Anaesthetic management of abdominal hysterectomy in patient with congenital sinus node dysfunction

A 45 years old woman having dysfunctional uterine bleeding was scheduled for total abdominal hysterectomy with bilateral salpingo-oophorectomy under general anaesthesia. On pre-operative anaesthesia assessment, she was found to have junctional rhythm at rate of 44 beats/minute with bigeminies and pre-mature ventricular contractions on ECG. On further evaluation, she was diagnosed as having congenital sinus node dysfunction on the basis of 24 hours Holter monitoring. She was asymptomatic, no prior comorbidity and belonged to functional class one. General anaesthesia was successfully managed by vigilance, invasive monitoring, standby transcutaneous and transvenous pacemakers; use of cardiostable and vagolytic anaesthetic agents like Etomidate, Atracurium and Pethidine during the procedure and for postoperative pain management. Transcutaneous external pacing pads were placed just after induction of anaesthesia, their functional capability was confirmed and was ready for use if needed. The transcutaneous and transvenous pacemakers were on backup and both were not required. Patient was successfully managed and was discharged home on third postoperative day with uneventful hospital course. The elective pacemaker implantation was therefore not required

Atresia of the coronary sinus ostium to the right atrium with a persistent left superior vena cava / Atresia del ostium del seno coronario en el atrio derecho con una vena cava superior izquierda persistente

The coronary sinus has lately assumed an important role in the cardiologic clinic once it has been widely used in invasive procedures of the heart. Commonly, it is used during the electrodes implants for the epimiocardic monitoring of the cardiac rhythm, through a biventricular pace maker. These invasive procedures are not possible in hearts with an atresic coronary sinus ostium. In the presence of this anomaly, another may occur: the development of the "Marchal" vein which is a remaining of the left superior vena cava (LSVC). This happens so that the venous blood from the heart can drain into the right atrium, by a communication between the LSVC and the left brachiocephalic vein. The presence of a LSVC brings difficulties when performing an invasive procedure in order to access the right atrium through the superior vena cava, usually done in the cardiologic clinic. Moreover, the LSVC crossing over the left atrium is vulnerable to cardiovascular surgical interventions, confirmed by clinical reports. In the present study, 400 formalin fixed hearts from male cadavers, aged between 35 and 80 years, were investigated, particularly for the anatomy of the coronary sinus. The obliterated ostium of the coronary sinus to the right atrium associated with a persistent LSVC was present in only one (0.25 percent). We performed a diameter study of these structures since they were dilated due to the venous blood from the heart draining into the right atrium, by a communication between the LSVC and the left brachiocephalic vein. We also perform a literature review of these cases and discuss our finding in relation to its clinical importance.

El seno coronario recientemente ha asumido un papel importante en la clínica cardiológico, siendo ampliamente utilizado en procedimientos invasivos del corazón. Comúnmente, se utiliza en los implantes de los electrodos para el monitoreo epimiocárdico del ritmo cardiaco, a través de un ritmo biventricular establecido. Estos procedimientos invasivos no son posibles en los corazones con una atresia del ostium del seno coronario. En presencia de esta condición, se puede producir otra anomalía: el desarrollo de la vena de "Marchal" la cual es un vestigio de la vena cava superior izquierda (VCSI). Esto provoca que la sangre venosa del corazón pueda drenar en el atrio derecho, por una comunicación entre la VCSI y la vena braquicefálica izquierda. La presencia de una VCSI trae dificultades a la hora de realizar un procedimiento invasivo con el fin de acceder al atrio derecho a través de la vena cava superior, usualmente hecho en la clínica cardiológica. Por otra parte, el cruzamiento de la VCSI sobre el atrio izquierdo es vulnerable en las intervenciones quirúrgicas cardiovasculares, confirmado por informes clínicos. En el presente estudio, 400 corazones fijados en formalina provenientes a cadáveres de sexo masculino, con edades comprendidas entre los 35 y 80 años, fueron investigados, en particular por la anatomía del seno coronario. El ostium obliterado del seno coronario al atrio derecho asociado con una VCSI persistente estuvo presente en sólo una muestra (0,25 por ciento). Se realizó un estudio del diámetro de estas estructuras dilatadas debido a que la sangre venosa drena desde el corazón hacia el atrio derecho, por una comunicación entre la VCSI y la vena braquicefálica izquierda. También se realiza una revisión de la literatura de estos casos y se discuten nuestros hallazgos en relación con su importancia clínica.