LIDOCAINE-INDUCED INTERMITTENT LEFT BUNDLE BRANCH BLOCK AND CHATTERJEE PHENOMENON

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: The frequency of new onset left bundle branch block (LBBB) during anaesthesia and surgery is rare. The most common causes for LBBB are structural heart diseases, acute myocardial infarction, dilated cardiomyopathy, heart failure, and exercise-induced LBBB[1]. We present a rare case of Lidocaine-induced Intermittent Left Bundle Branch Block. CASE PRESENTATION: A 63-year-old female with no medical history had hysterectomy/high uterosacral ligament suspension as an elective procedure for uterine prolapse. The baseline EKG was normal. She went to the operating room as scheduled, but after the injection of 100 mg local Lidocaine, she developed a LBBB on the EKG with ST-T changes (Figure-1). The surgery was aborted, and cardiology was consulted Cardiac enzymes were normal. Upon evaluation by the cardiology team, the patient had no particular complaints, and soon her LBBB had resolved spontaneously without any intervention. A follow-up EKG done a few hours later showed normal sinus rhythm with evidence of T-wave inversion suggestive of cardiac memory or "Chatterjee's phenomenon" (Figure-2). Echocardiogram and Nuclear stress testing were performed, and which were negative for ischemic changes. DISCUSSION: There have been several reports of adverse effects of lidocaine on cardiac conduction after standard doses of intravenous lidocaine. These have included the appearance of type II second-degree heart block, asystole, and complete heart block in an infant. One of the first cases of transient LBBB induced by lidocaine was reported back in 1989 by Tagliente et al[2]. It is not understood how lidocaine may induce a transient LBBB; however, the literature has suggested that lidocaine in high doses can cause a conduction delay within the Purkinje system and subsequently leading to a conduction block. Cardiac memory, or Chatterjee's phenomenon, first described in 1969 by Kanu Chatterjee et al., is defined as a deep inversion of T-wave with ST depression in the un-paced heart following ventricular pacing[3]. It has also been described to occur in other patients with abnormal electricity, including those with intermittent LBBB, WPW, and episodic tachycardia. CONCLUSIONS: On rare occasions, Lidocaine can induce intermittent left bundle branch block. REFERENCE #1: Sarter BH, Hook BG, Callans DJ, Marchlinski FE. Effect of bundle branch block on local electrogram morphologic features: implications for arrhythmia diagnosis by stored electrogram analysis. American heart journal. 1996;131(5):947-52. REFERENCE #2: Tagliente TM, Jayagopal S. Transient left bundle branch block following lidocaine. Anesthesia & Analgesia. 1989;69(4):545-7. REFERENCE #3: Chatterjee K, Harris A, Davies G, Leatham A. Electrocardiographic changes subsequent to artificial ventricular depolarization. British heart journal. 1969;31(6):770 DISCLOSURES: No relevant relationships by Mostafa Abohelwa, source=Web Response No relevant relationships by Monica Botros, source=Web Response No relevant relationships by Zeyad Elharabi, source=Web Response No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Sima Shahbandar, source=Web Response No relevant relationships by Victor Test, source=Web Response