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Following corrective surgical repair for transposition of
Summary
Arrhythmias occurs commonly following Cardiopulmonary bypass. Patients with Ebstein�s anomaly commonly develop Atrio-ventricular nodal block post-operatively due to injury to the sinus node. Atrio-ventricular sequential pacemaker is indicated in this situation. Arrhythmias and pacemaker malfunction can occur due to the use of monopolar electrocautery. Here we are presenting a case of Ebstein�s anomaly undergoing corrective surgery developed ventricular fibrillation due to the use of electrocautery when the patient was on Atrio-ventricular sequential pacing. We revived the patient successfully and use of ultrasonic harmonic cautery is safe in these cases. 

Introduction
Following corrective surgical repair of Ebstein�s anomaly, patients have a high incidence of arrhythmias in the postoperative period. The atrio-Ventricular (AV) node can be injured during surgical repair1. AV sequential pacing is used when there is heart block, which is frequently present for 30-60 minutes as the myocardium recovers after cross-clamp removal2. Cardiac pacemakers have been utilized as a treatment for arrhythmias in such patients. Arrhythmias and pacemaker malfunction have been reported during the use of electrosurgery in patients with cardiac pacemakers3. We describe a case in which a patient with AV sequential pacemaker with epicardial leads just after cardiopulmonary bypass experienced ventricular fibrillation intraoperatively due to the use of electrocautery.

Key Words
Cardiac pacemakers; ebstein�s anomaly; Cardiopulmonary bypass; Atrioventricular sequential paing; ventricular fibrillation; electrosurgery; microshock.

Case report
A 14 year old girl with preoperative diagnosis of Ebstein�s anomaly with severe tricuspid regurgitation underwent repair of tricuspid valve with atrial septal defect closure using cardiopulmonary bypass (CPB) and hypothermic (temperature 26�C) cardioplegic arrest. After successful surgical correction and adequate rewarming with normal electrolytes, we planned to terminate CPB. Patient developed complete heart block and Atrio-Ventricular sequential pacemaker was used with epicardial leads. The epicardial leads were connected to DDD generator (MEDTRONIC 2556). The pacemaker settings consist of a pulse amplitude of 3.7 V, a pulsewidth of 375 msec, a rate of 100 beats/min. with a sensitivity of  2 mV and a refractory period of 300 msec. Patient successfully came off CPB with sequential pacemaker support and became hemodynamicaly stable. Arterial blood gas (ABG) analysis shows normal parameters with normal serum potassium level. A unipolar electrosurgery (Geister ESU-X250) was used to provide hemostasis. A disposable, pre-gelled dispersal pad was placed on the patient's left anterior thigh. The electrosurgery unit (ESU) was used in a blend mode with cutting set at 20 and coagulation set at 30. The ESU had a return electrical monitoring system with an audible alarm for fault. During the use of the ESU, cardiac rhythm suddenly changed to ventricular fibrillation. Ventilation with 100% oxygen continued and efibrillation was accomplished with intracardiac 20 joules, and intravenous administration of a bolus of lidocaine 0.5 mg/kg) which aborted the fibrillation. Heart rate subsequently maintained at 100 beats/min with AV sequential pace maker. The pacemaker generator was re-evaluated and was noted to be functioning properly. The ESU was examined for faults postoperatively and found to be functioning normally. No other instruments that could have provided conduction for electrical current were in the field. An ultrasonic scalpel (Ultracision generator- Ethicon Endo-Surgery) which uses harmonic energy was then used to secure hemostasis which did not produce any complications. For the remainder of the intraoperative period, the patient was hemodynamically stable. The patient was left intubated and transferred to the intensive care unit for recovery and further observation. Examination of the patient revealed no areas of skin burns. 

Discussion
Ventricular fibrillation is a rare complication of electrosurgery in patients with cardiac pacemakers4,5. In the present case, we suggest that ventricular fibrillation occurred because of the direct conduction of current from the tip of the electrosurgery applicator to the surrounding tissues, and then via the exposed ends of the inner portion the epicardial pacing wires to the myocardium. This event can be classified as microshock. As opposed to macroshock, which results from large amounts of current coming into contact with the surface of the body, microshock is due to very small amounts of current directly applied to the heart, producing a large current density. Various factors that determine whether a particular episode of electric shock will result in ventricular arrhythmias include duration of contact, intensity of the current and type of electricity5-8. Ventricular fibrillation occurs only if the duration of the shock is 10 msec or greater6. Direct current requires several times more energy to cause ventricular fibrillation than does alternating current. One hundred to 300 mA of 60 Hz alternating current is required for macroshock, while only 100 �A of current applied directly to the heart can lead to ventricular arrhythmias7. Very large currents, in the range of amperes, are useful for defibrillation. Also, there is a wide individual variation in the fibrillation threshold, depending on body habitus. Electrolyte imbalances such as hypokalemia and hypomagnesemia, as well as previous myocardial infarction, can perhaps lower the fibrillation threshold. But in our patient all the electrolyte and ABG parameters were normal.
ESUs generate very high frequency current (500,000 to 1,000,000 Hz). When this high-frequency current is used to cut or coagulate tissues, it is usually harmless to the heart as it has low tissue penetration and passes across the pericardium without causing ventricular arrhythmias. However, when an electrosurgery applicator is used, an arc may occur between the tissue and the tip of the applicator (the active electrode). Foster9 noted that Pierce had shown that the presence of an arc in an electrosurgical current caused the energy spectrum to widen, resulting in enhanced lower frequency components, including frequencies below 10 kHz. This modified current may produce malignant ventricular arrhythmias if conducted directly to the heart. In this case, 500- kHz bursts of sinusoid current at a duty cycle of 25 to 50% recurring at 31 kHz are thought to have traveled through tissue into the ends of epicardial leads. Precautions necessary in patients with pacemakers are described in detail elsewhere10. Another possible mechanism that can lead to ventricular fibrillation is competing rhythm. Demand pacemakers in the presence of prolonged electromagnetic interference from the continuous use of electrosurgery are programmed to change to an asynchronous mode (pacemaker fires at a fixed rate irrespective of the spontaneous cardiac activity). Hayes et al.11 have shown that pacemakers revert to this alternate mode in 21% of procedures in which electrosurgery is used. Competing rhythms may occur in the patient with spontaneous rhythm when the pacemaker is in an asynchronous mode. Ventricular tachycardia or ventricular fibrillation can result if the cardiac pacemaker stimulus occurs during the vulnerable period of the cardiac cycle and the patient has concomitant underlying susceptibility to arrhythmias. The ESU should be used only in short bursts so as not to produce pacemaker inhibition, and to prevent potential occurrence of malignant ventricular arrhythmias. A potential solution would be the use of an ultrasonic scalpel which uses harmonic energy to cut and coagulate tissues. This system would reduce potential electromechanical interference and has been used successfully in patients with pacemakers and ICDs12.
In conclusion, ventricular arrhythmias can occasionally develop in patients with cardiac pacemakers if an ESU is used without proper precautions. Careful, continuous monitoring of cardiac rhythm and pulse rate are essential for the safe conduct of an anesthetic in these patients. The present case report describes a unique potential mechanism, stimulation of epicardial leads by electrosurgery, whereby malignant ventricular arrhythmias can be induced. Appropriate precautions include the use of minimal power settings, distant grounding patch placement and vigilant patient monitoring with immediate access to cardioverter-defibrillators and the use of ultrasonic harmonic scalpel.

Reference:

1. Victor C. Baum et al, Abnormalities of the Atrioventricular Valves; Pediatric Cardiac Anesthesia 4th edition, page- 512; Lippincott Williams & Wilkins.

2. Jack S. Shanewise et al, Discontinuing Cardiopulmonary bypass; Kaplan�s Cardiac Anesthesia 5th edition; page-1025; Elsevier Saunders.

3. Belott PH, Sands 8, Warren J. Resetting of DDD pacemakers due to EMI. Pace 1984; 7: 169-172.

4. Titel JH, El-Err AA. Fibrillation resulting from pacemaker electrodes and electrocautery during surgery. Anesthesiology 1968; 29: 845.

5. Bruner JMR, Leonard PE,  Electricity, Safety and the Patient, 1st ed. Chicago: Year Book Medical Publishers, Inc., 1989: 149-151.

6. Zoll PM, Linenthal AJ. External electric stimulation of the heart. Ann NYAcad Sci !964; 111: 932-937.

7. Voorhees WD III, Foster KS, Geddes LA, Babbs CF. Safety factor for precordial pacing: Minimum current thresholds for pacing and for ventricular fibrillation by vulnerable-period stimulation. Pace 1984; 7: 356-360.

8. Raftery EB, Green HL, Yacoub MH. Disturbances of heart rhythm produced by 50-Hz leakage currents in human subjects. Cardiovasc Res 1975; 9:263-265.

9. Foster KS, Geddes LA. The cause of stimulation with electrosurgical current. Med Instrument 1986; 20: 335- 336.

10. ZaidanJR: Pacemaker. Anesthesiology 1984; 60: 319-334.

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