Thorax: first published as 10.1136/thx.15.4.317 on 1 December 1960. Downloaded from

Thorax (1960), 15, 317.

ARRHYTHMIAS FOLLOWING CARDIAC SURGERY * BY R. W. EMANUEL From the Brompton Hospital, London

(RECEIVED FOR PUBLICATION MARCH 25, 1960)

One of the many new problems created by small haemorrhage into the pericardial sac may cardiac surgery is the management of post-operative cause without obvious signs of tampon- disturbances of rhythm. ade. Similarly, a small haemothorax may keep the The following observations are based on 48 cases pulse rate high. The commonest cause of persistent seen during the last 18 months at the Brompton tachycardia, however, is incomplete expansion of Hospital, where it is our practice to give digitalis the lung, and there is usually a dramatic fall in pulse before operation to all cardiac cases. rate after this has been corrected by physiotherapy Clinically theproblemsfall into three main groups: or bronchoscopy. (1) Cases of " tachycardia" which give rise to There still remain a considerable number of concern during the first post-operative week; patients in whom no adequate explanation can be (2) the restoration of after mitral found for the tachycardia. In these cases it may valvotomy in cases with established atrial represent an unusually prolonged reaction to the before operation; (3) cases in which general metabolic disturbance caused by the developed after closure of an atrial septal defect. operation, but if it fails to subside by the end of copyright. The management of after closure of the first post-operative week the possibility of ventricular septal defects and problems of resus- haematoma or infection should be considered. citation associated with are , , and the post-cardio- not included. tomy syndrome have not, in my experience, been the cause of persistent tachycardia during the first GROUP 1: "TACHYCARDIA" DURING FIRST POST- four or five post-operative days. http://thorax.bmj.com/ OPERATIVE WEEK If the tachycardia persists, increasing the dose This group accounted for 40% (19 cases) of the of digitalis may slow the atrial rate. This pharma- seen. Clinical and electrocardiographic cological action is more widely appreciated in examinations rarely fail to establish the nature of America than in this country. Sedation may be the ; it is, however, much more difficult useful, but quinidine has no place in the treatment to determine whether there is a specific factor of post-operative sinus tachycardia. responsible. There is a small group of cases of congenital The common disturbances of rhythm occurring heart in which persistent post-operative at this time are (a) sinus tachycardia, (b) supra- tachycardia may be sinister. These are cases of on September 29, 2021 by guest. Protected , (c) , and pulmonary stenosis with or without a normal (d) multiple ectopic beats, coupling, and nodal aortic root, in which the stenosis has been inade- rhythm. quately relieved or where a secondary functional (a) SiNus TACHYCARDIA is inevitable after any stenosis or infundibular shutdown is embarrassing operation and normally starts to subside between the ventricle. In Fallot's tetralogy persistent the second and fifth post-operative day. Persistent tachycardia may indicate infundibular shutdown tachycardia at a rate of over 130 beats per minute which can lead to syncope and death, and in pure after the first 24 hours may give rise to some concern. pulmonary stenosis obstruction to right ventricular Fluid imbalance and haemorrhage are the first outflow from a secondary functional stenosis may things to think of, and the latter is not always cause acute right . Such cases should easily excluded, particularly when bleeding is be nursed in an oxygen tent and heavily sedated. confined within the . The pericardium Recent work on syncope in Fallot's tetralogy can seal off remarkably quickly after surgery, and a suggests that morphine is the best drug for relaxing * This paper formed part of a symposium on post-operative care infundibular tone (Wood, 1958; Braudo and which was held at the Institute of of the Chest on December 18, 1959. Zion, 1959). Thorax: first published as 10.1136/thx.15.4.317 on 1 December 1960. Downloaded from

318 R. W. EMANUEL

(b) and (c) SUPRAVENTRICULAR TACHYCARDIA after an extensive ventriculotomy than after atrial AND ATRIAL FIBRILLATION.-Occurring at or shortly surgery. Withdrawal of digitalis and additional after operation this is rarely a difficult problem. sedation may be expected to correct these arrhyth- Any of the predisposing causes of sinus tachycardia mias. During the early post-operative period may be responsible. In atrial fibrillation in spite of quinidine should be avoided as more than one case pre-operative digitalis the initial ventricular rate is of closed aortic valvotomy has been lost associated always fast, around 120-140 per minute. Digitalis with quinidine therapy at this time (Brock, 1959). should be increased, usually by mouth, until ade- quate slowing has been achieved. In supraventricu- GROUP 2: ATRIAL FIBRILLATION AND RESTORA- lar tachycardia digitalis should again be given to TION OF SINUS RHYTHM AFTER MITRAL VALVOTOMY increase the degree of atrio-ventricular block from the usual 2: 1 to 3 or even 4: 1, thus slowing the All cases in this group have established atrial ventricular rate. Sinus rhythm may return without fibrillation before surgery. Those developing atrial further treatment. If the arrhythmia persists and fibrillation at or shortly after surgery have already quinidine is required this should be withheld until been discussed. the third or fourth post-operative week (vide infra). After successful mitral valvotomy it is our practice One group of cases which seem particularly to attempt to restore sinus rhythm in all cases, prone to atrial fibrillation are elderly patients who irrespective of the duration of atrial fibrillation. have extensive resection of a lung and in whom the Using quinidine sulphate we revert 50%0 of cases, pericardium has been opened. These patients but in about half of these fibrillation recurs before almost invariably revert to sinus rhythm spon- the patient leaves hospital or shortly afterwards taneously. (Wood, 1954). We do not use anticoagulants when attempting (d) MULTIPLE ECTOPIC BEATS, COUPLING, AND to restore sinus rhythm after successful valvotomy NODAL RHYTHM.-These are usually due to excessive because the risk of post-operative embolus is negli- digitalis, but ventricular ectopics are more common gible. The rarity of this complication is attributed copyright. f;i;F =jff !I !jF .ih HH11IRRPIR Hi4i HIIH _, 4 +T 1. Illill:111i' lillill '~~~V ......

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Fi(i. 1.-A, Sino-auticular block after a total daily dose of 13 grains quinidine sulphate (woman, 64 years, rheumatic heart disease, dominiant mitral incompetence and resistant supraventricular tachycardia). B, Atrial flutter with a ventricular response of 145'min. and widening of QRS to 0-24 sec. occurring after a total daily dose of 32 grains quinidine sulohate. (Man, 20 years, developed atrial flutter after closure of an atrial septal defect.) C. Same patient as in B, showing his usual QRS complex in V1 of 0 08 sec. Thorax: first published as 10.1136/thx.15.4.317 on 1 December 1960. Downloaded from

ARRHYTHMIAS FOLLOWING CARDIAC SURGERY 319 to the removal of the left atrial appendix, washing post-operative week, the remainder do so in the out all fresh clot from the left at the operation, third to sixth post-operative week. The atrial rate and the improved flow of blood through the left varies between 250 and 375 per minute with an heart. average of 294 per minute. All patients were It is our usual practice to start quinidine during taking digitalis when atrial flutter occurred. the third post-operative week. The patient is fully As with so many other arrhythmias no cause was digitalized and confined to bed. After a test dose found although there were a number of associated of 3 grains we give 3, 5, and 8 grains at six-hourly factors. Atrial flutter never followed the closure intervals on the first day, 8 grains t.d.s. on the of a small defect. The size of the defect in the second and third days, 10 grains t.d.s. on the affected cases varied between 3.5 x 3.5 cm. and fourth day, 8 grains every two hours for four doses 6.0 x 8.0 cm. Two of the nine cases had severe on the fifth day, and 10 grains every two hours for post-operative , a third had a pulmonary four doses on the sixth day. An electrocardiogram infarct, and a fourth developed thrombosis of is taken before treatment on the sixth day and tranmposed anomalous veins. The age and sex of again before the final dose of quinidine on that day. the patient, the development of ventricular fibrilla- Toxic symptoms, which include severe nausea, tion at operation, and the length of time the vomiting, diarrhoea, tinnitus, deafness, disturbances circulation was occluded did not appear to be of rhythm, and widening of the QRS complex on significant factors. This complication, however, the electrocardiogram, must be heeded and treat- cannot be ignored if 2% of patients who have had ment stopped, otherwise sooner or later sudden otherwise successful operations develop persistent death may occur. Two examples of arrhythmias atrial flutter. due to quinidine are illustrated in Fig. 1. SUMMARY successful The main factors mitigating against and management of the common are an incomplete The significance restoration of sinus rhythm arrhythmias occurring during the first week after valvotomy, mitral incompetence (pre-existing or copyright. pericarditis at the cardiac surgery are described. created at operation), and active The problems of restoring sinus rhythm after time of quinidine therapy. The restoration of of atrial should be achieved mitral valvotomy and the association sinus rhythm is important and with the surgery of atrial septal defect have fibrillation alone can flutter whenever possible since atrial been discussed. reduce the resting output by one third.

The patients studied were under the care of Dr. Paul http://thorax.bmj.com/ GROUP 3: ATRIAL FLUTTER AFTER CLOSURE OF Wood and one of the following surgeons: Sir Russell ATRIAL SEPTAL DEFECTS Brock, N.r. N. R. Barrett, Mr. 0. S. Tubbs, Mr. W. P. or Mr. M. Paneth. I am most to these a of 100 cases in which the atrial septal Cleland, grateful In total members of the Brompton Hospital staff for their help defect was closed using hypothermia, post-operative and co-operation. I am particularly indebted to Dr. atrial flutter occurred in nine. Paul Wood for his help in preparing this paper. In most patients it stopped spontaneously, but two patients required quinidine and a further two REFERENCES all treatment and atrial flutter has now Brit. med. 1323. have defied Braudo, J. L., and Zion, M. M. (1959). J., 1, on September 29, 2021 by guest. Protected in the cases Brock, R. C. (1959). Personal communication. persisted for over two years each. Half Wood, P. (1954). Brit. nied. J., 1, 1051. that develop this complication do so in the first - (1958). Brit. Heart J., 20, 282.