Abstract
We report a case with trifascicular block (asymptomatic first degree atrioventricular block with a bifascicular block) complicated with acute respiratory distress syndrome that progressed to complete atrioventricular block during general anesthesia. A 74-year-old male, previously diagnosed as having arteriosclerosis obliterans who underwent aorto-bi-femoral bypass grafting surgery eleven years ago, developed severe dyspnea, and he was diagnosed as having idiopathic interstitial pneumonitis. In spite of corticosteroid therapy, he presented with severe intermittent claudication. His CT-angiography showed total occlusion of the infra-renal abdominal aorta, and he underwent emergent thrombectomy surgery. His preoperative electrocardiogram showed first-degree atrioventricular block with complete right bundle branch block and left anterior hemiblock, but he had experienced no cardiovascular symptoms. Anesthesia was induced with midazolam and vecuronium bromide, and maintained with fentanyl and sevoflurane in oxygen. Just after the operation was started, the ECG abruptly changed from a sinus rhythm to complete atrioventricular block, and his systolic atrial blood pressure decreased to 0mmHg. His heart was responsive to bolus intravenous injection of atropine and epinephrine, and the surgery was completed successfully without any further complications. He was admitted to the intensive care unit post-operatively. The case described here suggests that preoperative insertion of a temporary pacemaker should be considered in a case with trifascicular block complicated by other life-threatening disorders.
