Perioperative management of lobectomy in a patient with hypertrophic obstructive cardiomyopathy treated with dual-chamber pacing

Abstract

previously. A routine chest roentgenogram taken during an annual check-up showed a suspicious shadow. The patient was referred to another hospital for a complete medical evaluation. Left lung cancer was diagnosed. His electrocardiogram (ECG) showed a negative T wave in leads V5 and V6, indicating a pattern of old septal and inferior myocardial infarction with mild left ventricular (LV) hypertrophy. Furthermore, epicardial echocardiography (EE) revealed interventricular septal hypertrophy (ISH) and LV outflow hypertrophy, without deterioration of LV wall motion but with mild mitral regurgitation (MR). His cardiac index (CI), ejection fraction (EF), and EE-derived LV-Ao PG were 3.85 l·min Ϫ1 ·m Ϫ2 , 86%, and 72 mmHg, respectively. Finally, HOCM accompanied with MR were diagnosed. The patient was scheduled for right upper lobectomy in the same hospital without any specific medical treatment for HOCM prior to surgery.The patient was premedicated with intramuscular atropine (0.5 mg) and hydroxyzine (50 mg) prior to the induction of anesthesia. On arrival at the operating theater, his heart rate was 78 beats·min Ϫ1 , and his systolic and diastolic blood pressure showed 132/86 mmHg. After the placement of an epidural catheter via the thoracic segment T8/9, anesthesia was induced with bolus intravenous (iv) fentanyl (0.8 µg·kg Ϫ1 ) and propofol (1 mg·kg Ϫ1 ), as well as with continuous infusion of propofol (10 mg·kg Ϫ1 ·h Ϫ1 ), followed by vecuronium (0.03 mg·kg Ϫ1 ). Hypotension (60 mmHg) and profound bradycardia (35 beats·min Ϫ1 ) were observed after anesthesia was induced. Hypotension was controlled rapidly both by volume replacement and intermittent administration of bolus iv methoxamine (1 mg), whereas bradycardia persisted at less than 40 beats·min Ϫ1 . The anesthetists discontinued the induction of anesthesia and cancelled the operation. Ten minutes later, the heart rate of the patient gradually recovered to a level of 50 beats·min Ϫ1 . Oral atenolol (50 mg·day Ϫ1 ) and disopyramide (300 mg·day Ϫ1 ) were started immediately