Background

 We present a brief case in which ventricular fibrillation (VFib) required multiple attempts of electrical defibrillation after minimally invasive, off-pump, robotic-assisted left atrial appendage (LAA) clipping.

Pre-operative Presentation

 A 55-year-old male with persistent atrial fibrillation (Afib) presented with fatigue and underwent investigations for LAA clipping.

PMH: Gastrointestinal bleeding, morbid obesity (BMI =40.1 kg/m²), and end-stage renal dialysis.

Robotic Clip Application and Complications

 After robotic LAA clipping the patient experienced persistent VFib refractory to multiple defibrillations. Differential diagnosis included stenosis of the circumflex coronary artery due to LAA clipping, a clot occluding the coronary arteries, or electrical R-on-T ventricular extrasystole of distinct cause.

Management

Coronary angiography demonstrated a spasm of the left anterior descending artery that resolved after intravenous nitroglycerin administration.

Conclusion

 Coronary spasm is a complication of LAA clipping and a prompt diagnosis and treatment impacts clinical outcomes.