Potential for Infra-Nodal Heart Block and Cardiogenic Shock With Propofol Administration

Abstract

We report a case of infra-nodal complete heart block and cardiogenic shock in a previously healthy 64-year-old man after administration of 180 mg of intravenous Propofol. Although bradycardia, hypotension, and heart block are commonly seen with propofol administration, such findings are transient and respond quickly to administration of vagolytic or sympathomimetic agents suggesting an AV nodal mechanism of heart block. Sustained left ventricular systolic dysfunction and cardiogenic shock by an alternative, non-autonomic mechanism has also been described in the setting of Propofol administration. Our case is the first to note sustained complete infra-nodal heart block in this setting. Early recognition of such a complication, restoration of atrio-ventricular (A-V) synchrony with dual chamber pacing, and aggressive circulatory support is essential in bridging such patients to recovery.

Keywords: Anesthesia; Cardiogenic shock; Cardiomyopathy; Heart block; Heart failure; Hypotension; Impella; Left ventricular assist device; Propofol; Propofol infusion syndrome.

Figure 1

Pre-operative ECG demonstrating RBBB, PR interval of 190, and QRS duration of 150 msec.

Figure 2

Post implantation of a single lead VVI transvenous pacemaker demonstrating sinus tachycardia at 150 bpm, complete heart block, and ventricular demand pacing at 100 bpm.

Figure 3

Day 5 ECG demonstrating a PR interval of 230 msec and a QRS duration of 150 msec with LBBB morphology.

Figure 4

Day 5 ECG demonstrating PR interval of 190 msec and QRS duration of 150 msec with RBBB morphology and Mobitz type 2 AV block.

Figure 5

Day 6 ECG demonstrating baseline RBBB, PR interval of 188 msec and QRS duration of 150 msec.