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Colombian Journal of Anestesiology

Print version ISSN 0120-3347On-line version ISSN 2256-2087

Rev. colomb. anestesiol. vol.49 no.3 Bogotá July/Sept. 2021  Epub June 12, 2021

https://doi.org/10.5554/22562087.e952 

Images

Cardiac dysrhythmias in systemic sclerosis

a Department of Cardiothoracic Anesthesiology, Department of General Anesthesiology and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation. Cleveland, Ohio, USA.

b Department of Cardiothoracic Anesthesiology and Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation. Cleveland, Ohio, USA.


Systemic sclerosis is an immunological disorder characterized by tissue fibrosis and multi-organ dysfunction.1 The accompanying images exhibit electrocardiographic changes in severe systemic sclerosis. Advanced 3:1 atrioventricular block, best observed in Lead Vi, suggests extensive fibrosis of the conduction system (Image A). While one P wave is buried in the T wave (black arrows), two are evident (red arrows) along the isoelectric line. Bradyarrhythmia related prolonged QT interval, best measured in Lead II represents increased risk for torsades-de-pointes, a polymorphic ventricular tachyarrhythmia. Additionally, right bundle branch block with giant T wave inversions (T wave depth > 10 mm) in precordial leads V2- 4 suggests pulmonary hypertension. Post-induction the rhythm abruptly changes to torsades-de-pointes (Image B) necessitating defibrillation.

SOURCE: Authors.

IMAGE A Advanced 3:1 atrioventricular block, best observed in Lead Vi, suggests extensive fibrosis of the conduction system. 

SOURCE: Authors.

IMAGE B Post-induction the rhythm abruptly changes to torsades-de-pointes necessitating defibrillation. 

Immune deregulation and recurrent ischemia-reperfusion injury in systemic sclerosis leads to vascular dysfunction, myocardial systolic and diastolic impairment and conduction system fibrosis. Consequently, pulmonary arterial hypertension, heart failure, coronary artery disease and arrhythmias occur frequently in severe disease. Patients often present with dyspnea, fatigue and syncope.

Advanced atrioventricular blocks merit expert consultation to assess need for transvenous pacing, as unexpected progression to complete heart block and/or torsades-de-pointes increases risk of sudden cardiac death.2 Pulmonary hypertension in systemic sclerosis increases right ventricular strain and elevates end-diastolic pressure with leftward interventricular septal shift, compromising left heart filling and ejection. Decreased cardiac output and anesthesia induced hypotension jeopardize coronary perfusion and perpetuate right ventricular ischemia. In addition to causing ventricular tachyarrhythmias, myocardial ischemia can worsen atrioventricular conduction, leading to complete heart block.

Consequently, pre-induction establishment of invasive arterial monitoring and transvenous pacing is prudent. Anesthetic goals include decreasing pulmonary vascular resistance with pulmonary vasodilators like epoprostenol and maintaining systemic vascular resistance with vasopressors like norepinephrine to ensure adequate coronary perfusion. Although hemodynamically stable torsades-de-pointes frequently suppresses with magnesium administration and overdrive pacing, pulseless ventricular tachyarrhythmia necessitates defibrillation.3

ACKNOWLEDGEMENTS

Author's contributions

SK: Conception of project, planning and final writing of manuscript.

CT: Conception of project, approval of manuscript.

REFERENCES

1. Roberts JG, Sabar R, Gianoli JA, Kaye AD. Progressive systemic sclerosis: Clinical manifestations and anesthetic considerations. J Clin Anesth. 2002;14:474-7. doi: https://doi.org/10.1016/S0952-8180(02)00380-X. [ Links ]

2. Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019;140:e382-e482. doi: https://doi.org/10.1161/CIR.0000000000000627. [ Links ]

3. O'Hare M , Maldonado Y , Munro J , Ackerman MJ, Ramakrishna H, Sorajja D. Perioperative management of patients with congenital or acquired disorders of the QT interval. Br J Anaesth. 2018;120:629-44. doi: https://doi.org/10.1016/j.bja.2017.12.040. [ Links ]

Assistance with the study None declared.

Financial support and sponsorship None declared.

Conflicts of interest None declared.

Presentation None declared.

How to cite this article: Khanna S, Trombetta C. Cardiac dysrhythmias in systemic sclerosis. Colombian Journal of Anesthesiology. 2021;49:e952.

Received: September 29, 2020; Accepted: October 10, 2020; Accepted: November 11, 2020

Correspondence: Department of Cardiothoracic Anesthesiology, Department of General Anesthesiology and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation. 9500 Euclid Avenue, E3-108, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

*Email:khannas@ccf.org

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