Transient remission of pre-existing left bundle branch block during general anesthesia in a centenarian

Abstract

We present a case of a centenarian patient in whom preexisting left bundle branch block (LBBB) transiently reverted to normal ventricular conduction during general anesthesia. A 104-year-old woman with a history of hypertension, chronic heart failure, and cognitive impairment was admitted for surgical repair of a femoral neck fracture. The standard 12-lead electrocardiogram (ECG) on admission revealed left axis deviation and complete LBBB with a heart rate (HR) of 60 bpm. Echocardiography indicated left ventricular dyssynchrony with an ejection fraction of 51%. Due to her restless and agitated behavior, general anesthesia was selected for surgery.On arrival in the operating room, the patient's blood pressure (BP) was 170/110 mmHg and HR was 110 bpm with a regular rhythm. ECG monitoring showed a wide QRS complex (140 ms) with RsrS pattern (Fig. 1a). Anesthesia was induced with fentanyl, remifentanil, propofol, and rocuronium, followed by insertion of a supraglottic airway, and maintained with desflurane, remifentanil, and fentanyl. Her lungs were mechanically ventilated. Twenty minutes after the commencement of anesthesia, the QRS complex abruptly narrowed to an rSr′ pattern (80 ms) with a HR of 80 bpm and BP of 100/50 mmHg (Fig. 1b). Surgery was commenced after femoral nerve block using levobupivacaine.Intraoperatively, HR, BP, S P O 2 , and end-tidal CO 2 were maintained at 50-80 bpm, 90/40-120/60 mmHg, 99-100%, and 32-43 mmHg, respectively. At the end of the surgery that lasted for 33 min, the QRS complex widened to an RSr pattern (140 ms) at a HR of 50 bpm and BP of 100/60 mmHg (Fig. 1c) for a few minutes.

Brief remission of cardiac conduction defect under anaesthesia during trans-sphenoidal pituitary surgery

“…Minute variations in HR can cause the disappearance of the block depending upon the critical HR. 4 Anaesthesia drugs have negative chronotropic and dromotropic effects that might cause changes in the conduction velocities. 5 During emergence, a transient rise in HR and intrathoracic pressures increase myocardial demand and can precipitate bundle blocks.…”