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Soonchunhyang Medical Science 20(1):24-26, June 2014 pISSN: 2233-4289 I eISSN: 2233-4297 CASE REPORT Intraoperative Detection of Rate Dependent Left Bundle Branch Block Bon-Sung Koo, Mi-Soon Lee, Sung-Hwan Cho, Sang-Hyun Kim Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea Rate dependent left bundle branch block (RDLBBB) is an uncommon case. RDLBBB is defined as an intraventricular conduction defect that may return, if only temporarily, to sinus rhythm at lower heart rates. It appears when the heart rate exceeds a certain critical value. Although RDLBBB is usually benign, its diagnosis and treatment have clinical importance for association of RDLBBB and myocardial ischemia and infarction. Therefore, in the case of detection of intraoperative RDLBBB, a clear differentiation should be done as soon as possible. Also it is important to start appropriate treatment and to do clinical follow-up examination. We report a case of intraoperative RDLBBB during general anesthesia for laparoscopic cholecystectomy in 82 years old female patient who has a history of hypertension. Keywords: Bundle-branch block; Myocardial ischemia; Electrocardiography; General anesthesia INTRODUCTION roscopic cholecystectomy due to gallbladder stones. She had histories of cerebral infarction, Alzheimer’s disease, and hypertension. Left bundle branch block (LBBB) is a common electrocardio- She was being medicated with calcium channel blocker and beta graphic abnormal finding in hypertensive patients. In a healthy blocker for the treatment of hypertension for 10 years. Preopera- young patient, LBBB may be benign. But in hypertensive or older tive laboratory values were within normal limits. Preoperative patients, it may be related to cardiovascular disease [1,2]. electrocardiogram (ECG) was normal sinus rhythm with heart Rate dependent left bundle branch block (RDLBBB) is a rare ar- rates at 60 beats per minute (bpm). Cardiac echocardiography re- rhythmia during general anesthesia. RDLBBB is a transient bun- vealed mild diastolic dysfunction with normal ventricular systolic dle branch block that occurs when heart rate exceeds a certain function and normal chamber sizes. critical value. Although RDLBBB is usually benign, its diagnosis Glycopyrrolate 0.2 mg was given intramuscularly 30 minutes and treatment have clinical importance for association of RDLBBB before arriving at operation theatre. On arrival in the operating and myocardial ischemia and infarction [3]. Therefore, it is neces- theatre, the patient was monitored using a three-lead ECG, pulse sary to do careful observation and clear differentiation. We report oximetry, non-invasive arterial pressure measurement (Solar a case of intraoperative RDLBBB during general anesthesia for 8000; GE, Milwaukee, WI, USA), and a bispectral index monitor laparoscopic cholecystectomy in 82 years old female patient who (BIS, BIS XP; Aspect Medical Systems, Newton, MA, USA). Gen- has a history of hypertension. eral anesthesia was induced using infusion pump (Fresenius Kabi, orchestra) with propofol (Marsh mode) and remifentanil (Minto CASE REPORT mode) at target effect site concentrations of 3.0 μg/mL and 3.0 ng/ mL, respectively. Trachea was intubated uneventfully after 2 min- An 82 years old female patient was scheduled for elective lapa- utes of bolus rocuronium bromide 0.6 mg/kg. After tracheal intu- Correspondence to: Bon-Sung Koo Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea Tel: +82-32-621-5330, Fax: +82-32-621-5322, E-mail: [email protected] Received: Oct. 24, 2013 / Accepted after revision: Apr. 9, 2014 24 http://jsms.sch.ac.kr © 2014 Soonchunhyang Medical Research Institute This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/). Intraoperative Arrhythmia • Koo BS, et al. bation, the heart rate increased to 80 bpm and a wide QRS com- for additional testing, initially noninvasive such as echocardiogra- plex with ST depression appeared at lead II on ECG. Blood pres- phy, 24-hour ambulatory Holter monitoring, and exercise testing. sure was within normal limits at this moment. Heart rate gradual- In the selected case, invasive tests such as coronary angiography ly decreased to 60 bpm after increasing plasma concentration of and electrophysiologic study may be necessary to confirm or rule remifentanil and propofol to 3.5 ng/mL and 3.5 μg/mL. Then ECG out the suspicion of the heart disease [7]. was returned to normal sinus rhythm. As ECG abnormalities was Rate dependent bundle branch block is defined as an intraven- recovered suddenly without accompanying gradual changes in tricular conduction defect that may return, if only temporarily, to QRS width or ST segment, authors presumed that the ECG find- sinus rhythm at lower heart rates [8]. The exact mechanism of ing of this patient is relevant to that of RDLBBB. such a block remains obscure but may result from anatomic and During the operation, conversion between RDLBBB and NSR pathologic interruptions in cardiac conducting bundle either due was occurred 5 to 6 times as heart rate changes between early 60 to ventricular enlargement or strain from neurogenic or function- bpm and over 70 bpm. Overall, the ECG finding was NSR when al depression with or without underlying pathological lesions of heart rates were within 60 bpm. Operation finished uneventfully. the conducting tissue [9]. RDLBBB occurs when the heart rate ex- RDLBBB reappeared at emergence phase and continued until the ceeds a certain critical value [3]. The onset of RDLBBB is sudden patient stayed at post-anesthesia care unit. Postoperative creatine in most patients and once initiated, it persists until the heart rate is kinase-MB, troponin-T values were within normal limits. On slower than that which triggered it [3]. Bauer [9] reported that the postoperative day 6, she was discharged from the hospital without transition from normal to abnormal intraventricular conduction any episodes. may be related alterations of the rate by only 1 or 2 beats/min. This critical heart rate is dependent on change in heart rate. With rapid DISCUSSION decrease in heart rate, sinus rhythm may appear at higher rates and with rapid acceleration in heart rate, it may appear at lower Recently, ECG is one of the most common diagnostic tools in heart rates [8]. RDLBBB is usually found in patients with hyper- routine clinical setting because of its wide diffusion, undemand- tension or coronary artery disease, although up to ten percent may ing feasibility, and low cost. As a result of a its broad use, the find- have no evidence of organic heart disease [3,9]. In this case, the pa- ing of LBBB in the absence of well-defined clinical setting has be- tient also had a history of hypertension. And her preoperative come relatively frequent and raises questions and often concerns ECG finding was normal sinus rhythm with heart rates at 60 bpm. [4]. Although RDLBBB is usually benign, its diagnosis and treatment LBBB is a frequent electrocardiographic abnormality in hyper- have clinical importance for several reasons. First, it may mask the tensive patients. Also it may imply associated coronary artery dis- electrocardiographic manifestations of other less benign distur- ease, aortic valve disease or cardiomyopathies [5]. In a healthy bances, such as myocardial ischemia and infarction. Second, the young adult, isolated LBBB may be benign. But in hypertensive or ST-T wave changes associated with LBBB may be mistaken for older patients, it may signify a progressive degenerating myocardi- ST-T changes due to ischemia. RDLBBB may also be mistaken for um involving cardiac conduction system [1,2]. Incidence of LBBB slow ventricular tachycardia and may be inappropriately treated increases with age [5]. During last 30 years, the prevalence of LBBB [3]. A clear differentiation of LBBB into a benign RDLBBB, and in the general population has been reported to vary considerably LBBB associated with myocardial ischemia or infarction, may according to population size, sampling criteria, ranging 0.16% to avoid the unnecessary postponement of a case because of high 0.82% [4]. The prognosis of LBBB has varied widely, mainly as a cardiac risk [8]. result of the different population from which the cases were select- Diagnostic methods should first be attempted by observation of ed, presence or absence of heart disease, and the type and severity changes in conduction with spontaneously occurring changes in of heart disease [6]. Therefore, physicians should be aware of the heart rate. If the diagnosis is not obvious and the bundle branch role of LBBB and investigate the risk of cardiovascular events [4]. block persists, then judiciously changing the heart rate may prove Corrado et al. [7] reported that patients who positive findings at helpful [3]. Pharmacologic and physiologic manipulations which basic clinical evaluation, as in the case of LBBB, should be referred alter heart rate can be used to change conduction in patients with Soonchunhyang Medical Science 20(1):24-26 http://jsms.sch.ac.kr 25 Koo BS, et al. • Intraoperative Arrhythmia RDLBBB. Normal conduction is changed to LBBB in these pa- REFERENCES tients by increasing heart rate with exercise, valsalva, arterial cuff release, amyl nitrate, or atropine [3]. Manipulations which slow heart rate such as carotid massage, deep inspiration, and pharmacological agents like neostigmine, edrophonium or propranolol, change the aberrant conduction back to normal with the slowing of heart rate [10,11]. Manipulations which increase heart rate to induce a LBBB should be attempted with extreme caution by careful titration of atropine only after myocardial ischemia has been ruled out. Drug doses should be appropriately chosen to avoid inducing tachyarrhythmias or precipitating myocardial ischemia [3]. These provocative maneuvers should be used with caution in patients with hypertension, angina, cerebrovascular or atrioventricular node disease. Prevention of tachycardia and in some cases deliberately slowing the heart rate, can be of diagnostic and therapeutic value [3]. In conclusion, rate dependent LBBB is an uncommon entity. During anesthesia, RDLBBB may be related to hypertension or tachycardia. And its appearance makes the diagnosis of acute myocardial ischemia or infarction difficult. Therefore, in co-morbid patients with LBBB, it is always better to do further cardiac evaluations in order to rule out an associated coronary artery disease. 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Mechanisms influencing conduction in a case of intermittent bundle branch block. Am Heart J 1961;61:548-55. amination. 26 http://jsms.sch.ac.kr Soonchunhyang Medical Science 20(1):24-26