Intraoperative interfascicular ventricular tachycardia: A rare occurrence
A 66-year-old, 70 kg male patient with a BMI of 33 presented for laparoscopic cholecystectomy. He was a chronic smoker with chronic obstructive pulmonary disease which required salbutamol MDI. He was a hypertensive on treatment with oral ramipril and losartan. He had one episode of acute coronary syndrome 18 months back which required percutaneous intervention with stenting of right coronary artery. Subsequently, the patient was advised to take aspirin and clopidogrel orally which had been stopped 5 days prior to the surgery. History pertaining to other organ systems was unremarkable. On preoperative evaluation he was NYHA class II with decreased effort tolerance (<4 METs). His ECG showed normal sinus rhythm with left anterior fascicular block [] while his resting echocardiography showed regional wall motion abnormalities in the right coronary artery territory with an ejection fraction of 40%.\nIn the operation theatre ECG, non-invasive blood pressure and SpO2 monitor were attached. After intravenous access and radial artery cannulation, anaesthesia was induced with 150 mcg of fentanyl and 100 mg of propofol. 35 mg of atracurium was given to attain muscle relaxation to facilitate tracheal intubation. There was a fall in blood pressure to 70/40 mmHg after induction which was managed with 6 mg of ephedrine. The haemodynamics recovered to normal limits after endotracheal intubation. However, immediately after creation of pneumoperitoneum, the patient developed regular WCT with a ventricular rate of 150/min and a mean blood pressure of 80-90 mmHg. The abnormal heart rhythm immediately reverted back to normal on deflation of pneumoperitoneum. An open cholecystectomy was planned in consultation with the surgeons. Following skin incision the same pattern of WCT recurred. The arrhythmia reverted spontaneously within 3 to 4 min of stopping the surgery. The surgery was abandoned and the patient immediately shifted to ICU without reversal of anaesthesia. In the ICU, the patient had multiple episodes of WCT with severe hypotension which required synchronised DC cardioversion with 100-150 joules biphasic energy. An infusion of dopamine was also started at the rate of 10 mcg/kg/min. Cardiologist was urgently summoned who diagnosed the WCT as interfascicular VT on 12 lead ECG [Figure , ] and thus a loading dose of 150 mg of amiodarone was administered over 10 min intravenously followed by infusion at 1 mg/min for 6 hours and 0.5 mg/min for subsequent 18 hours. Despite the treatment the patient had multiple episodes of WCT which required cardioversion again with 150 joules of biphasic energy. All his biochemical parameters like serum electrolytes, renal and liver function tests were normal, and no increase in cardiac enzymes occurred thus ruling out possible myocardial ischemia. An echocardiography could not be done at as facilities of in-bed echocardiography were not available with us. The patient was weaned off inotropes over a period of 6 hours, the tracheal tube was subsequently removed, and he could be discharged from the hospital after 3 days.