Ventricular fibrillation likely resulting from electrocautery and amiodarone: a rare clinical case report

Abstract

Monopolar electrocautery is usually a safe and effective technique used in laparoscopic cholecystectomy and bile duct surgery, but it may lead to adverse consequences, even ventricular fibrillation (VF). Amiodarone is an effective antiarrhythmic drug commonly used in practice to treat ventricular and atrial arrhythmias, but it may induce tachyarrhythmia or even VF. We report a case of VF occurring twice during cholecystectomy. The first VF was caused by low-frequency leakage current of the monopolar electrocautery. The second VF was due to amiodarone causing further prolongation of the corrected QT interval. By performing cardiopulmonary resuscitation and defibrillation, the patient recovered and was eventually discharged in good condition. In cholecystectomy surgery, especially when separating adhesive tissue from liver, caution should be exercised when using a monopolar electrotome, which is recommended to stop bleeding in the bipolar mode. After cardiopulmonary resuscitation, caution should be exercised when using amiodarone to prevent arrhythmia, even if prolongation of the corrected QT interval does not reach the diagnostic indicators of 470 ms for men and 480 ms for women. In addition, defibrillators should be in standby mode during the perioperative period.

Introduction

Monopolar electrocautery ¹ is usually a safe and effective technique used in laparoscopic cholecystectomy and bile duct surgery, but it may lead to adverse consequences, and even ventricular fibrillation (VF). Amiodarone ² is an effective antiarrhythmic drug commonly used in practice to treat ventricular and atrial arrhythmias, but it may induce tachyarrhythmia or even VF. To the best of our knowledge, there have been no reports of VF caused by the mechanical separation of adhesions around the gallbladder and bile duct under the liver. Additionally, there have been no reports of VF caused by the use of amiodarone for preventing arrhythmia. We report a case of VF that occurred twice during cholecystectomy. The reporting of this study conforms to the CARE guidelines. ³

Case report

A man in his early 40s (height: 170 cm; weight: 60 kg) was scheduled for laparoscopic cholecystectomy and common bile duct stone removal under general anesthesia. He had coronary heart disease and underwent coronary stent implantation 1 year previously. After surgery, he received anticoagulation therapy of oral aspirin and clopidogrel.

In a preoperative evaluation, his electrocardiogram (ECG) showed sinus rhythm and abnormal ST-T changes (Figure 1(a)). Echocardiography showed reduced left ventricular diastolic function, with a left ventricular ejection fraction of 59% (53%–70%) and fractional shorting of 31% (>25%). After taking anticoagulants via a low-molecular-weight heparin bridge interface for 6 days, a selective operation was scheduled after an evaluation by staff at the Cardiology and Anesthesiology Departments, and the patient’s heart function was classified as grade I. Upon arrival in the operating room, routine monitoring, including ECG, noninvasive blood pressure, and pulse oximetry (SpO₂), was performed. After the Allen test was shown to be negative, left radial artery puncture was performed to monitor invasive blood pressure, and bispectral index monitoring was performed. Anesthesia induction and maintenance were performed routinely. When the surgery had lasted for approximately 1 hour, the patient suddenly experienced VF while separating tissue adhered to the liver, and the invasive blood pressure dropped to 0. Therefore, cardiopulmonary resuscitation was started and defibrillation (bidirectional wave, 200 J) was immediately performed. After one defibrillation, sinus rhythm was restored, and invasive blood pressure returned to 120 to 140/60 to 80 mmHg and heart rate to 60 to 80 beats/minute. Echocardiography showed reduced left ventricular systolic function and amplitude of left ventricular motion, with a left ventricular ejection fraction of 45%. The administration of 250 mL of amiodarone 300 mg + 5% glucose solution by pump at 50 mL/hour was recommended to prevent arrhythmia. The ECG showed sinus rhythm, abnormal ST changes, and a corrected QT (QTc) interval > 440 ms, which was less than an abnormal value (normal value: 470 ms for men and 480 ms for women) (Figure 1(b)). The surgery continued and was changed to open surgery later with stable vital signs in the patient. VF occurred again when disinfecting the skin. Two defibrillations were performed to restore sinus rhythm. Amiodarone was discontinued and lidocaine 1000-mg solution was administered by pump at 6 mL/hour. An arterial blood gas analysis was performed five times, and no abnormalities were observed during the procedure. During the operation, 1500 mL of liquid and 900 mL of urine were administered. The anesthesia record sheet is shown in Figure 2. The patient was successfully extubated after being transferring to the intensive care unit for 1 hour, and he was transferred to the regular ward the next day.

Figure 1.

Electrocardiograms at different stages of the perioperative period. (a) Preoperative electrocardiogram with sinus rhythm and abnormal ST-T changes. (b) Perioperative electrocardiogram with sinus rhythm, abnormal ST changes, and a QTc interval >440 ms, which is less than an abnormal value (470 ms for men and 480 ms for women) and (c) Postoperative electrocardiogram with sinus rhythm and high left ventricular voltage.

Figure 2.

Anesthesia record sheet.

Follow up echocardiography showed normal left ventricular systolic function with a left ventricular ejection fraction of 56%. An ECG showed sinus rhythm and high left ventricular voltage (Figure 1(c)). Perioperative myoglobin, troponin T, creatine kinase isoenzyme, and N-terminal pro-brain natriuretic peptide concentrations of the patient are shown in Table 1. He was discharged in good condition in 4 days. We obtained consent from the patient for treatment.

Table 1.

Perioperative changes in MYO, TNT, CK-MB, and NT-proBNP concentrations.

Time of measurement	MYO (normal: 28–72 ng/mL)	TNT (normal: <0.014 ng/mL)	CK-MB (normal: 0–6.22 ng/mL)	NT-proBNP (normal: <125 pg/mL)
Preoperatively	<21.00	0.013	1	165
During surgery	62.9	0.027	1.5	174
POD 0	611.1	0.031	7.9	9238
POD 1	285	0.061	4.3	6112
POD 2	131	0.041	2.8	2823
POD 3	36.7	0.007	1.1	1026

MYO, myoglobin; TNT, troponin T; CK-MB, creatine kinase isoenzyme; NT-proBNP, N-terminal pro-brain natriuretic peptide; POD, postoperative day.

Discussion

Common causes of VF include gas embolism, electrolyte disturbance, gallbladder–heart reflex, and coronary artery spasm during laparoscopic cholecystectomy surgery. In our patient, echocardiography showed no air bubbles in the ventricle to exclude gas embolism. Multiple traction of the gallbladder during the operation did not result in VF to exclude a gallbladder–heart reflex. Echocardiography did not show Takotsubo ⁴ sign to exclude coronary artery spasm, and there was no balloon-like dilation of the left ventricular apex or excessive contraction of the left ventricular base. There were no signs of permanent cardiac damage and no need for vasoactive drugs to maintain blood pressure after cardiopulmonary resuscitation. After excluding the above-mentioned possible causes of VF, the cause of VF in this case was considered unnecessary cardiac electrical damage due to low-frequency leakage current of the monopolar electrocautery conducted through the liver because of the monopolar cutting and coagulation mode used in the surgery. There have been reports of perioperative arrhythmias caused by electrosurgical instruments, but only involving surgeries near the diaphragm, such as resection of subphrenic masses ⁵ and gastrectomy to the His angle.^6,7 Electrical stimulation may be the cause of VF because of the proximity of the right ventricle to the diaphragm.

Monopolar electrocautery is usually a safe and effective instrument used in laparoscopic surgery. This device uses high-frequency current (>200 kHz) in a circuit to cut tissues and stop bleeding in the human body. The electrocoagulation hook is the most common monopolar electrotome in laparoscopic cholecystectomy surgery. In our case, VF mainly occurred during the electrical separation of adhesive tissue around the gallbladder under the liver. The possible cause of the patient’s first VF is that low-frequency current leaked by monopolar electrocoagulation owing to the location of the liver under the diaphragm and having good electrical conductivity. In the monopolar mode, high-frequency current flows from the generator through the active electrode, enters the target tissue, passes through the patient, disperses the electrode, and then returns to the generator. The electrosurgical effect required for a monopolar electrotome only occurs at the active electrode, but low-frequency (50–60 Hz) “stray current,” may be transmitted to other parts of the human body. The most sensitive frequency of the myocardium is 30 to 110 Hz. Therefore, this low-frequency leakage is an ideal condition for inducing VF.

During re-disinfection of the skin, the patient experienced a second VF, which was suspected to be caused by amiodarone to some extent. Amiodarone is an effective antiarrhythmic drug commonly used in practice to treat ventricular and atrial arrhythmias. The adverse reactions of amiodarone mainly include thyroid abnormalities, pulmonary fibrosis, and transaminase abnormalities. Cardiac-related adverse reactions mainly include sinus bradycardia and QTc prolongation. ² A meta-analysis showed that the odds of experiencing bradycardic adverse effects with amiodarone were higher than those with a placebo. ⁸ Additionally, the trend of increased bradycardic adverse effects in the amiodarone group was a consistent finding among all four trials in this meta-analysis. Furthermore, life-threatening refractory hypotension was reported to be caused by amiodarone. ⁹ To the best of our knowledge, there have been no reports of VF induced by amiodarone. Amiodarone is a widely used antiarrhythmic drug that has various ion channel blocking effects, such as blocking sodium, potassium, and calcium channels, and beta receptors. These effects help to prolong the action potential duration and effective refractory period of myocardial tissue and reduce reentry excitation, which cause anti-arrhythmic effects. However, while amiodarone prolongs the action potential duration and effective refractory period of myocardial cells, it can also prolong the QTc and increase repolarization dispersion. Patients with a long QTc experience an increase in action potential duration difference and an increase in the dispersion of their effective refractory period. An early afterdepolarization, which can induce torsade de pointes and develop into VF, can occur in the late repolarization stage because of the varying degrees of excitability recovery in different parts of the heart. After the first defibrillation in our patient, the ECG showed a QTc > 440 s (i.e., 450 s), and amiodarone may have further prolonged the QTc and caused VF. According to the pharmacological characteristics of amiodarone, the effect of intravenous amiodarone on the QTc interval usually takes several days to manifest. However, the amiodarone-induced arrhythmias were acceptable because our patient had his previous VF when the myocardium was damaged and the cardiac electrophysiological system was not stable. The further QTc prolongation caused by the recommendation of performing amiodarone treatment to prevent arrhythmia was unfortunate. The patient needs to be referred to exercise ECG testing and/or coronary angiography by a cardiologist. Additionally, if any progression of coronary atherosclerosis is excluded, the patient should have electrophysiological testing performed after consultation with a cardiologist with a subspecialty in electrophysiology.

Our findings suggest that surgeons should be familiar with the characteristics of electrocautery in laparoscopic surgery. In cholecystectomy surgery, especially when separating adhesive tissue from the liver, caution should be exercised when using a monopolar electrotome, which is recommended to stop bleeding in the bipolar mode. After cardiopulmonary resuscitation of patients, caution should be exercised when using amiodarone to prevent arrhythmia, even if QTc prolongation does not reach diagnostic indicators (470 ms for men and 480 ms for women). In addition, defibrillators should be in standby mode during the perioperative period.