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Year : 2015  |  Volume : 9  |  Issue : 3  |  Page : 423-426  

Role of temporary pacing at the right ventricular outflow tract in anesthetic management of a patient with asymptomatic sick sinus syndrome

Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India

Date of Web Publication8-Sep-2015

Correspondence Address:
Amrutha Bindu Nagella
Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry - 607 405
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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.

DOI: 10.4103/0259-1162.159770

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A 60-year-old woman posted for percutaneous nephrolithotomy with ureterolithotripsy was found to have a history of hypertension and ischemic heart disease from past 6 months on regular treatment. Pulse rate was irregularly irregular in a range of 56–60/min, unresponsive to atropine, with a sinus pause on the electrocardiogram. Although the patient was asymptomatic, anticipating unmasking of the sick sinus syndrome during general anesthesia in the prone position, a temporary pacemaker was implanted at right ventricular outflow tract (RVOT) septum before the scheduled surgery. A balanced anesthesia technique with endotracheal intubation was administered. There were several episodes of continuous pacing by the temporary pacemaker intraoperatively, which may be attributed to unmasking of the sinus node dysfunction due to general anesthesia. At the end of surgery, patient was extubated after adequate reversal from neuromuscular blockade. Postoperative period remained uneventful, and the pacemaker wires were removed on the 2nd postoperative day. With this case report, we highlight the importance of inserting a temporary pacemaker prior to anesthesia even in an asymptomatic patient if a sinus node dysfunction is suspected preoperatively and if intraoperative access to transvenous pacing is difficult such as in prone position. Pacing at RVOT septum minimizes ventricular dyssynchrony and improves hemodynamic parameters.

Keywords: Anesthetic management, asymptomatic sick sinus syndrome, right ventricular outflow tract temporary pacing

How to cite this article:
Nag K, Nagella AB, Hemanth Kumar V R, Singh DR, Ravishankar M. Role of temporary pacing at the right ventricular outflow tract in anesthetic management of a patient with asymptomatic sick sinus syndrome. Anesth Essays Res 2015;9:423-6

How to cite this URL:
Nag K, Nagella AB, Hemanth Kumar V R, Singh DR, Ravishankar M. Role of temporary pacing at the right ventricular outflow tract in anesthetic management of a patient with asymptomatic sick sinus syndrome. Anesth Essays Res [serial online] 2015 [cited 2021 Mar 5];9:423-6. Available from:

   Introduction Top

Sick sinus syndrome refers to a condition of the sinoatrial node, where it is unable to perform its pacing function resulting in abnormal cardiac impulse formation, the etiology being idiopathic in most instances. It may be asymptomatic or present with a variety of nonspecific symptoms resulting from reduced cardiac output. Several anesthetic factors are known to cause autonomic disturbances resulting in unmasking of a sinus node dysfunction, significant bradycardia, and cardiovascular collapse during the intraoperative period. Through this case report, we emphasize the importance of inserting a right ventricular outflow tract (RVOT) temporary pacemaker before instituting anesthesia if a sinus node dysfunction is suspected preoperatively.

   Case Report Top

A 60-year-old woman with a diagnosis of left renal calculus was scheduled for left percutaneous nephrolithotomy. The preanesthetic evaluation revealed the history of poor effort tolerance. She had a past history of ischemic heart disease with hypertension since 6 months and was on regular treatment. On examination, pulse rate was irregularly irregular with a range of 56–60/min and blood pressure was 130/70 mm Hg. Clinical examination of the cardiovascular system and the respiratory system was normal. Laboratory investigations were within normal limits. Electrocardiogram (ECG) showed an irregular rate with intermittent sinus pause. Chest X-ray was normal. In view of the irregularly irregular pulse and abnormal ECG in an elderly, a cardiology opinion was sought. The cardiologist ascertained a diagnosis of an asymptomatic sinus node dysfunction, which was resistant to atropine. Echocardiography was normal. Anticipating the autonomic disturbances that could occur in prone position under anesthesia, which may have significant hemodynamic implications when superimposed on the sick sinus syndrome, the cardiologist was again referred to for temporary pacing, and a temporary pacemaker at RVOT septum was inserted prior to surgery [Figure 1].
Figure 1: Pacing wire at the right ventricular outflow tract

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The anesthetic technique planned was balanced general anesthesia with endotracheal intubation. Once the patient was taken into the operation theater, five-lead ECG, noninvasive blood pressure, pulse oximetry, were connected. After giving glycopyrrolate 0.2 mg, midazolam 0.05 mg/kg, and morphine 0.1 mg/kg intravenously, patient was induced with propofol 2 mg/kg and vecuronium 0.1 mg/kg intravenously. Airway was secured under direct laryngoscopy with size 7.0 endotracheal tube. Maintenance was done with oxygen: Nitrous oxide 50:50 with sevoflurane 2% on low flows with circle system. Intraoperatively there were repeated episodes of continuous pacing by the temporary pacemake [Figure 2] followed by a resumption of normal sinus rhythm. Other vital parameters were stable in the intraoperative period. The surgery lasted for 2 h. Neuromuscular blockade was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. Patient was shifted to the post anesthesia care unit with stable vitals. Postoperative analgesia was provided with intravenous paracetamol infusion and intravenous injection tramadol. Postoperative period remained uneventful with no evidence of pacing. Temporary pacemaker was removed on the 2nd postoperative day after consultation with the cardiologist. There were no further episodes of bradycardia in the postoperative period, and the patient was discharged on the 5th postoperative day.
Figure 2: Intraoperative continuous pacing by the temporary pacemaker

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   Discussion Top

Sinus node dysfunction is a generalized abnormality of cardiac impulse formation that may be caused by an intrinsic disease of the sinus node that makes it unable to perform its pacing function or by extrinsic causes.[1] It most commonly affects elderly; the etiology being idiopathic.[2] Age-related degenerative fibrosis of nodal tissue is the most common cause of intrinsic changes in the sinoatrial node that lead to its dysfunction. Coronary artery disease may coexist with the sick sinus syndrome in a significant number of patients.

Patients with sick sinus syndrome present with symptoms related to the decreased cardiac output. These include symptoms due to reduced cerebral perfusion such as dementia, irritability, lethargy light-headedness, nocturnal wakefulness, syncope, and presyncope. Cardiovascular symptoms include angina pectoris, arterial thromboemboli, cerebrovascular accidents, congestive heart failure, and palpitations.

The diagnosis of the sick sinus syndrome is difficult because the symptoms may be variable, intermittent or too subtle to be noticed and many times attributable to old age. ECG may show atrial bradyarrhythmias, atrial tachyarrhythmias, and alternating bradyarrhythmias and tachyarrhythmias.[3] A 24 h Holter monitoring increases the likelihood of diagnosis in asymptomatic patients. Several other methods for diagnosis have been advocated by different authors in the past, such as evaluation of cardiovascular responses to atropine, beta-stimulants or electrical atrial pacing, and evaluation of the response to carotid massage.[4],[5] Electrophysiological testing is invasive and no longer routinely recommended for diagnostic purposes because of its poor sensitivity and specificity.[6]

Anesthesia related autonomic imbalance may unveil an undiagnosed sick sinus syndrome.[7] Levy described recurrent severe bradycardia resistant to atropine as a common feature of sick sinus syndrome.[8] Alex et al. described a case of sick sinus syndrome for exploratory laparotomy in which failure of efficient transcutaneous pacing on operating table warranted the need of immediate insertion of the transvenous temporary pacemaker.[9] In diagnosed, asymptomatic patients preoperative insertion of a temporary pacemaker has been recommended because anesthesia as such or surgical maneuvers may induce serious dysrhythmias resistant to conventional pharmacological treatment.[10] Although our patient was asymptomatic, a well-documented sinus pause on ECG and unresponsiveness to atropine warranted the need for instituting temporary pacing preoperatively as prone position during surgery prevents access to transvenous pacing if required. Apart from severe bradycardia and unexpected asystole, cases of the complete atrioventricular block have also been reported under general anesthesia in patients with sick sinus syndrome.[11] Hence, ventricular demand pacing appears a logical approach for perioperative temporary pacing. Pacing from the right ventricular apex (RVA) produces intraventricular dyssynchrony[12] of cardiac contraction and poses a risk of left ventricular dysfunction.[13] Many studies have found significant differences in hemodynamic parameters in favor of RVOT septal pacing as compared to pacing at RVA.[14],[15] This positive effect is attributed to the shortening of the duration of QRS complex during septal pacing as paced QRS duration reflects homogenization of contraction.

Anesthetic technique can be chosen depending upon the patients need. Both inhalational agents and narcotics can be used safely in patients with temporary pacing.[16] However, it has been reported that sevoflurane does not impair the sinoatrial rate[17] and can be used more safely over other inhaled anesthetics. In patients with the sick sinus syndrome, sinus node arrest with atrial or nodal escape beats have been reported after induction with propofol, ketamine, and fentanyl.[8] Profound bradycardia was observed with a small dose of lignocaine given intravenously prior to propofol.[18] Hence, we chose to use morphine and thiopentone for induction and sevoflurane for maintenance of anesthesia. Muscle fasciculation produced by succinylcholine can be avoided by using nondepolarizing muscle relaxants. Intraoperative continuous ECG monitoring, manual palpation of pulse and pulse oximetry provide essential information of the adequacy of pacemaker functioning, cardiac function, and peripheral perfusion. Isoproterenol should be kept available for use in case of any pacemaker dysfunction. Pacemaker function should be verified before and after initiating mechanical ventilation and positioning as there may be dislodgement of the pacemaker leads by positive pressure ventilation.[19] Despite the fact that the external pulse generator can be separated from patient and is usually programmed for prevention of high-intensity electromagnetic interference, it is recommended to use bipolar cautery or in case of unipolar cautery the ground plate placed more than 15 cm away from pulse generator.[20]

In our patient, intermittent episodes of continuous pacing by the temporary pacemaker throughout the surgery can be attributed to unmasking of bradycardia due to sinus node dysfunction by anesthetic drugs and surgical manipulation which could have been otherwise deleterious during surgery in prone position in absence of a temporary pacemaker.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Adán V, Crown LA. Diagnosis and treatment of sick sinus syndrome. Am Fam Physician 2003;67:1725-32.  Back to cited text no. 1
Lamas GA, Lee K, Sweeney M, Leon A, Yee R, Ellenbogen K, et al. The mode selection trial (MOST) in sinus node dysfunction: Design, rationale, and baseline characteristics of the first 1000 patients. Am Heart J 2000;140:541-51.  Back to cited text no. 2
Wahls SA. Sick sinus syndrome. Am Fam Physician 1985;31:117-24.  Back to cited text no. 3
Burt DE. The sick sinus syndrome. A complication during anaesthesia. Anaesthesia 1982;37:1108-11.  Back to cited text no. 4
McConachie I. Value of pre-operative carotid sinus massage. Anaesthesia 1987;42:636-8.  Back to cited text no. 5
Beers MH, Porter SR. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, N.J.: Merck; 1999. p. 1719.  Back to cited text no. 6
Murakawa T, Ishihara H, Matsuki A. Marked bradycardia during anesthetic induction treated with temporary cardiac pacing in a patient with latent sick sinus syndrome. Masui 2001;50:65-8.  Back to cited text no. 7
Levy DM. Recurrent bradycardia due to latent sick sinus syndrome. Anaesthesia 1990;45:488-9.  Back to cited text no. 8
Alex S, Saneesh JP, Rao R, Upadya M. Anaesthetic management of a patient with sick sinus syndrome for exploratory laparotomy. S Afr J Anaesthesiol Analg 2010;16:24-6.  Back to cited text no. 9
Ishida R, Shido A, Kishimoto T, Sakura S, Saito Y. Prolonged cardiac arrest unveiled silent sick sinus syndrome during general and epidural anesthesia. J Anesth 2007;21:62-5.  Back to cited text no. 10
Iinuma Y, Maruyama K, Hara K. Complete atrioventricular block during anesthesia in a patient with sick sinus syndrome under atrial pacing. J Anesth 2005;19:92.  Back to cited text no. 11
Pastore G, Noventa F, Piovesana P, Cazzin R, Aggio S, Verlato R, et al. Left ventricular dyssynchrony resulting from right ventricular apical pacing: Relevance of baseline assessment. Pacing Clin Electrophysiol 2008;31:1456-62.  Back to cited text no. 12
Tantengco MV, Thomas RL, Karpawich PP. Left ventricular dysfunction after long term right ventricular apical pacing in the young. J Am Coll Cardiol 2002;40:1451-8.  Back to cited text no. 13
Giudici MC, Thornburg GA, Buck DL, Coyne EP, Walton MC, Paul DL, et al. Comparison of right ventricular outflow tract and apical lead permanent pacing on cardiac output. Am J Cardiol 1997;79:209-12.  Back to cited text no. 14
De Cock CC, Meyer A, Kamp O, Visser CA. Hemodynamic benefits of right ventricular outflow tract pacing: Comparison with right ventricular apex pacing. Pacing Clin Electrophysiol 1998;21:536-41.  Back to cited text no. 15
Nakamura S, Nishiyama T, Hanaoka K. General anesthesia for a patient with asymptomatic sick sinus syndrome. Masui 2005;54:912-3.  Back to cited text no. 16
Manabe M, Ookawa I, Nonaka A, Kumazawa T. Effects of sevoflurane with or without nitrous oxide on cardiac contractility and sinoatrial node rate. J Anesth 1989;3:145-8.  Back to cited text no. 17
Kim KO, Chung S, Lee K, Cho H. Profound bradycardia with lidocaine during anesthesia induction in a silent sick sinus syndrome patient. J Clin Anesth 2011;23:227-30.  Back to cited text no. 18
Thiagarajah S, Azar I, Agres M, Lear E. Pacemaker malfunction associated with positive-pressure ventilation. Anesthesiology 1983;58:565-6.  Back to cited text no. 19
Seo K, Takayama H, Araya Y, Miura K, Tanaka Y, Kobayashi Y, et al. Electromagnetic interference of an external temporary pacemaker during maxillofacial and neck surgery. Anesth Prog 1996;43:64-6.  Back to cited text no. 20


  [Figure 1], [Figure 2]


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