Turn left or turn right? Lessons from the management of intraoperative cardiac arrest due to Type I Kounis syndrome: a case report

Kounis syndrome (KS), also known as allergic angina syndrome, is a potentially life-threatening perioperative condition that may be underrecognized under general anesthesia. Management is challenging because anaphylaxis and acute coronary events can occur concurrently and progress to cardiac arrest. We report a 70-year-old man undergoing elective left thoracoscopic lobectomy under general anesthesia. During the procedure, he developed abrupt hypotension and ST-segment elevation followed by ventricular fibrillation (VF). Cardiopulmonary resuscitation (CPR) was initiated, and 1 mg intravenous (IV) epinephrine was administered. The first defibrillation attempt failed to restore an organized rhythm. Marked erythema on both upper extremities was noted and intraoperative anaphylaxis was suspected. Despite anti-anaphylaxis treatment and two additional defibrillation attempts, there was no response. A cardiologist was consulted and internal defibrillation was initiated. After opening the pericardium, papaverine was administered. Sinus rhythm was obtained after the fourth defibrillation, with a total resuscitation time of 29 min. The patient was transferred to the intensive care unit (ICU) and was ultimately diagnosed with Type I Kounis syndrome. He was discharged without complications. This case suggests that in patients without underlying coronary artery disease, reversible coronary vasospasm may represent a pre-dominant pathophysiological mechanism in Type I Kounis syndrome. Early consideration of coronary vasodilator therapy, alongside standard anaphylaxis management, may therefore be warranted in selected perioperative settings.