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LETTER TO EDITOR
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 272-273

Liver transplant in a patient with sick sinus syndrome and a permanent pacemaker: Anesthetic implications


Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission30-Apr-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Lakshmi Kumar
Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_37_20

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How to cite this article:
Nagabhushan RM, Varghese AO, Shyamsundar P, Kumar L. Liver transplant in a patient with sick sinus syndrome and a permanent pacemaker: Anesthetic implications. Indian J Transplant 2020;14:272-3

How to cite this URL:
Nagabhushan RM, Varghese AO, Shyamsundar P, Kumar L. Liver transplant in a patient with sick sinus syndrome and a permanent pacemaker: Anesthetic implications. Indian J Transplant [serial online] 2020 [cited 2020 Oct 20];14:272-3. Available from: https://www.ijtonline.in/text.asp?2020/14/3/272/296891



Dear Editor,

Liver transplant in patients with cardiac comorbidities is common, but transplant in patients on pacemakers has not been widely reported in literature. We wish to present the management of a 57-year-old cirrhotic, model for end-stage liver disease (MELD) 30, with a permanent pacemaker inserted 18 years ago for sick sinus syndrome scheduled to undergo a living donor liver transplant [Figure 1]a.
Figure 1: (a) X-ray with pacemaker lead. (b) Electrocardiogram with pacemaker

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The anesthetic concerns were potential interference with cautery and management of ventricular arrhythmias or decompensation during transplant. After confirming the battery efficiency, the pacemaker was reprogrammed mode that would deliver preprogrammed impulses independent of the patient's rhythm below the set heart rate [Figure 1]b. In the OR, electrocardiogram (ECG) displaying pacing spikes was set and cautery pad was placed away from the pacemaker site. During surgery, bipolar cautery and cavitron ultrasonic surgical aspirator were used with no interference to the patient's rhythm. After an uneventful surgery, he was shifted to the intensive care unit with the pacemaker in the VOO mode until extubation 12 h later when it was reprogrammed to the VVI mode.(antibradycardia pacing only).

In patients with advanced cirrhosis, cardiovascular changes are extensive and present a challenge for the anesthetist.[1] In patients with a permanent pacemaker, preoperative stress testing can be achieved by increasing the pacing rate without a need for dobutamine with accuracy in identifying coronary artery disease.[2] Transthoracic echocardiography and technetium 99mTc MIBI (methoxyisobutylisonitrile) scan after administration of dobutamine were performed preoperatively for cardiac assessment in our patient.

Guidelines for the preoperative and intraoperative management of patients with a pacemaker undergoing surgery are provided in [Table 1].[3] The function of a pacemaker during surgery with an ongoing use of cautery remains a major concern. Continuous ECG, SpO2, and intra-arterial monitoring are required during anesthesia until the patient is transferred out of the anesthetizing location. Electrosurgical instruments and dispersive electrodes are placed ensuring that current pathway does not pass through or near the pacemaker system and use of bipolar cautery is preferred.[4] Cirrhotics are prone to the development of cirrhotic cardiomyopathy with elements of systolic and diastolic dysfunction and a prolonged QTC. This predisposes them to ventricular arrhythmias at the time of graft reperfusion.[1] In the event of a perioperative emergency, all sources of electromagnetic interference should be discontinued to allow proper interpretation of the rhythm [Table 1].[3],[5] Defibrillator paddles are placed avoiding the site of pacemaker or anteroposteriorly. The pacemaker should be reprogrammed after confirmation of the hemodynamic stability and need for relaparotomy for surgical complications.
Table 1: Guidelines for intraoperative management of patients with permanent pacemakers undergoing liver transplant*

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We wish to highlight management of cirrhotic patients with pacemakers undergoing transplant emphasizing the fragile cardiovascular state and predisposition to arrhythmias and present guidelines for their management.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rahman S, Mallett SV. Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients. World J Hepatol 2015;7:507-20.  Back to cited text no. 1
    
2.
Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG; American Society of Echocardiography. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 2007;20:1021-41.  Back to cited text no. 2
    
3.
Bryant HC, Roberts PR, Diprose P. Perioperative management of patients with cardiac implantable electronic devices. BJA Education 2016;16:388-96.  Back to cited text no. 3
    
4.
American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: Pacemakers and implantable cardioverter-defibrillators: An updated report by the American Society of Anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology 2011;114:247-61.  Back to cited text no. 4
    
5.
Chakravarthy M, Prabhakumar D, George A. Anaesthetic consideration in patients with cardiac implantable electronic devices scheduled for surgery. Indian J Anaesth 2017;61:736-43.  Back to cited text no. 5
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