P073: CASE REPORT: REFRACTORY ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE DURING EXPLORATORY LAPAROTOMY FOR BOWEL OBSTRUCTION REQUIRING INTRAOPERATIVE CARDIOVERSION
Jordyn Agins, BS; Matthew Diaz, MD
University of Miami
Introduction/Background: Perioperative Atrial Fibrillation (POAF) occurs in up to 15% of patients undergoing non-cardiac surgery. Although often transient, it is associated with elevated perioperative risks, including hemodynamic instability, stroke, and increased mortality. Rapid ventricular response (RVR) exacerbates instability by impairing ventricular filling in diastole and increasing myocardial oxygen demand. Effective intraoperative management is essential, with initial strategies targeting rate control via beta-blockers or calcium channel blockers. Severe cases may require urgent electrical cardioversion. This case highlights the management of intraoperative AF with RVR refractory to beta-blockers, emphasizing decision-making challenges in high-risk surgical scenarios.
Methods: We present the case of a 65-year-old male with coronary artery disease (post-CABG), CKD stage II, hypertension, type 2 diabetes, and a recent NSTEMI who initially presented to the emergency department with abdominal pain, vomiting, and unintentional weight loss. Several days later, this patient underwent an emergent laparotomy for suspected ischemic bowel obstruction which resulted in new onset POAF with RVR resistant to beta-blockers requiring electrical cardioversion.
Results: Preoperative vitals were stable, and the patient was in normal sinus rhythm. He was intravenously induced with Etomidate 18mg, Succinylcholine 100mg, 2% Lidocaine 100mg, and Fentanyl 100 mcg and was intubated via direct laryngoscopy without issue. Shortly after induction, the patient developed new-onset AF with RVR (HR =120 bpm), while maintaining stable blood pressure (BP=113/73). Initial treatment with esmolol (20 mg IV boluses ×3) transiently controlled the ventricular response but did not restore sinus rhythm (HR = 104).
After incision, the patient’s heart rate rose to the 110s, still in AF with stable BP. Metoprolol tartrate (5 mg IV) was administered. Worsening AF with RVR led to hemodynamic instability (HR 140 bpm, BP 80/60 mmHg) 45 minutes after incision. Anterior-posterior electrical pads were placed and synchronized electrical cardioversion at 200J successfully restored sinus rhythm. Despite ongoing surgical stress from necrotic bowel resection, sinus rhythm was maintained for the remainder of the procedure.
Following the partial colectomy, hypotension was managed with 5L crystalloid, 500 mL albumin, and norepinephrine and vasopressin infusions. Intraoperative arterial blood gas analysis was unremarkable (7.44/42/181/26/2, K 3.6). The patient was transported to the ICU intubated and on vasopressor support in stable condition.
Discussion/Conclusion: This case underscores the complexity of managing POAF with RVR. While beta-blockers are typically effective for rate control, this patient’s arrhythmia was refractory, likely due to the interplay of autonomic dysregulation, chronic cardiovascular disease, and acute surgical stressors. Electrical cardioversion proved lifesaving, highlighting its role in managing hemodynamically unstable AF.
The resistance to pharmacologic therapy emphasizes the need for individualized anesthetic approaches. Factors such as electrolyte imbalances, ischemic stress, and autonomic responses to surgery may predispose certain patients to refractory arrhythmias. This case underscores the importance of vigilance, rapid decision-making, and tailored management plans for high-risk patients.
Future research should aim to identify predictors of refractory AF in the perioperative setting and optimize management strategies to reduce the associated morbidity and mortality. Multidisciplinary collaboration and advanced intraoperative monitoring are essential in managing complex arrhythmias successfully.