Introduction

Orthotropic liver transplantation can be marked by significant hemodynamic instability requiring many invasive and noninvasive tools for patient monitoring to aid in intraoperative management. The most common abnormal ECG findings included prolonged QT interval, left ventricular hypertrophy, right bundle branch block, and left bundle branch block. Despite the potential complications, a Pulmonary Artery Catheter (PAC) has been used for advanced hemodynamic monitoring during liver transplantation, and that is because of the valuable information obtained from such monitoring devices. Arrhythmia and heart block is one of the rare complications of pulmonary catheter insertion. The most common arrhythmia after PAC is premature ventricular and arterial contractions, ventricular tachycardia, or fibrillation; however, we present a case to report one other complication: Right Bundle Branch Block (RBBB).

Case Report

A 52-year-old male (height 172 cm, weight 75 kg) was scheduled for orthotropic liver transplantation due to alcoholic liver cirrhosis. He had a history of end-stage liver disease with a MELD score of 24. His past medical history was significant for chronic hypertension and with preexisting left bundle branch block.

His preoperative vital signs were normal, and his physical examination was unremarkable. A twelve-lead electrocardiogram showed normal sinus rhythm, nonspecific ST-T changes, and a left bundle branch block (Figure 1). His Echocardiography revealed normal-sized ventricles, mild anterior hypokinesis, normal wall motion, and a left ventricular ejection fraction of 65%.

Figure 1: Preoperative ECG showing the preexisting left bundle branch block.

 Preoperative serum sodium, potassium, and magnesium were normal. On the patient's arrival at the operating room, his vital signs were within normal limits. Standard monitoring, according to the American Society of Anesthesia (ASA) protocols: five-leads ECG, pulse oximetry, noninvasive blood pressure and temperature, and attached pads of the defibrillator before induction of anesthesia.

General anesthesia was induced with midazolam 5 mg, fentanyl 200 mcg, lidocaine 60 mg, and propofol 100 mg IV. Rocuronium was used for muscle relaxation. Isoflurane was used to maintain the anesthesia. Arterial and central venous accesses were established without difficulty. In our institute, we use MAC Two-Lumen Central Venous Access with 7-7.5 Fr. Catheters. In this case, the insertion of the pulmonary artery catheter was difficult that required many attempts. In every attempt, there was right atrial tracing followed by a right ventricular waveform; when we pushed more, we didn't get the Pulmonary Artery (PA) waveform. On the fourth attempt, when the ECG monitor suddenly demonstrated a complete heart block with a heart rate of less than 30/minute (Figure 2), systolic BP decreased dramatically from 120 to less than 50 mmHg, and the arterial waveform became shallow. The PA catheter was immediately deflated and withdrawn completely. Cardiopulmonary Resuscitation (CPR) was initiated, and intravenous administration of epinephrine 1mg, atropine 1mg, and the defibrillator was put on pacing mode. The CPR took around three minutes; the vital signs returned to normal. After that, a transesophageal echocardiography was inserted to provide real-time visual information on ventricular function and hemodynamic volume status. The finding was normal ventricular function with normal hemodynamics and normal volume status.