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A case of intra-operative ventricular fibrillation: Electro-cauterization, undiagnosed Takotsubo cardiomyopathy or long QT syndrome?
CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 3 (2012) 155–157
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
A case of intra-operative ventricular fibrillation: Electro-cauterization, undiagnosed Takotsubo cardiomyopathy or long QT syndrome? Michael Lieb a , Timothy Orr b , Christopher Gallagher b,∗ , Hadi Moten b , Jonathan M. Tan b a b
Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794, United States Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY 11794, United States
a r t i c l e
i n f o
Article history: Received 18 November 2011 Accepted 18 January 2012 Available online 3 February 2012 Keywords: Electrocauterization Takotsubo cardiomyopathy Ventricular fibrillation Cardiac arrest Long QT syndrome
a b s t r a c t INTRODUCTION: Cardiac arrest in the perioperative setting is an extremely serious event that is estimated to occur between 4.6 and 19.7 per 10,000 anesthetics.1–5 While risk factors for cardiac complications can be identified pre- operatively, in many cases workup of risk factors are not indicated by standard pre-operative testing guidelines. PRESENTATION OF CASE: We present a case of a 47-year-old female undergoing an elective bilateral mastectomy who suddenly converted to ventricular fibrillation. While ventricular fibrillation is not a unique finding, our search for its etiology revealed two previously undiagnosed cardiac conditions, and possible electro- cautery induced ventricular fibrillation. DISCUSSION: In this case study, we discuss the possible etiology of ventricular fibrillation in our patient and highlight the importance pre-operative patient investigation and history provide. CONCLUSION: Searching for the potential causes that may have contributed to the cardiac arrest is an extremely useful exercise as it allows us to better prepare patients pre-operatively, improve intraoperative care, and prevent future cardiac events. © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Case description A 47-year-old female was scheduled for bilateral mastectomy and reconstruction with tissue expanders for infiltrative ductal carcinoma. Her past medical history was significant for hypertension and asthma. Additionally, eighteen months earlier the patient had been hospitalized for a hypertensive crisis. During that hospitalization the patient underwent a cardiac workup including an echocardiogram (ECHO), Regadenoson stress test, electrocardiogram (EKG), and routine lab work. Her laboratory studies were within normal limits with the exception of elevated cardiac troponin, which peaked at 0.50 ng/ml, and then trended to normal. The EKG revealed non-specific ST segment changes and a prolonged QTc of 535 ms. The ECHO revealed no major structural heart lesions or dynamic disturbances and a normal left ventricular ejection fraction (EF) of 61%. The stress test was within normal limits for the patient’s age. Given this history, the patient was evaluated by her cardiologist prior to surgery. A repeat ECHO was unchanged. Her EKG showed unchanged non-specific ST segment changes and a normal QTc. The patient was deemed optimized for the planned procedure.
∗ Corresponding author at: Department of Anesthesiology, Stony Brook University Medical Center, Health Sciences Center, L4-060, Stony Brook, NY 11794-8480, United States. Tel.: +1 631 624 7001; fax: +1 631 444 2907. E-mail address: [email protected] (C. Gallagher).
On physical exam she was 72 kg, and 163 cm with a normal physical exam. Pre-operative vital signs were BP 122/78, HR 88, RR 16 and SaO2 of 98% on room air. Laboratory results and EKG were within normal limits. The patient was brought to the operating room, standard ASA monitors were placed, induction and intubation were uneventful and the surgery proceeded from 07:45 am until 11:00 am without incident. The patient was hemodynamically stable in normal sinus rhythm without ectopy. Blood loss was 50 cc and 1500 cc of crystalloid was infused. At this point the surgical team had elevated the right pectoralis major muscle and was preparing to elevate the left pectoralis major muscle. The electrocautery was applied to the left anterior chest wall and simultaneously the patient went into ventricular fibrillation. The standard ACLS algorithm for ventricular fibrillation was initiated; chest compressions and 1 mg of epinephrine were administered and the patient received one 200 J defibrillation. Within 2 min of the resuscitation effort, the patient was converted back to sinus rhythm and was hemodynamically acceptable. An arterial blood gas after resuscitation revealed no abnormalities with a pH 7.37, PO2 377, PCO2 39, Hct 29, and K 4.0 mEq/L. The operation was aborted and the patient had an uneventful surgical closure, emergence and extubation were successful and the patient was brought to the post-anesthesia care unit (PACU). The patient was neurologically intact and appropriate. Post-operative EKG demonstrated new inferolateral ischemia, and a normal QTc. The patient underwent cardiac catheterization which showed non-obstructive double vessel coronary artery disease, moderate left ventricular (LV) systolic dysfunction (EF 40%), and Takotsubo
2210-2612/$ – see front matter © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2012.01.007
CASE REPORT – OPEN ACCESS 156
M. Lieb et al. / International Journal of Surgery Case Reports 3 (2012) 155–157
syndrome. On post operative day (POD) one the patient went into sinus arrhythmia with prolongation of her QTc to 483 ms. Given these findings, and history of prolonged QTc in the past, the patient was diagnosed with long QT syndrome (LQTS). The patient had a single chamber automatic internal cardiac defibrillator (AICD) placed. The patient returned three days after discharge for elective debridement of necrotic skin edges at the mastectomy site. Her peri-operative course was uneventful and she was discharged home the same day.
2. Discussion Cardiac arrest in the perioperative setting has an incidence between 4.6 and 19.7 per 10,000 anesthetics.1–5 In a study conducted at the Mayo Clinic the overall incidence of perioperative cardiac arrest in patients undergoing non-cardiac surgery from 1990 to 2000 was 4.3 per 10,000 anesthetics. In this study, the annual incidence of cardiac arrest decreased over time, however survival was statistically unchanged.6 While a relatively rare event, cardiac arrest represents a major cause of morbidity and mortality in the perioperative period. Understanding potential causes is a useful exercise as it allows us to improve our ability to better prepare patients pre-operatively, improve intra-operative care, and prevent future cardiac events. We presented a case in which ventricular fibrillation occurred in the middle of an otherwise routine non-cardiac surgery under general anesthesia in a patient that was not considered at risk for intra-operative cardiac events based on preoperative data. In this case we found several interesting competing etiologies that may have caused or contributed to the cardiac event including the use of electrocautery in close proximity to the heart, Takotsubo cardiomyopathy and long QT syndrome. Electrocautery devices are ubiquitous in modern surgical procedures. In this case, the application of electrocautery close to the heart (the intercostal muscles left of the sternal border) coincided exactly to the onset of ventricular fibrillation. This temporal relationship suggests that electrocautery could have been an inciting event in the cardiac arrest. Electrocautery as a cause of ventricular fibrillation has been reported in the literature.7–9 Fu et al. describe a case of ventricular fibrillation during a thoracotomy while electrocautery was being utilized. They concluded that the use of electorcautery in the cardiac region was the most likely cause of cardiac arrest.7 Klop et al. describe a case of ventricular fibrillation during a laparoscopic gastric banding while using electrocautery.8 In yet another case, Yan et al. describe the occurrence of ventricular fibrillation following the application of electrocautery to the left diaphragm during a laparoscopic subphrenic mass resection.9 These authors suggest that the electrical arc between the patient and the electrocautery tool produces a lowfrequency current that can incite an arrhythmia. Lo et al. reviewed surgical implantation and explantation of pacemakers and AICD’s over a 5 year period and found that of 4698 device cases, 4 patients developed electrocautery-induced ventricular tachyarrhythmias; an incidence of 0.09%.10 Here the ventricular fibrillation was the result of direct current energy moving through the pacemaker or AICD leads directly to the myocardium. In our case, and the three others presented, the patients did not have cardiac hardware. Nonetheless, these published reports demonstrate that there is a potential for electrocautery induced cardiac arrest. Long QT syndrome was another potential cause for the intraoperative ventricular fibrillation. Long QT syndrome is a congenital disorder with prolongation of the QT interval and is associated with increased risk for ventricular tachyarrythmias, torsade de pointes, cardiac arrest, and death. Long QT syndrome is due to mutations in genes encoding for cardiac ion channel proteins leading to
abnormal ion channel kinetics. The prolonged QT interval represents a protracted period of recovery from electrical excitation leading to increased probability of the myocardium being refractory to the next depolarization.11,12 It is rare and is estimated to occur in 1 in 10,000 individuals.13 Females (60–70%) are more likely to be affected than males. Long QT syndrome is usually only diagnosed after an individual suffers a cardiac related event such as syncope, cardiac arrest or when there is high suspicion of familial long QT syndrome. The patient presented in this case study was found to have a prolonged QTc eighteen months earlier, but on her pre-operative evaluation she was found to have a normal EKG. Post-operatively the patient again had a prolonged QTc which was ultimately determined to be long QT syndrome. Due to this finding and the intra-operative events, an AICD was placed. The last possible cause of our patient’s unexpected intraoperative ventricular fibrillation was Takotsubo cardiomyopathy. The patient’s diagnosis of Takotsubo cardiomyopathy was made post-operatively during catheterization and was surprising particularly since the patient had a relatively benign medical history (with the exception of one episode of palpitations). The presence of cardiomyopathy was unexpected and unsuspected.Takotsubo cardiomyopathy, also known as stress cardiomyopathy, transient apical ballooning or broken heart syndrome is a disorder whereby the left ventricle has transient dysfunction that can lead to chest pain, dyspnea, ST-segment changes, and wall motion abnormalities without coronary artery obstruction. Most patients undergo a complete recovery of cardiac function although the mechanism of action is unclear.14 It is known to occur in 0.7–2.5% of patients who present with symptoms similar to myocardial infarction, most are postmenopausal women (90%), and high levels of catecholamine release is central to its pathology.15–17 Of importance to this case study, a review of the literature reveals that not only does Takotsubo cardiomyopathy lead to increased risk of ventricular arrhythmias, this disorder has been described as also causing sudden dysrhythmias in the intra-operative setting.18–20 3. Conclusion We present a case of intra-operative ventricular fibrillation that was otherwise unexpected and unsuspected in a 47-year-old female undergoing a non-cardiac surgery. While intra-operative ventricular fibrillation is a rare event it is clear that both anesthesia and surgical services must be prepared to quickly identify these events, initiate ACLS protocol and search for potential causes to prevent recurrence and future events. In this case, we had three potential causes for the sudden and unexpected fibrillation in an otherwise routine case including, proximity of electrocauterization to the myocardium, long QT syndrome, and Takotsubo cardiomyopathy. Each of these causes, in retrospect, were highly suspicious etiologies of the ventricular fibrillation, although we may never know for sure if it was one in specific, or simply a “perfect storm.” Most importantly, the process of establishing a differential diagnosis served as more than an academic exercise and may help to prevent future cardiac events. Conflict of interest statement All authors claim no conflicts of interests in relation to this case report. Funding None.
CASE REPORT – OPEN ACCESS M. Lieb et al. / International Journal of Surgery Case Reports 3 (2012) 155–157
Ethical approval Each author adhered to the ethical guidelines for publication of this case report. Author contributions All authors contributed. References 1. Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology 2002;97(December (6)):1609–17. 2. Newland MC, Ellis SJ, Lydiatt CA, Peters KR, Tinker JH, Romberger DJ, et al. Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital. Anesthesiology 2002;97(July (1)):108–15. 3. Olsson GL, Hallen B. Cardiac arrest during anaesthesia. A computer-aided study in 250,543 anaesthetics. Acta Anaesthesiol Scand 1988;32(November (8)):653–64. 4. Pottecher T, Tiret L, Desmonts JM, Hatton F, Bilaine J, Otteni JC. Cardiac arrest related to anaesthesia: a prospective survey in France (1978–1982). Eur J Anaesthesiol 1984;1(December (4)):305–18. 5. Tiret L, Desmonts JM, Hatton F, Vourc’h G. Complications associated with anaesthesia – a prospective survey in France. Can Anaesth Soc J 1986;33(May (3 Pt 1)):336–44. 6. Sprung J, Warner ME, Contreras MG, Schroeder DR, Beighly CM, Wilson GA, et al. Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery: a study of 518,294 patients at a tertiary referral center. Anesthesiology 2003;99(August (2)):259–69. 7. Fu Q, Cao P, Mi WD, Zhang H. Ventricular fibrillation caused by electrocoagulation during thoracic surgery. Acta Anaesthesiol Scand 2010;54(February (2)):256.
157
8. Klop WM, Lohuis PJ, Strating RP, Mulder W. Ventricular fibrillation caused by electrocoagulation during laparoscopic surgery. Surg Endosc 2002;16(February (2)):362. 9. Yan CY, Cai XJ, Wang YF, Yu H. Ventricular fibrillation caused by electrocoagulation in monopolar mode during laparoscopic subphrenic mass resection. Surg Endosc 2010;(June). 10. Lo R, Mitrache A, Quan W, Cohen TJ. Electrocautery-induced ventricular tachycardia and fibrillation during device implantation and explantation. J Invasive Cardiol 2007;19(January (1)):12–5. 11. Goldenberg I, Moss AJ. Long QT syndrome. J Am Coll Cardiol 2008;51(June (24)):2291–300. 12. Schwartz PJ, Moss AJ, Vincent GM, Crampton RS. Diagnostic criteria for the long QT syndrome. An update. Circulation 1993;88(August (2)):782–4. 13. Roden DM. Clinical practice. Long-QT syndrome. N Engl J Med 2008;358(January (2)):169–76. 14. Nef HM, Mollmann H, Akashi YJ, Hamm CW. Mechanisms of stress (Takotsubo) cardiomyopathy. Nat Rev Cardiol 2010;7(April (4)):187–93. 15. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or Takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27(July (13)):1523–9. 16. Prasad A. Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation 2007;115(February (5)):e56–9. 17. Pernicova I, Garg S, Bourantas CV, Alamgir F, Hoye A. Takotsubo cardiomyopathy: a review of the literature. Angiology 2010;61(February (2)):166–73. 18. Bonello L, Com O, Ait-Moktar O, Théron A, Moro PJ, Salem A, et al. Ventricular arrhythmias during Tako-tsubo syndrome. Int J Cardiol 2008;128(August (2)):e50–3. 19. Zaman S, Ramesh N, Kovoor P. Arrhythmogenic right ventricular cardiomyopathy presenting with intra-operative aborted sudden cardiac death and Takotsubo-Like left ventricular functional abnormalities. Hellenic J Cardiol 2009;50(July–August (4)):330–4. 20. Olivotti L, Moshiri S, Nicolino A, Chiarella F. Stress cardiomyopathy and arrhythmic storm in a 14-year-old boy. J Cardiovasc Med (Hagerstown) 2010;11(July (7)):519–21.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
A case of intra-operative ventricular fibrillation: Electro-cauterization, undiagnosed Takotsubo cardiomyopathy or long QT syndrome? Michael Lieb a , Timothy Orr b , Christopher Gallagher b,∗ , Hadi Moten b , Jonathan M. Tan b a b
Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794, United States Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY 11794, United States
a r t i c l e
i n f o
Article history: Received 18 November 2011 Accepted 18 January 2012 Available online 3 February 2012 Keywords: Electrocauterization Takotsubo cardiomyopathy Ventricular fibrillation Cardiac arrest Long QT syndrome
a b s t r a c t INTRODUCTION: Cardiac arrest in the perioperative setting is an extremely serious event that is estimated to occur between 4.6 and 19.7 per 10,000 anesthetics.1–5 While risk factors for cardiac complications can be identified pre- operatively, in many cases workup of risk factors are not indicated by standard pre-operative testing guidelines. PRESENTATION OF CASE: We present a case of a 47-year-old female undergoing an elective bilateral mastectomy who suddenly converted to ventricular fibrillation. While ventricular fibrillation is not a unique finding, our search for its etiology revealed two previously undiagnosed cardiac conditions, and possible electro- cautery induced ventricular fibrillation. DISCUSSION: In this case study, we discuss the possible etiology of ventricular fibrillation in our patient and highlight the importance pre-operative patient investigation and history provide. CONCLUSION: Searching for the potential causes that may have contributed to the cardiac arrest is an extremely useful exercise as it allows us to better prepare patients pre-operatively, improve intraoperative care, and prevent future cardiac events. © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Case description A 47-year-old female was scheduled for bilateral mastectomy and reconstruction with tissue expanders for infiltrative ductal carcinoma. Her past medical history was significant for hypertension and asthma. Additionally, eighteen months earlier the patient had been hospitalized for a hypertensive crisis. During that hospitalization the patient underwent a cardiac workup including an echocardiogram (ECHO), Regadenoson stress test, electrocardiogram (EKG), and routine lab work. Her laboratory studies were within normal limits with the exception of elevated cardiac troponin, which peaked at 0.50 ng/ml, and then trended to normal. The EKG revealed non-specific ST segment changes and a prolonged QTc of 535 ms. The ECHO revealed no major structural heart lesions or dynamic disturbances and a normal left ventricular ejection fraction (EF) of 61%. The stress test was within normal limits for the patient’s age. Given this history, the patient was evaluated by her cardiologist prior to surgery. A repeat ECHO was unchanged. Her EKG showed unchanged non-specific ST segment changes and a normal QTc. The patient was deemed optimized for the planned procedure.
∗ Corresponding author at: Department of Anesthesiology, Stony Brook University Medical Center, Health Sciences Center, L4-060, Stony Brook, NY 11794-8480, United States. Tel.: +1 631 624 7001; fax: +1 631 444 2907. E-mail address: [email protected] (C. Gallagher).
On physical exam she was 72 kg, and 163 cm with a normal physical exam. Pre-operative vital signs were BP 122/78, HR 88, RR 16 and SaO2 of 98% on room air. Laboratory results and EKG were within normal limits. The patient was brought to the operating room, standard ASA monitors were placed, induction and intubation were uneventful and the surgery proceeded from 07:45 am until 11:00 am without incident. The patient was hemodynamically stable in normal sinus rhythm without ectopy. Blood loss was 50 cc and 1500 cc of crystalloid was infused. At this point the surgical team had elevated the right pectoralis major muscle and was preparing to elevate the left pectoralis major muscle. The electrocautery was applied to the left anterior chest wall and simultaneously the patient went into ventricular fibrillation. The standard ACLS algorithm for ventricular fibrillation was initiated; chest compressions and 1 mg of epinephrine were administered and the patient received one 200 J defibrillation. Within 2 min of the resuscitation effort, the patient was converted back to sinus rhythm and was hemodynamically acceptable. An arterial blood gas after resuscitation revealed no abnormalities with a pH 7.37, PO2 377, PCO2 39, Hct 29, and K 4.0 mEq/L. The operation was aborted and the patient had an uneventful surgical closure, emergence and extubation were successful and the patient was brought to the post-anesthesia care unit (PACU). The patient was neurologically intact and appropriate. Post-operative EKG demonstrated new inferolateral ischemia, and a normal QTc. The patient underwent cardiac catheterization which showed non-obstructive double vessel coronary artery disease, moderate left ventricular (LV) systolic dysfunction (EF 40%), and Takotsubo
2210-2612/$ – see front matter © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2012.01.007
CASE REPORT – OPEN ACCESS 156
M. Lieb et al. / International Journal of Surgery Case Reports 3 (2012) 155–157
syndrome. On post operative day (POD) one the patient went into sinus arrhythmia with prolongation of her QTc to 483 ms. Given these findings, and history of prolonged QTc in the past, the patient was diagnosed with long QT syndrome (LQTS). The patient had a single chamber automatic internal cardiac defibrillator (AICD) placed. The patient returned three days after discharge for elective debridement of necrotic skin edges at the mastectomy site. Her peri-operative course was uneventful and she was discharged home the same day.
2. Discussion Cardiac arrest in the perioperative setting has an incidence between 4.6 and 19.7 per 10,000 anesthetics.1–5 In a study conducted at the Mayo Clinic the overall incidence of perioperative cardiac arrest in patients undergoing non-cardiac surgery from 1990 to 2000 was 4.3 per 10,000 anesthetics. In this study, the annual incidence of cardiac arrest decreased over time, however survival was statistically unchanged.6 While a relatively rare event, cardiac arrest represents a major cause of morbidity and mortality in the perioperative period. Understanding potential causes is a useful exercise as it allows us to improve our ability to better prepare patients pre-operatively, improve intra-operative care, and prevent future cardiac events. We presented a case in which ventricular fibrillation occurred in the middle of an otherwise routine non-cardiac surgery under general anesthesia in a patient that was not considered at risk for intra-operative cardiac events based on preoperative data. In this case we found several interesting competing etiologies that may have caused or contributed to the cardiac event including the use of electrocautery in close proximity to the heart, Takotsubo cardiomyopathy and long QT syndrome. Electrocautery devices are ubiquitous in modern surgical procedures. In this case, the application of electrocautery close to the heart (the intercostal muscles left of the sternal border) coincided exactly to the onset of ventricular fibrillation. This temporal relationship suggests that electrocautery could have been an inciting event in the cardiac arrest. Electrocautery as a cause of ventricular fibrillation has been reported in the literature.7–9 Fu et al. describe a case of ventricular fibrillation during a thoracotomy while electrocautery was being utilized. They concluded that the use of electorcautery in the cardiac region was the most likely cause of cardiac arrest.7 Klop et al. describe a case of ventricular fibrillation during a laparoscopic gastric banding while using electrocautery.8 In yet another case, Yan et al. describe the occurrence of ventricular fibrillation following the application of electrocautery to the left diaphragm during a laparoscopic subphrenic mass resection.9 These authors suggest that the electrical arc between the patient and the electrocautery tool produces a lowfrequency current that can incite an arrhythmia. Lo et al. reviewed surgical implantation and explantation of pacemakers and AICD’s over a 5 year period and found that of 4698 device cases, 4 patients developed electrocautery-induced ventricular tachyarrhythmias; an incidence of 0.09%.10 Here the ventricular fibrillation was the result of direct current energy moving through the pacemaker or AICD leads directly to the myocardium. In our case, and the three others presented, the patients did not have cardiac hardware. Nonetheless, these published reports demonstrate that there is a potential for electrocautery induced cardiac arrest. Long QT syndrome was another potential cause for the intraoperative ventricular fibrillation. Long QT syndrome is a congenital disorder with prolongation of the QT interval and is associated with increased risk for ventricular tachyarrythmias, torsade de pointes, cardiac arrest, and death. Long QT syndrome is due to mutations in genes encoding for cardiac ion channel proteins leading to
abnormal ion channel kinetics. The prolonged QT interval represents a protracted period of recovery from electrical excitation leading to increased probability of the myocardium being refractory to the next depolarization.11,12 It is rare and is estimated to occur in 1 in 10,000 individuals.13 Females (60–70%) are more likely to be affected than males. Long QT syndrome is usually only diagnosed after an individual suffers a cardiac related event such as syncope, cardiac arrest or when there is high suspicion of familial long QT syndrome. The patient presented in this case study was found to have a prolonged QTc eighteen months earlier, but on her pre-operative evaluation she was found to have a normal EKG. Post-operatively the patient again had a prolonged QTc which was ultimately determined to be long QT syndrome. Due to this finding and the intra-operative events, an AICD was placed. The last possible cause of our patient’s unexpected intraoperative ventricular fibrillation was Takotsubo cardiomyopathy. The patient’s diagnosis of Takotsubo cardiomyopathy was made post-operatively during catheterization and was surprising particularly since the patient had a relatively benign medical history (with the exception of one episode of palpitations). The presence of cardiomyopathy was unexpected and unsuspected.Takotsubo cardiomyopathy, also known as stress cardiomyopathy, transient apical ballooning or broken heart syndrome is a disorder whereby the left ventricle has transient dysfunction that can lead to chest pain, dyspnea, ST-segment changes, and wall motion abnormalities without coronary artery obstruction. Most patients undergo a complete recovery of cardiac function although the mechanism of action is unclear.14 It is known to occur in 0.7–2.5% of patients who present with symptoms similar to myocardial infarction, most are postmenopausal women (90%), and high levels of catecholamine release is central to its pathology.15–17 Of importance to this case study, a review of the literature reveals that not only does Takotsubo cardiomyopathy lead to increased risk of ventricular arrhythmias, this disorder has been described as also causing sudden dysrhythmias in the intra-operative setting.18–20 3. Conclusion We present a case of intra-operative ventricular fibrillation that was otherwise unexpected and unsuspected in a 47-year-old female undergoing a non-cardiac surgery. While intra-operative ventricular fibrillation is a rare event it is clear that both anesthesia and surgical services must be prepared to quickly identify these events, initiate ACLS protocol and search for potential causes to prevent recurrence and future events. In this case, we had three potential causes for the sudden and unexpected fibrillation in an otherwise routine case including, proximity of electrocauterization to the myocardium, long QT syndrome, and Takotsubo cardiomyopathy. Each of these causes, in retrospect, were highly suspicious etiologies of the ventricular fibrillation, although we may never know for sure if it was one in specific, or simply a “perfect storm.” Most importantly, the process of establishing a differential diagnosis served as more than an academic exercise and may help to prevent future cardiac events. Conflict of interest statement All authors claim no conflicts of interests in relation to this case report. Funding None.
CASE REPORT – OPEN ACCESS M. Lieb et al. / International Journal of Surgery Case Reports 3 (2012) 155–157
Ethical approval Each author adhered to the ethical guidelines for publication of this case report. Author contributions All authors contributed. References 1. Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology 2002;97(December (6)):1609–17. 2. Newland MC, Ellis SJ, Lydiatt CA, Peters KR, Tinker JH, Romberger DJ, et al. Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital. Anesthesiology 2002;97(July (1)):108–15. 3. Olsson GL, Hallen B. Cardiac arrest during anaesthesia. A computer-aided study in 250,543 anaesthetics. Acta Anaesthesiol Scand 1988;32(November (8)):653–64. 4. Pottecher T, Tiret L, Desmonts JM, Hatton F, Bilaine J, Otteni JC. Cardiac arrest related to anaesthesia: a prospective survey in France (1978–1982). Eur J Anaesthesiol 1984;1(December (4)):305–18. 5. Tiret L, Desmonts JM, Hatton F, Vourc’h G. Complications associated with anaesthesia – a prospective survey in France. Can Anaesth Soc J 1986;33(May (3 Pt 1)):336–44. 6. Sprung J, Warner ME, Contreras MG, Schroeder DR, Beighly CM, Wilson GA, et al. Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery: a study of 518,294 patients at a tertiary referral center. Anesthesiology 2003;99(August (2)):259–69. 7. Fu Q, Cao P, Mi WD, Zhang H. Ventricular fibrillation caused by electrocoagulation during thoracic surgery. Acta Anaesthesiol Scand 2010;54(February (2)):256.
157
8. Klop WM, Lohuis PJ, Strating RP, Mulder W. Ventricular fibrillation caused by electrocoagulation during laparoscopic surgery. Surg Endosc 2002;16(February (2)):362. 9. Yan CY, Cai XJ, Wang YF, Yu H. Ventricular fibrillation caused by electrocoagulation in monopolar mode during laparoscopic subphrenic mass resection. Surg Endosc 2010;(June). 10. Lo R, Mitrache A, Quan W, Cohen TJ. Electrocautery-induced ventricular tachycardia and fibrillation during device implantation and explantation. J Invasive Cardiol 2007;19(January (1)):12–5. 11. Goldenberg I, Moss AJ. Long QT syndrome. J Am Coll Cardiol 2008;51(June (24)):2291–300. 12. Schwartz PJ, Moss AJ, Vincent GM, Crampton RS. Diagnostic criteria for the long QT syndrome. An update. Circulation 1993;88(August (2)):782–4. 13. Roden DM. Clinical practice. Long-QT syndrome. N Engl J Med 2008;358(January (2)):169–76. 14. Nef HM, Mollmann H, Akashi YJ, Hamm CW. Mechanisms of stress (Takotsubo) cardiomyopathy. Nat Rev Cardiol 2010;7(April (4)):187–93. 15. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or Takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27(July (13)):1523–9. 16. Prasad A. Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation 2007;115(February (5)):e56–9. 17. Pernicova I, Garg S, Bourantas CV, Alamgir F, Hoye A. Takotsubo cardiomyopathy: a review of the literature. Angiology 2010;61(February (2)):166–73. 18. Bonello L, Com O, Ait-Moktar O, Théron A, Moro PJ, Salem A, et al. Ventricular arrhythmias during Tako-tsubo syndrome. Int J Cardiol 2008;128(August (2)):e50–3. 19. Zaman S, Ramesh N, Kovoor P. Arrhythmogenic right ventricular cardiomyopathy presenting with intra-operative aborted sudden cardiac death and Takotsubo-Like left ventricular functional abnormalities. Hellenic J Cardiol 2009;50(July–August (4)):330–4. 20. Olivotti L, Moshiri S, Nicolino A, Chiarella F. Stress cardiomyopathy and arrhythmic storm in a 14-year-old boy. J Cardiovasc Med (Hagerstown) 2010;11(July (7)):519–21.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.