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LETTER TO EDITOR
Year : 2023 | Volume
: 13
| Issue : 1 | Page : 122-124
Anaesthetic management of pregnant patient with idiopathic ventricular tachycardia for emergency caesarean section
Arun Aravind
Department of Anaesthesiology, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India
Correspondence Address:
Dr. Arun Aravind
Department of Anaesthesiology, DM Wayanad Institute of Medical Sciences, Wayanad - 673 577, Kerala
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/JOACC.JOACC_13_22
Sir,
Pregnancy is associated with an increased risk of arrhythmia in women with both structurally normal and abnormal hearts. Idiopathic ventricular tachycardia (VT) though rare is having good prognosis if it is not associated with any structural heart disease and responds well to medical management.
A 25-year-old lady with a previous history of cesarean section presented to the emergency room with labor pains at 38 weeks of gestation was planned for emergency cesarean section in view of fetal distress. She was already diagnosed to have ventricular bigeminy for which she was on treatment with Verapamil and Metoprolol. An electrocardiogram was taken which showed frequent ventricular ectopics with periods of non-sustained VT with left bundle branch block pattern and right axis deviation suggestive of right ventricular outflow tract ventricular tachycardia (RVOT VT) [Figure 1]. An echocardiogram showed a structurally normal heart with good left ventricular function. All blood investigations including serum electrolytes and thyroid functions were within normal limits. General anesthesia with controlled ventilation with epidural analgesia and invasive blood pressure monitoring was planned as surgical anesthesia with sole epidural anesthesia was not possible due to lack of time in the setting of fetal distress. An arterial cannula was secured in the left radial artery and blood pressure was continuously monitored. The epidural catheter was inserted in the L2-L3 space and 6 ml of 1% preservative-free lignocaine followed by 4 ml of 0.2% ropivacaine was given to get analgesia between T10 and L2. About 1 gm of magnesium sulfate and 1 gram of paracetamol were given as an infusion over 10 minutes.
Figure 1: Preoperative ECG showing episodes of non-sustained vetricular tachycardia with LBBB patternGeneral anesthesia with modified rapid sequence induction using inj. etomidate 16 mg and inj. rocuronium 80 mg was performed after 3 minutes of pre-oxygenation and intubated after 1 minute. Blood pressure was maintained above baseline with intermittent 20 microgram boluses of phenylephrine. The patient went into sustained VT with a heart rate of around 160 beats/minute maintaining a mean arterial pressure above 70 mmHg. This episode of VT was terminated using an 80 mg bolus of preservative-free lignocaine and deepening the depth of anesthesia with inj. fentanyl and propofol. Delivered active male baby of 2.8 kg with an Appearance Pulse Grimace Activity And Respiration (APGAR) score of 9 at 1 minute was handed over to pediatrician. About 10 units of oxytocin were given as an infusion over 30 minutes without a bolus dose after delivery. The cardiac rhythm became ventricular bigeminy with stable hemodynamics10 minutes after delivery. At the end of the surgery, there were only some occasional ventricular ectopic beats hence reversed and extubated on the table and shifted the patient to the surgical intensive care unit. Post operative analgesia was continued with 0.1% ropivacaine epidural infusion. Postoperatively the rhythm became normal sinus rhythm with stable hemodynamics [Figure 2]. The patient had an uneventful recovery and was discharged on the 5th postoperative day.
Some of the arrhythmias in pregnancy are benign and may sometime disappear completely in the postpartum period. VT can occur at any time during pregnancy and is usually associated with structural heart diseases like peripartum cardiomyopathy, congenital heart diseases or channelopathies like long QT syndrome and are having a poor outcome. VT can also occur in a structurally normal heart and is called idiopathic VT[1] which is usually precipitated by hypomagnesemia, hypertension, thyrotoxicosis etc., and are having a good prognosis.
90% of outflow tract VT occurs from right ventricular outflow just below the pulmonary valve (RVOT VT) and responds well to beta-blocker therapy. This RVOT VT can either be a no-sustained monomorphic VT or a paroxysmal sustained VT.[2] Left ventricular outflow tract VT is less common, has an Right Bundle Branch Block (RBBB) pattern, and respond well to verapamil. VT with hemodynamic instability needs to be treated with emergency cardioversion preferably with lower energies.[3] Drugs having the least effect on the fetus like digoxin, adenosine, flecainide, procainamide, propranolol, propafenone, quinidine, sotalol, and verapamil can be used when absolutely indicated. The use of beta blockers is generally considered safe, particularly in the later stages of pregnancy.[4] There are reports of induction of VT with hormonal therapy followed by catheter radiofrequency ablation also with good outcomes.[5]
In our case, the rhythm was ventricular bigeminy later became nonsustained RVOT VT which was not responding to verapamil and beta-blocker. Amiodarone was avoided because of the possible effects on the fetus and reports of untoward responses in some cases.[6] The patient was hemodynamically stable and the option of radiofrequency ablation was not possible because of the emergency nature of the surgery. So we proceeded with medical management using lignocaine and magnesium sulfate and invasive monitoring of hemodynamics as above.
Acknowledgements
Dr. Ravi Kumar, Professor & Head of department, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India, PIN: 673577Dr. Arun Gopi, Consultant Interventional cardiologist, Metro International cardiac centre, Kozhikode, Kerala.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.
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