Canadian Journal of Anaesthesia

, Volume 44, Issue 5, pp 520–524

Protamine-induced hypotension and bradycardia in a cardiac transplant patient

  • Steven B. Backman
  • Ian Gilron
  • Ross Robbins
Clinical Reports

Abstract

Purpose

The potential for functional reinnervation of the transplanted heart in man is controversial. We report the sudden onset of bradycardia in a cardiac transplant patient following a period of hypotension subsequent to the administration of protamine. Possible mechanisms underlying this response, including reinnervation of the transplanted heart, are assessed.

Clinical features

Eight weeks after cardiac transplantation, a patient returned to hospital for a left femoraltibial artery bypass vein graft. The patient was anaesthetized using general anaesthesia. Upon completion of the procedure, protamine was administered to reverse the heparin-induced anticoagulation. Although administration of a 5.0 mg “test-dose” appeared to be without cardiovascular effect, after an additional 20.0 mg, blood pressure decreased from 98/52 to 62/40 mmHg. After blood pressure reached its nadir, heart rate decreased precipitously from 57 to 29 beats·mm−1.

Conclusions

This report demonstrates that heart rate can change considerably in patients who have undergone cardiac transplantation. It is argued that the change in heart rate observed in the present report cannot be explained by reinnervation of the transplanted heart, as the patient had undergone transplantation only eight weeks previously. Rather, we suggest that the change was mediated by mechanisms intrinsic to the transplanted heart and extrinsic to the CNS.

Résumé

Objectif

La réinnervation éventuelle du coeur humain transplanté demeure un sujet controversé. Nous rapportons une tachycardie subite chez un transplanté après un épisode d’hypotension subséquente à I’administration de protamine. Les mécanismes possibles de ce phénomène, incluant la réinnervation du coeur transplanté, sont discutés.

Éléments cliniques

Huit semaines après une transplantation cardiaque, un patient était réhospitalisé pour un pontage fémoro-tibial gauche, L’intervention s’est déroulée sous anesthésie générale. À la fin de I’intervention, la protamine était administrée pour neutraliser I’héparinisation. Bien que la dose-test de 5.0 mg n’ait pas provoqué d’effets cardiovasculaires, après I’ajout de 20 mg la pression arténelle a fait une chute pnécipitée passant de 98/52 à 62/40 mmHg. Au niveau le plus bas de la pression arténelle, la fréquence cardiaque a subitement chuté de 57 à 29 b·min−1

Conclusions

Ce compte rendu montre que la fréquence cardiaque peut changer considérablement chez le cardiaque transplanté. Comme la transplantation cardiaque ne datait que de huit semaines. il est peu probable que le changement de la fréquence cardiaque observé ici s’explique par la réinnervation du greffon. Nous suggérons plutôt que ce changement était sous médiation de mécanismes intrinsèques au greffon et extnnsèques au SNC.

References

  1. 1.
    Stainback R. Orthotopic cardiac transplantation: a model of the denervated heart.In: Robertson D, Biaggioni I (Eds.). Disorders Of The Autonomic Nervous System, Luxembourg: Harwood Academic Publishers, 1995: 335–74.Google Scholar
  2. 2.
    Stinson EB, Griepp RB, Schroeder JS, Dong E Jr, Shumway NE. Hemodynamic observations one and two years after cardiac transplantation in man. Circulation 1972; 65: 1183–94.Google Scholar
  3. 3.
    Pope SE, Stinson EB, Daughters GT II,Schroeder JS, Ingels NB Jr, Alderman EL. Exercise response of the denervated heart in long-term cardiac transplant recipients. Am J Cardiol 1980; 46: 213–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Kavanagh T, Yacoub MH, Mertens DJ, Kennedy J, Campbell RB, Sawyer P. Cardiorespiratory responses to exercise training after orthotopic cardiac transplantation. Circulation 1988;77: 162–71.PubMedGoogle Scholar
  5. 5.
    Smith ML, Ellenbogen KA, Eckberg DL, Sbeeban HM, Thames MD. Subnormal parasympathetic activity after cardiac transplantation. Am J Cardiol 1990;66: 1243–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Ehrman J, Keteyian S, Fedel F, Rhoads K, Levine TB, Shepard R. Cardiovascular responses of heart transplant recipients to graded exercise testing. J Appl Physiol 1992; 73: 260–4.PubMedGoogle Scholar
  7. 7.
    Gao SZ, Schroeder JS, Hunt SA, Billingham ME, Valantine HA, Stinson EB. Acute myocardial infarction in cardiac transplant recipients. Am J Cardiol 1989; 64: 1093–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Stark RP, McGinn AL, Wilson RF. Chest pain in cardiac-transplant recipients. Evidence of sensory reinnervation after cardic transplatation. N Eng J Med1991; 324: 1791–4.Google Scholar
  9. 9.
    Akosah K, Olsovsky M, Mohanty PK. Dobutamine stressinduced angina in patients with denervated cardiac transplants. Chest 1995; 108: 695–700.PubMedCrossRefGoogle Scholar
  10. 10.
    Bernardi L, Valle F, Leuzzi S, et al. Non-respiratory components of heart rate variability in heart transplant recipients: evidence of autonomic reinnervation? Clin Sci 1994; 86: 537–45.PubMedGoogle Scholar
  11. 11.
    Schwaiger M, Hutchins GD, Kalff V, et al. Evidence for regional catecholamine uptake and storage sites in the transplanted human heart by positron emission tomography. J Clin Invest 1991; 87: 1681–90.PubMedCrossRefGoogle Scholar
  12. 12.
    Wilson RF, Christensen BV, Olivari MT, Simon A, White CW, Laxson DD. Evidence for structural sympathetic reinnervation after orthotopic cardiac transplantation in humans. Circulation 1991; 83: 1210–20.PubMedGoogle Scholar
  13. 13.
    Rudas L, Pflugfelder PW, Menkis AH, Novick RJ, McKenzie FN, Kostuk WJ. Evolution of heart rate responsiveness after orthotopic cardiac transplantation: Am J Cardiol 1991; 68: 232–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Fallen EL, Kamath MV, Ghista DN, Fitchett D. Spectral analysis of heart rate variability following human heart transplantation: evidence for functional reinnervation. J Auton Nerv Syst 1988; 23: 199–206.PubMedCrossRefGoogle Scholar
  15. 15.
    Scherrer U, Vissing S, Morgan BJ, Hanson P, Victor RG. Vasovagal syncope after infusion of a vasodilator in a heart-transplant recipient. N Eng J Med 1990; 322: 602–4.CrossRefGoogle Scholar
  16. 16.
    Rudas L, Pflugfelder PW, Kostuk WJ. Vasodepressor syncope in a cardiac transplant recipient: a case of vagal re-innervation? Can J Cardiol 1992; 8: 403–5.PubMedGoogle Scholar
  17. 17.
    Giannattasio C, Grassi G, Mancia G. Vasovagal syncope with bradycardia during lower body negative pressure in a heart transplant recipient. Blood Press 1993; 2: 309–11.PubMedCrossRefGoogle Scholar
  18. 18.
    Horrow JC. Protamine allergy. J Cardiothorac Anesth 1988; 2: 225–42.PubMedCrossRefGoogle Scholar
  19. 19.
    Victor RG, Jost CMT, Converse RL Jr, Jacobsen TN. Paroxysmal autonomic syncope.In: Robertson D, Biaggioni I (Eds.). Disorders Of The Autonomic Nervous System. Luxembourg: Harwood Academic Publishers, 1995: 287–309.Google Scholar
  20. 20.
    Bexton RS, Milne JR, Cory-Pearce R, English TAH, Camm AJ. Effect of beta blockade on exercise response after cardiac transplantation. Br Heart J 1983; 49: 584–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Grinstead WC, Smart FW, Pratt CM, et al. Sudden death caused by bradycardia and asystole in a heart transplant patient with coronary arteriopathy. J Heart Lung Transplant 1991; 10: 931–6.PubMedGoogle Scholar
  22. 22.
    DiBiase A, Tse T-M, Schnittger I, Wexler L, Stinson EB, Valantine HA. Frequency and mechanism of bradycardia in cardiac transplant recipients and need for pacemakers. Am J Cardiol 1991; 67: 1385–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Blinks JR. Positive chronotropic effect of increasing right atrial pressure in the isolated mammalian heart. Am J Physiol 1956; 186: 299–303.PubMedGoogle Scholar
  24. 24.
    Bernardi L, Salvucci F, Suardi R, et al. Evidence for an intrinsic mechanism regulating heart rate variability in the transplanted and the intact heart during submaximal dynamic exercise? Cardiovasc Res 1990; 24: 969–81.PubMedCrossRefGoogle Scholar
  25. 25.
    Mason JW, Harrison DC. Electrophysiology and electropharmacology of the transplanted human heart.In: Narula OS (Ed). Cardiac Arrhythmias: Electrophysiology, Diagnosis and Management. Baltimore: Williams and Wilkins Company, 1979: 66–81.Google Scholar

Copyright information

© Canadian Anesthesiologists 1997

Authors and Affiliations

  • Steven B. Backman
    • 1
  • Ian Gilron
    • 1
  • Ross Robbins
    • 1
  1. 1.Departments of AnaesthesiaRoyal Victoria Hospital and McGill UniversityMontréalCanada

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