History of presentation
A 60-years-old man with a previous history of persistent atrial fibrillation (AF) treated with oral amiodarone was admitted for an elective electrical cardioversion. A 200 J shock, under sedation with propofol and midazolam, was ineffective and the decision was made to administer a 300 mg bolus of intravenous amiodarone. Immediately after, the patient presented an extensive skin rash associated with pruritus that was shortly followed by cardiac arrest secondary to pulseless electrical activity. Advanced cardiopulmonary resuscitation (CPR) was started but the patient persisted in cardiac arrest. ST-segment elevation was observed on the monitor so the patient was transferred to the cathlab for emergent coronary angiography. A left main coronary artery spasm was observed (figure 1) and complete reversal of spasm was achieved after 5 bolus of intracoronary nitroglycerin. After 19 minutes of advanced CPR with administration of 8 mg of adrenaline, 200 mg of hydrocortisone and 5 mg of dexchlorpheniramine recovery of spontaneous circulation was achieved. Echocardiography revealed biventricular severe dysfunction (video 1). The patient remained in refractory shock despite of high doses of vasoactive drugs so VA-ECMO and intra-aortic balloon pump (IABP) were implanted.