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Mobitz Type II Atrioventricular Block Followed by Remifentanil in a Patient with Severe Aortic Stenosis

DOI: 10.1155/2013/852143

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Abstract:

Opioids have been considered for their hemodynamic stability. Remifentanil is an opioid analgesic with rapid metabolism and fast primary effect and recovery. In this paper, a very rare effect of using remifentanil along with propofol was presented. An 84-year-old male patient with severe aortic stenosis underwent general anesthesia. In order to induce anesthesia and maintain it, fentanyl, pancuronium, and propofol, along with a combination of propofol and remifentanil, were used, respectively. At beginning of remifentanil infusion, bradycardia and then Mobitz type II conduction block with a hemodynamic disorder occurred for the patient. The decreased blood pressure responded to injection of atropine and ephedrine; however, dysrhythmia only improved after cessation of remifentanil. Therefore remifentanil should be used with caution in aortic stenosis. 1. Introduction Remifentanil is a congener of fentanyl family of narcotics which is separable from others for the ester structure. Complications of this drug are like those of other opioids and include bradycardia, itching, nausea, vomiting, and muscular rigidity [1]. Aortic stenosis is the most common valvular disorder of heart which is seen in cardiac rheumatic disease and old ages and is divided to slight, moderate, and severe types based on valvular diameter and transvalvular pressure gradient. Anesthesia in these patients could be accompanied by decreased cardiac output, and cardiopulmonary resuscitation is hardly done at this situation. In this study, a serious complication of remifentanil was considered during management of anesthesia in a patient with severe aortic stenosis. 2. Case Description The patient was an 84-year-old man, weighting 72?kg, who was hospitalized for open prostate surgery. In records, the patient was only complaining from exertional dyspnea, had no obvious cardiopulmonary problems, and did not mention using any specific drugs. In the conducted examination, pulmonary auscultation had no problems. Examination of abdomen and organs was normal, and only IV/VI systolic murmur and a thrill were heard in the aortic area. In order to evaluate the patient before the operation, blood tests, electrocardiogram, and echocardiogram were requested. The only positive point in the lab tests was prothrombin time (PT) = 15.6?sec. In the electrocardiogram (ECG), heart rate was 65 beats per minute, and the rhythm was regular; however, left axis deviation and left ventricle hypertrophy were observed. In echo, ejection fraction was 57%, severe hypertrophy of left ventricle, calcified and narrow aortic

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