Kosin Med J.  2019 Jun;34(1):65-71. 10.7180/kmj.2019.34.1.65.

Persistent Complete Atrioventricular Block after Induction of General Anesthesia in a Healthy Patient

• Byeon GJ
• Kim HJ
• Ri HS
• Lee SS
• Kim HY

• KMID: 2451778
• DOI: http://doi.org/10.7180/kmj.2019.34.1.65

Abstract

A 38-year-old female patient had bradycardia in the preoperative electrocardiogram (ECG), and she showed severe bradycardia, with the heart rate (HR) under 40 beats per minute (bpm) even after arrival in the operating room. Immediately after endotracheal intubation, ventricular tachycardia with HR over 200 bpm occurred, but it disappeared voluntarily. The surgery was postponed for additional cardiac evaluation because of the persistent severe bradycardia. On postanesthesia day 2, complete atrioventricular (AV) block appeared. We expected spontaneous recovery over 2 weeks, but the complete AV block persisted. A permanent pacemaker was eventually inserted, and the patient was discharged without other complications on day 4 after insertion of the pacemaker. We report this case because complete AV block has commonly occurred in patients with risk factors such as first AV block, secondary AV block, or bundle branch block, but complete AV block has occurred despite the absence of arrhythmia in this patient.

Keyword

Atrioventricular block; Bradycardia; General anesthesia

MeSH Terms

Adult
Anesthesia, General*
Arrhythmias, Cardiac
Atrioventricular Block*
Bradycardia
Bundle-Branch Block
Electrocardiography
Female
Heart Rate
Humans
Intubation, Intratracheal
Operating Rooms
Risk Factors
Tachycardia, Ventricular

Figure

• 

  Fig. 1 Preoperative ECG showing sinus bradycardia with heart rate at 46 beats per minute. ECG, electrocardiogram.

• 

  Fig. 2 ECG obtained in the immediate postanesthesia period shows a 2:1 AV block. The red arrows indicate P-waves. ECG, electrocardiogram; AV, atrioventricular.

• 

  Fig. 3 ECG obtained on postanesthesia day 2 shows a complete AV block. The red arrows indicate P-waves. ECG, electrocardiogram; AV, atrioventricular.

Reference

1. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation. 2008; 117:e350–e408.

2. Noh JI, Lee JH, Woo SY, Kim YK, Cho SH, Kim SH, et al. Complete atrioventricular nodal block after propofol administration in an elderly patient undergoing total knee replacement arthroplasty-A case report-. Korean J Anesthesiol. 2013; 64:363–366.

3. Shigematsu-Locatelli M, Kawano T, Nishigaki A, Yamanaka D, Aoyama B, Tateiwa H, et al. General anesthesia in a patient with asymptomatic second-degree two-to-one atrioventricular block. JA Clin Rep. 2017; 3:27.

4. Barra SN, Providência R, Paiva L, Nascimento J, Marques AL. A review on advanced atrioventricular block in young or middle-aged adults. Pacing Clin Electrophysiol. 2012; 35:1395–1405.

5. Kertesz NJ, Fenrich AL, Friedman RA. Congenital complete atrioventricular block. Tex Heart Inst J. 1997; 24:301–307.

6. Atlee JL 3rd, Rusy BF. Halothane depression of A-V conduction studies by electrograms of the bundle of his in dogs. Anesthesiology. 1972; 36:112–118.

7. Atlee JL 3rd, Rusy BF. Atrioventricular conduction times and atrioventricular nodal conductivity during enflurane anesthesia in dogs. Anesthesiology. 1977; 47:498–503.

8. Kazama T, Ikeda K. The comparative cardiovascular effects of sevoflurane with halothane and isoflurane. J Anesth. 1988; 2:63–68.

9. Conzen PF, Vollmar B, Habazettl H, Frink EJ, Peter K, Messmer K. Systemic and regional hemodynamics of isoflurane and sevoflurane in rats. Anesth Analg. 1992; 74:79–88.

10. Zhou W, Fontenot HJ, Liu S, Kennedy RH. Modulation of cardiac calcium channels by propofol. Anesthesiology. 1997; 86:670–675.

11. Maruyama K, Agata H, Ono K, Hiroki K, Fujihara T. Slow induction with sevoflurane was associated with complete atrioventricular block in a child with hypertension, renal dysfunction, and impaired cardiac conduction. Paediatr Anaesth. 1998; 8:73–78.

12. Yokota S. Comparative effects of inhalation anesthetics on atrioventricular conduction with and without calcium entry blockers. Hokkaido Igaku Zasshi. 1989; 64:43–54.

13. Zaballos M, Jimeno C, Almendral J, Atienza F, Patiño D, Valdes E, et al. Cardiac electro-physiological effects of remifentanil: study in a closed-chest porcine model. Br J Anaesth. 2009; 103:191–198.

14. Miller RD. Miller's Anesthesia. 8th ed. Philadelphia, USA: Elsevier;2014. p. 1439.

15. Atlee JL, Bernstein AD. Cardiac rhythm management devices (Part I): indications, device selection, and function. Anesthesiology. 2001; 95:1265–1280.