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Successful use of iv diltiazem to control perioperative refractory complex atrial tachyarrhythmias in a patient with pneumoconiosis

[L’utilisation réussie du diltiazem iv dans le contrôle de tachyarythmies périopératoires, auriculaires, réfractaires, complexes, chez un malade souffrant de pneumoconiose]

Chi-Hsiang Tsou, MD^*, Chern-En Chiang, MD PhD, Jiing-Tarng Liou, MD, Shi-Tai Hsin, MD and Hsiang-Ning Luk, MD MS PhD

^* From the Departments of Respiratory Therapy and
Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei; and
the Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Address correspondence to: Dr. Hsiang-Ning Luk, Associate Professor, Department of Anesthesiology, Chang Gung Memorial Hospital, No 5, Fu-Hsin Street, Kwei-Shan Hsiang, Taoyuan, Taiwan. Phone/Fax: 886-3-328-3110; E-mail: luk1015{at}adm.cgmh.org.tw

Purpose: To present a patient with pneumoconiosis who developed a complex, life-threatening atrial tachyarrhythmia during anesthesia. Intravenous diltiazem was effective in controlling the ventricular rate and hemodynamics after failure of other antiarrhythmic drugs and direct current cardioversion.

Clinical features: A 79-yr-old man with pneumoconiosis complicated by cor pulmonale suffered from gout-related cellulitis of the left lower limb. Debridement of the left gangrenous big toe was carried out under general anesthesia. During anesthesia, a wide-QRS tachycardia occurred suddenly and a complex atrial tachyarrhythmia was later diagnosed. Hemodynamics deteriorated despite aggressive treatment with lidocaine, verapamil, direct current cardioversion, magnesium, digoxin and amiodarone. Correction of the underlying respiratory acidosis was not sufficient to control the rapid ventricular response. Eventually, iv diltiazem adequately controlled the rapid ventricular rate and quickly improved the deteriorating hemodynamics.

Conclusion: Life-threatening complex atrial tachyarrhythmias may occur in patients with chronic lung diseases perioperatively. Intravenous diltiazem was effective in the management of complex atrial tachyarrhythmia in a patient with underlying cor pulmonale.