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Neurology India, Vol. 58, No. 1, January-February, 2010, pp. 146 Letter To Editor Complete heart block complicating intracranial aneurysm surgery in a pregnant patient Pragati Ganjoo, Deepa V. Navkar, Monica S. Tandon Department of Anaesthesiology and Intensive Care, G. B. Pant Hospital, New Delhi - 110 002, India. Correspondence Address: Pragati Ganjoo, Department of Anaesthesiology and Intensive Care, G. B. Pant Hospital, New Delhi - 110 002, India, pganjoo@gmail.com Date of Acceptance: 30-Nov-2009
Code Number: ni10037 DOI: 10.4103/0028-3886.60414 Sir, Intracranial aneurysm clipping in a pregnant patient is challenging [1] , more so in the presence of a coexisting complete heart block (CHB) with the potential to compromise hemodynamic stability. Adequate control of blood pressure (BP) is vital during aneurysm surgery and may not always be guaranteed by temporary pacing. A primigravida at 28 weeks of gestation was diagnosed with a left internal carotid artery aneurysm with subarachnoid hemorrhage, World Federation of Neurosurgical Societies (WFNS) Grade-2, necessitating urgent aneurysm clipping. Relevant preoperative check-up included no apparent history of syncopal episodes, a BP of 90/60 mm of Hg, a heart rate of 41 beats/min, a CHB on ECG and no evidence of underlying cardiac disease on echocardiography. The patient was paced with a temporary transvenous pacemaker at a rate of 80 beats/min; her post-pacing BP was 118/72 mm of Hg. During surgery, the patient′s BP fell abruptly to 82/56 mm of Hg which was normalized by resetting the pacemaker rate at 90 beats/min. Repeated pacemaker adjustments became necessary in the postoperative period to maintain stable post-clipping systolic BP in the range of 140-160 mmHg; a permanent pacemaker was then inserted in her. Pregnancy is often associated with benign arrhythmias, mostly atrial in origin and without any hemodynamic sequel, though sometimes they may signify an underlying heart disease. CHB in pregnancy is unusual and mostly asymptomatic and prophylactic permanent pacing is usually not considered. [2] American Heart Association/American College of Cardiology guidelines do not recommend permanent pacing in patients with asymptomatic CHB. [3] Permanent pacing is preferred for symptomatic CHB diagnosed during thefirst and second trimester of pregnancy whereas near-term pregnant patients are usually managed by short-term temporary pacing just before delivery. Temporary pacing is limited to symptomatic short duration bradycardias, asymptomatic atropine-resistant bradycardias, first and second-degree heart blocks and atrial fibrillation with a low ventricular rate. [2] We used temporary pacing due to the emergent nature of surgery and lack of definite CHB-related symptoms. Aneurysm surgery in pregnant patients necessitates stable systemic, cerebral and placental hemodynamics, especially in the important post-clipping period. Perioperative pacing is advisable to avoid CHB-induced adverse hemodynamics; temporary pacing in pregnant patients with CHB has been reported earlier. [2],[4] However, temporary pacemakers are known to malfunction unexpectedly, [2],[5] leading to sudden hemodynamic instability. Our patient also faced this complication, highlighting the fact that aneurysm surgery in a pregnant patient with a coexistent CHB can be risky even under the cover of temporary pacing. References
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