Intraoperative

Cardiac Arrhythmias
Cause, Recognition, and Treatment
Occurrence: 15-85%
Rare complication resulting from cardiac
arrhythmia in the healthy patients
Life-threatening arrhythmia during surgery
Fewer than 1% of patients
Almost all have cardiac disease
Physiology
The Action Potential


Physiology
The Action Potential
Spontaneous diastolic depolarization
Resting potential not stable in conductive tissue cell
Slow spontaneous depolarization until the threshold
potential is reached
Slope is controlled by ANS
Physiology
The Action Potential
Excitability: depolariztion to specific stimulus
Increased excitability
depolarization to a lesser stimuls or an exaggerated
response to normal stimulus
Refractoriness
Absolute refractory period: phase 0,1,2
Relative refractory period: late phase 3, early 4
Susceptable to strong stimuli
Physiology
The Conduct System
most rapid conduction
Control
ventricular
response to
increased supra
ventricular rates
Physiology
Electrophysiology of Arrhythmias
Disturbance of SA nodal rate
Reentry-associated arrhythmias
Alternate pathways
One-way or unidirectional block in one pathway
An area of slow conduction in the other pathway
Diagnostic Criteria
Supraventricular Arrhythmias
Rate
150 - atrial flutter with 2:1 AV block
>200 - accessory AV pathway
Regularity
AF: irregular rhythm
Regular SVT with variable AV block may be
misleading
Diagnostic Criteria
Supraventricular Arrhythmias
P waves
Presence of P wave before QRS: atrial origin
No P wave with regular tachycardia: AV node or
below
QRS width
<0.12 ms: supraventricular source
Wider QRS: BBB, aberrant conduction, accessory
path
Diagnostic Criteria
Supraventricular Arrhythmias
QRS axis
Severe LAD: ventricular origin
Paroxysmal SVT
Sinoatrial node reentry: normal P
Atrial tachycardias: upright but abnormal appearing P
Atrioventricular node reentry: no P or inverted
Accessory pathway: delta wave
AF: irregular narrow QRS
A-flutter: atrial rate 300 with AV block
Diagnostic Criteria
Ventricular Arrhythmias
Frequent PVCs, couplets or brief runs of VT
Healthy persons: benign
Presence of cardiac dis or LV dysfunction: dangerous
Frequent PVCs(> 6/min) after MI: increased
mortality risk
Cause and Significance
Congenital
Mostly benign
Accessory pathway tachycardia: compromise
hemodynamic stability
Congenital prolonged Q-T interval: predispose to
vetricular arrhythmia
Cause and Significance
Acquired
Vetricular arrhythmia
IHD., aortic stenosis, dis. associated with LVH
Atrial fibrillation
IHD., related to aging, distened aorta (MS, CHF)
Acquired prolonged Q-T interval
IHD., electrolyte abnormality, drug side effect
Progress polymorphic ventricular tachycardia
(torsades de pointes)
CNS dis, ICH, stroke: all types of SVT and
vetricular arrhythmia
Cause and Significance
Electrolyte Imbalance
Low potassium may trigger dangerous vetricular
arrhythmia
Low magnesium produce primarily SVT
Acute changes in pH
Anesthesia
Calcium antagonistic properties
Halothane: sensitize the heart to catecholamines

Treatment
Class I
Block the fast Na channel & decrease the rate of
rapid depolarization
Class IA
Vagolytic action, decrease contractility, -adrenergic
blockade
Quinidine, disopyramide, procainamide,
diphenylhydantoin
Treatment
Class I
Class IB
Lidocaine
Used in all types of vetricular arrhythmia
Except vetricular arrhythmia d/t prolonged Q-T interval
Toxic effect: CNS activation
Class IC
Suppressor of phase 0 sodium conductance
Increased mortality risk
Treatment
Class II
-adrenergic receptor blockers
Effective in all tachyarrhythmias
Perioperative management of congenital
prolonged Q-T interval
Toxicity related to bronchoconstriction
Treatment
Class III
Prolong reploarization
Increase action potential duration & the effective
refractory period
Bretylium
Facilitation of ventricular defibrillation
Effective in bupivacaine-induced arrhythmias
Treatment
Class III
Amiodarone
Effective all arrhythmia
Long onset & half-life
Side effect: photosensitivity, abnormal skin
pigmentation
Ibutilide
Effective in converting A-flutter & AF
Side effect: hypotension, prolongation of Q-T interval
Treatment
Class IV
Calcium channel antagonists
Supraventricular tachyarrhythmias: useful
Ventricular tachycardias: ineffective, severe
cardiac dysfunction
Potentiate the myocardial effects of anesthetics
Contraindication: AF with WPW syndrome
Treatment
Adenosine
Effective in acutely converting reentrant nodal
SVT & accessory pathway SVT
Digoxin
Perioperatively maintain rate control in A-flutter
& AF
Magnesium ion
Useful in the period around CPB operations
Conclusion
Tx only associated with hemodynamic
compromise and potential to progress to life-
threatening arrhythmias
Must be familiar with only selective drug