Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2016.11.002
Brazilian Journal of Anesthesiology
Clinical Informations

Intermittent left bundle branch block - reversal to normal conduction during general anesthesia

Bloqueio intermitente de ramo esquerdo - reversão para condução normal durante anestesia geral

Ana Maria Oliveira Correia da Silva; Emília Alexandra Gaspar Lima da Silva

http://dx.doi.org/10.1016/j.bjane.2016.11.002 Braz J Anesthesiol, vol.67, n4, p.430-434, 2017
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Abstract

Abstract Background and objectives: Transient changes in intraoperative cardiac conduction are uncommon. Rare cases of the development or remission of complete left bundle branch block under general and locoregional anesthesia associated with myocardial ischemia, hypertension, tachycardia, and drugs have been reported. Complete left bundle branch block is an important clinical manifestation in some chronic hypertensive patients, which may also be a sign of coronary artery disease, aortic valve disease, or underlying cardiomyopathy. Although usually permanent, it can occur intermittently depending on heart rate (when heart rate exceeds a certain critical value). Case report: This is a case of complete left bundle branch block recorded in the preoperative period of urgent surgery that reverted to normal intraoperative conduction under general anesthesia after a decrease in heart rate. It resurfaced, intermittently and in a heart-rate-dependent manner, in the early postoperative period, eventually reverting to normal conduction in a sustained manner during semi-intensive unit monitoring. The test to identify markers of cardiac muscle necrosis was negative. Pain due to the emergency surgical condition and in the early postoperative period may have been the cause of the increase in heart rate up to the critical value, causing blockage. Conclusions: Although the development or remission of this blockade under anesthesia is uncommon, the anesthesiologist should be alert to the possibility of its occurrence. It may be benign; however, the correct diagnosis is very important. The electrocardiographic manifestations may mask or be confused with myocardial ischemia, factors that are especially important in a patient under general anesthesia unable to report the characteristic symptoms of ischemia.

Keywords

Cardiac conduction defects, Arrhythmia, Complete left bundle branch block, General anesthesia

Resumo

Resumo Justificativa e objetivos: Alterações transitórias da condução cardíaca no intraoperatório são pouco frequentes. Foram reportados raros casos de desenvolvimento ou remissão de bloqueio completo de ramo esquerdo sob anestesia (geral e locorregional), associados a isquemia do miocárdio, hipertensão, taquicardia e fármacos. O bloqueio completo de ramo esquerdo é uma manifestação clínica importante em alguns hipertensos crônicos, pode também significar doença arterial coronária, doença valvular aórtica ou cardiomiopatia subjacentes. Embora habitualmente permanente, pode ocorrer na forma intermitente dependente da frequência cardíaca (quando a frequência cardíaca excede determinado valor crítico). Relato de caso: Este é um caso de bloqueio completo de ramo esquerdo registrado no pré-operatório de cirurgia urgente que reverteu para condução normal no intraoperatório sob anestesia geral após diminuição da frequência cardíaca. Ressurgiu, de forma intermitente e dependente da frequência cardíaca, no pós-operatório imediato, acabou por reverter novamente à condução normal de forma sustentada durante vigilância em unidade semi-intensiva. O estudo com marcadores de necrose muscular cardíacos foi negativo. A dor do quadro cirúrgico urgente e pós-operatório imediato pode ter estado na origem da subida da frequência cardíaca até ao valor crítico e causado bloqueio. Conclusões: Embora o desenvolvimento ou a remissão desse bloqueio sob anestesia sejam incomuns, o anestesiologista deverá estar alertado para a possibilidade da sua ocorrência. Pode ter caráter benigno, contudo o diagnóstico correto é muito importante. As manifestações eletrocardiográficas podem ser confundidas com ou encobrir isquemia miocárdica, fatos de especial importância num paciente sob anestesia geral incapaz de referir sintomatologia característica de isquemia.

Palavras-chave

Defeitos da condução cardíaca, Arritmia, Bloqueio completo de ramo esquerdo, Anestesia geral

References

Tanus-Santos JE. Transient left bundle branch block during anesthesia. Rev Mex Anest. 1998;21:211-3.

Tagliente TM, Jayagopal S. Transient left bundle branch block following lidocaine. Anesth Analg. 1989;69:545-7.

Edelman JD, Hurlbert BJ. Intermittent left bundle branch block during anesthesia. Anesth Analg. 1980;59:628-30.

Azar I, Turndorf H. Paroxysmal left bundle branch block during nitrous oxide anesthesia in a patient on lithium carbonate: a case report. Anesth Analg. 1977;56:868-70.

Domino KB, LaMantia KL, Geer RT. Intraoperative diagnosis of rate-dependent bundle branch block. Can Anaesth Soc J. 1984;31:302-6.

Chapman JH. Intermittent left bundle branch block in the athletic heart syndrome - autonomic influence on intraventricular conduction. Chest. 1977;71:776-9.

Herweg B, Marcus MB, Barold SS. Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing. Herzschr Elektrophys. 2016;27:307-22.

Breithardt G, Breithardt O-A. Left bundle branch block, an old-new entity. J Cardiovasc Trans Res. 2012;5:107-16.

Mishra S, Nasa P, Goyal GN. The rate dependent bundle branch block - transition from left bundle branch block to intraoperative normal sinus rhythm - case report. Middle East J Anesthesiol. 2009;20:295-8.

Grady TA, Chiu AC, Snader CE. Prognostic significance of exercise-induced left bundle branch block. JAMA. 1998;279:153-6.

Abben R, Rosen KM, Denes P. Intermittent left bundle branch block: anatomic substrate as reflected in the electrocardiogram during normal conduction. Circulation. 1979;59:1040-3.

Chakrabarti D, Bhattacharjee A, Bhattacharyya A. Intermittent left bundle branch block - a diagnostic dilemma. JIACM. 2013;14:278-9.

Sgarbossa EB. Recent advances in the electrocardiographic diagnosis of myocardial infarction: left bundle branch block and pacing. Pacing Clin Electrophysiol. 1996;19:1370-9.

Smith SW, Dodd KW, Henry TD. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012;60:766-76.

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