Anesthesia & Clinical Research
Open Access

Management of Third-degree Atrioventricular Block with Intraoperative Transvenous Temporary Pacemaker

Tomonori Morita^*, Hiroaki Kishikawa and Atsuhiro Sakamoto ^*Correspondence: Dr. Tomonori Morita, 1202-12-26-1Otowa, Bunkyo-Ku,Tokyo 112-0013, Japan, Tel: +81-3-3822-2131, Fax: +81-3-5685-3077, Email:

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Introduction

Patients with bifascicular block or complete right bundle branch block (CRBBB), or complete left bundle branch block (CLBBB) with additional first-degree atrioventricular (AV) block are at high risk for block progression and consequent complete AV blocks during procedures with general anesthesia [1-3]. Prompt treatment using anticholinergic and sympathomimetic drugs is required in the cases of complete AV blocks. Pacemakers should be considered for patients with recurrent complete heart blocks that do not respond to medical treatment. However, intraoperative pacemakers are not always effective or safe.

Here, we reported the case of a patient with preoperative CRBBB and atrial flutter (AFL) who developed a complete AV block during laparoscopic surgery, and was successfully managed with a temporary transvenous pacemaker (TVP) after capture failure using a transcutaneous pacemaker (TCP).

Case Presentation

An 82-year-old man (height 168 cm, weight 69 kg, body surface area 1.78 m²) was diagnosed with sigmoid colon cancer and was scheduled to undergo laparoscopic colectomy. He had a medical history of chronic renal failure and cerebral infarction. He was a heavy smoker (100 cigarettes per day) and presented with emphysema. Preoperative tests revealed CRBBB and AFL one lectrocardiography (ECG). We placed an epidural catheter into the epidural space between Th11 and Th12 and administered 8 ml of 0.375% levobupivacaine. We induced general anesthesia with propofol (70 mg) and rocuronium (50 mg) and maintained it with oxygen (40%), sevoflurane (1.5%), and remifentanil (0.1 μ/kg/min) combined with epidural anesthesia. His blood pressure, heart rate (HR), and ECG waves were stable during the initial stage of the laparoscopic procedure. After the establishment of a small laparotomy for colon resection, the HR decreased to 40 beats per minute (bpm) with a complete AV block on lead II. The intravenous administration of atropine was ineffective, and the block continued after a total of 0.2 mg of intravenousatropine and ephedrine (4 mg). We positioned paddles (apex to anterior) and initiated TCP (demand mode at 80 bpm), but we found no notable capture after increasing the current amplitude to 150 mA. The BP was at approximately 100/60 mmHg without exogenous catecholamines. We inserted a TVP lead with X-ray visualization, and initiated TVP (demand mode with an HR of 80 bpm); consequently, the patient remained hemodynamically stable. We completed the operation, and the patient woke up without neurological deficits. An electrocardiogram in the intensive care unit showed normal sinus rhythm (HR, bpm), TVP was stopped, and we removed the pelvic orthotic device and TVP leads. Provided the normal postoperative Holter ECG results without bradyarrhythmias, we prescribed no other medical treatment. We discharged him after 19days of hospitalization without signs of neurological complications.

Discussion

We reported the capture failure of a TCP in a patient with complete AV block during laparoscopic surgery that was successfully managed with a transvenous temporary pacemaker (TVP) to complete without incident.

Few studies on the perioperative application of TCPs are available, and in these studies, the number of patients is lesser than in the present study [1-3]. The occurrence rate of perioperative block progression is low at 1%for patients with asymptomatic bifascicular block, LBBB, or RBBB [4-6]. Even when compared with patients without additional AV blocks, the patients with additional first-degree AV block are not subject to a higher block progression rate [1]. Thus, the recommendation that all patients with asymptomatic bifascicular block, LBBB, or RBBB (and other AV blocks) be provided with a temporary pacemaker is exaggerated and not cost-effective [1-3,7]. However, some patients such as those with new bifascicular blocks or LBBB together with first-degree AV block and an acute myocardial infarction, those with LBBB and preexisting severe cardiovascular disease, and those with LBBB undergoing pulmonary artery catheterization appear to be particularly at risk [8-10]. In these cases, the prophylactic placement of a temporary TCP appears prudent. However, we had not expected that our patient with preoperative CRBBB and AFL would develop a third-degree block during the laparoscopic surgery.

In perioperative studies, TCP stimulation was effective in nearly all cases [4-6]. However, pacing thresholds tend to be higher in patients with emphysema or pericardial effusion, and in those under positive pressure ventilation [11]. Proper skin preparation and electrode positioning help ensure successful capture in most situations. Before applying the two pacing electrodes to the patient’s thorax, the skin site should be cleansed with soap and water. The negative electrode is placed on the anterior chest wall, at the lead V3 position, and the positive electrode on the patient’s back, to the left of the thoracic spine (between the spine and the left scapular bone); it may also be placed on the right side of the chest at the lead V1 position [11].

In our patient with emphysema under positive pressure ventilation, and we could not appropriately place the two pacing electrodes; the negative electrode was in the anterior chest wall and the positive electrode on the lateral chest wall. The suboptimal positioning may have led to capture failure.

In any case, insertion of a TVP lead without delay was the right call.

Conclusion

In conclusion, anesthesiologists need to consider TVPs for patients with severe bradycardia after laparoscopic intraoperative TCP capture failure.

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