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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 153-155  

Recurrent transient episodes of left bundle branch block immediately following surgery – A rare phenomenon


Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Gyaninder P Singh
Department of Neuroanaesthesiology and Critical Care, Room No. 711, (7th Floor), Neurosciences Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_637_18

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How to cite this article:
Chavali S, Singh GP, Prabhakar H, Chaturvedi A. Recurrent transient episodes of left bundle branch block immediately following surgery – A rare phenomenon. Indian J Anaesth 2019;63:153-5

How to cite this URL:
Chavali S, Singh GP, Prabhakar H, Chaturvedi A. Recurrent transient episodes of left bundle branch block immediately following surgery – A rare phenomenon. Indian J Anaesth [serial online] 2019 [cited 2019 Apr 20];63:153-5. Available from: http://www.ijaweb.org/text.asp?2019/63/2/153/251976



Sir,

We present a 52-year-old male, weighing 72 kg, with recurrent seizures (2–3 episodes of focal twitches and facial automatisms per day) for last 13 years. He was taking levetiracetam (1 g BD), phenytoin (300 mg HS) and topiramate (100 mg BD) for seizure control. He was scheduled for left temporal lobectomy and amygdalohippocampectomy under general anaesthesia, since MRI brain showed mesial temporal sclerosis and hippocampal atrophy. Previous medical history revealed hypertension, well controlled on atenolol (50 mg OD) and amlodipine (10 mg BD). He had no known history of coronary heart disease, and his exercise tolerance was >4 metabolic equivalents. All preoperative investigations were within normal limits, and electrocardiogram (ECG) demonstrated a normal sinus rhythm [Figure 1].
Figure 1: Preoperative electrocardiogram showing sinus rhythm

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On the day of surgery, after routine intravenous induction, anaesthesia was maintained with desflurane in air and oxygen mixture and infusions of rocuronium and fentanyl. His heart rate ranged from 55 to 75 beats/min, and ECG revealed normal sinus rhythm without any conduction anomalies. His systolic blood pressures ranged from 100 to 140 mmHg throughout the surgery. Arterial blood gas (ABG) analysis at the beginning of the case was normal and revealed normal serum electrolytes. After an uneventful surgery, neuromuscular blockade was reversed. Immediately prior to tracheal extubation, there was a sudden change in the ECG rhythm on the monitor, which showed left bundle branch block (LBBB) with acute prolongation in QRS complex duration. A 12-lead ECG was immediately obtained that revealed a complete LBBB at a rate of 140 beats/min [Figure 2]. A bedside transthoracic echocardiogram was done in the operating room, which did not show any regional wall motion abnormality. ABG repeated at this time was normal and showed no electrolyte abnormality. The patient was transferred to ICU without extubating the trachea for close monitoring. In the ICU, his heart rate was 142 beats/min, and arterial blood pressure was 148/78 mmHg. The patient remained comfortable and did not suffer any chest pain, dyspnoea, nausea, or dizziness. Cardiac biomarkers, including creatine kinase and troponin, at 1 and 6 h postoperatively were negative. Subsequent echocardiograms also remained within normal limits. After obtaining a cardiology consultation, atorvastatin (80 mg OD) was added to his regimen, and aspirin (75 mg OD) was added on the first postoperative day. Continuous ECG monitoring revealed multiple episodes of transient complete LBBB, with average duration of about 25 min. However, the patient remained haemodynamically stable, and the decision to extubate his trachea was made on the first postoperative day. At the time of tracheal extubation, his ECG continued to show the complete LBBB. After removal of the ETT, sinus rhythm was restored within 30 min, and further ECG monitoring was negative for any arrhythmias. Negative cardiac enzymes suggested an absence of clinically significant cardiac ischemia. He was instructed to follow up with his cardiologist, but further testing did not reveal the exact aetiology of the transient conduction defect.
Figure 2: Electrocardiogram showing LBBB postoperatively

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LBBB is associated with disruption of normal conduction through the His–Purkinje system, which manifests as prolonged ventricular depolarisation and widened QRS complexes. Its aetiology remains variable and includes electrolyte abnormalities, alterations in normal conduction of cardiac action potential, as well as structural heart disease. The development of new LBBB is a significant clinical event since both the development of LBBB as well as prolongation of the QRS complex >110 ms in the absence of BBB are associated with elevated all-cause mortality.[1] More innocuous aetiologies of new onset LBBB have also been suggested. Chow et al. reported a predictable transient LBBB triggered by laughter, which was possibly triggered by changes in intra-thoracic pressure leading to decreased cardiac perfusion.[2] Bauer et al. reported five cases of LBBB which were triggered at will by breath holding, deep inspiration or straining.[3] Edelman et al. described transient intermittent LBBB without hypertension or tachycardia because of anatomical or physiological interruption of a conduction due to ventricular dilation, or functional depression of cardiac conduction.[4] In our case, the patient developed new-onset LBBB in the immediate postoperative period which was associated with an increased heart rate. A potential cause could be transient ischemia because of increased intra-thoracic pressure caused by straining against ET tube during reversal and in the postoperative period. Moreover, no further episode occurred after removal of the endotracheal tube. Anaesthesiologists should be aware of this condition as well as its implications to manage patients more effectively and our case serves as a reminder of this entity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zhang Z, Rautaharju PM, Soliman EZ, Manson JE, Cain ME, Martin LW, et al. Mortality risk associated with bundle branch blocks and related repolarization abnormalities (from the Women's Health Initiative [WHI]). Am J Cardiol 2012;110:1489-95.  Back to cited text no. 1
    
2.
Chow GV, Desai D, Spragg DD, Zakaria S. Laughter-induced left bundle branch block. J Cardiovasc Electrophysiol 2012;23:1136-8.  Back to cited text no. 2
    
3.
Bauer GE. Bundle branch block under voluntary control. Br Heart J 1964;26:167-79.  Back to cited text no. 3
    
4.
Edelman JD, Hurlbert BJ. Intermittent left bundle branch block during anesthesia. Anesth Analg 1980;59:628-30.  Back to cited text no. 4
    


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