arrest owing to ventricular
fibrillation at the age of 15, at which time she was diagnosed as having
coronary spasm via a coronary angiogram and acetylcholine stress test.
She underwent ICD implantation, together with the initiation of
treatment with a Ca2+ blocker and coronary dilators.
The ICD was activated 4 times in 6 years, and the patient resumed a
self-paced heartbeat. After a careful interview regarding the
circumstances of the onset of her symptoms, we strongly suspected
menstrual-associated coronary spasm, as her symptoms occurred from just
before menstruation to the middle of menstruation. Estrogen/progesterone
replacement therapy was started, and her ICD activation and angina
attacks ceased. When she was 22 years old, we decided to perform an
endometrial ablation with tissue biopsy for endometrial hyperplasia that
was thought to be caused by the estrogen/progesterone medication. Her
family history included coronary angina pectoris in the father. Her oral
medications were diltiazem (120 mg/day), nifedipine (40 mg/day),
nicorandil (25 mg/day), and isosorbide mononitrate (40 mg/day), and an
isosorbide mononitrate patch (80 mg/day). She had no history of smoking.
Her first menstrual period was at 11 years old, and her menstrual cycle
was 30 days and regular. Her last menstrual period was 14 days before
the scheduled surgery. Blood test findings were normal. Chest X-ray
displayed no cardiac enlargement or abnormal shadows, except for the
presence of an ICD device. Preoperative estradiol levels were 63.1 pg/mL
in the follicular phase, and 42.9 pg/mL in the ovulatory phase, which
were within the normal ranges for these phases in nonpregnant women. Her
ECG results were normal, with a pulse of 55 beats/min, sinus rhythm, and
a corrected QTc of 403 ms. Transthoracic echocardiography displayed an
ejection fraction of 65%, no abnormal wall motion, no systolic or
diastolic dysfunction, and no apparent valvular disease. There were
load-induced right ventricular abnormalities, and she had a NYHA
classification of grade I. Anesthesia was induced with remifentanil (0.3
µg/kg/min) and propofol TCI (4.0 µg/mL), and muscle relaxation was
achieved with rocuronium bromide (50 mg). After endotracheal intubation
using a McGrath MAC® video laryngoscope (Medtronic Co., Minneapolis, MN,
USA), anesthesia was maintained with propofol TCI (4.0 µg/mL),
continuous infusion of remifentanil (0.1–0.2 µg/kg/min), and rocuronium
bromide 50mg, and sedation levels were monitored using the patient
state index measured with a Sedline® monitor (Masimo Co., Irvine, CA,
USA), and maintained at scores between 30 and 50. In addition, an
observation arterial pressure line was taken. Intraoperative and
postoperative nicorandil (1 µg/kg/min) and diltiazem (1 µg/kg/min) were
continuously administered intravenously. The patient remained unchanged
and her blood pressure did not decrease, and no antihypertensive or
antiarrhythmic medications were administered during the surgery. Surgery
time was 13 minutes, and anesthesia time was 49 minutes. Bleeding was
minimal. The surgery was completed without any complications, and the
patient was extubated and returned to the ICU after surgery. The patient
was discharged on the day after the surgery.