I read with great interest the case report by Boo et al. [1], in which the authors described coronary vasospasm after sugammadex injection in a patient undergoing radiofrequency ablation for atrial fibrillation under general anesthesia. However, a few key aspects must be addressed before drawing definitive conclusions.

First, the authors found angiographic vasospasms solely in the right coronary artery, whereas the left coronaries were unaffected. However, neostigmine-induced coronary vasospasm affects both the right and left coronary territories [2]. Therefore, selective right coronary artery spasms with sugammadex without involvement of the left coronary artery must be explained, as myocardial drug deposition is uniform following systemic administration. Second, the authors did not mention catheter-related events or information. Catheter-induced spasms may be caused by the size of the catheter, catheter approach site, type of catheter used, or the angiographer’s expertise. Although the authors defined the event as occurring after completion of the procedure, catheter-related coronary spasms can persist for a longer duration [3]. Hence, the possibility of catheter-induced subclinical spasms, which would have become apparent after discontinuing the anesthetics, cannot be ruled out. Third, all previous reports of sugammadex-induced coronary vasospasms mentioned by the authors occurred during non-cardiac procedures and because of allergic responses [4,5]. Furthermore, none of the earlier case reports mentioned the status of the left coronaries following sugammadex-induced coronary spasms.

Therefore, selective right coronary artery spasms induced by sugammadex in this case report should be explained. As catheter-induced vasospasms commonly involve the right coronary artery, this potential explanation cannot be excluded.