Obesity Surgery, 15, 716-718
Case Report
Tachyarrhythmia due to Atrial Fibrillation in an Intragastric Balloon Carrier: Coincidence or Consequence? Francesco Puglisi, MD; Palma Capuano, MD; Nicola Veneziani, MD1; Pierluigi Lobascio, MD; Angela D. Di Franco, MD; Giuseppe Lograno, MD; Onofrio Caputi Iambrenghi, MD D.E.T.O. – Section of General Surgery and Trapianto di Fegato, University of Bari; 1Section of Cardiac Surgery, University of Bari, Italy A morbidly obese patient is reported who underwent insertion of a BioEnterics® Intragastric Balloon (BIB) as a pre-surgical procedure (ie. prior to restrictive gastric banding). While carrying the BIB, the patient suffered an episode of severe supraventricular tachyarrhythmia (atrial fibrillation). Although such an event is not definitely correlated to the BIB, the episode led us to modify the pre-treatment protocol, introducing dynamic Holter ECG into the work-up investigations and excluding subjects with a pathological cardiac rhythm. Key words: Morbid obesity, intragastric balloon, atrial fibrillation
Introduction The intragastric balloon is a tool for obtaining weight loss in morbidly obese and super-obese patients before bariatric surgery. It also serves to predict response to subsequent gastric banding treatment. In addition, weight loss reduces the need for conversion to open surgery and the intraoperative complications in super-obese patients.1,2 The BIB (BioEnterics Intragastric Balloon, Santa Barbara, CA, USA) is currently in widespread use.3 Reprint requests to: Dott. Francesco Puglisi, D.E.T.O. Sez. di Chirurgia Generale e Trapianto di Fegato, Direttore Prof V. Memeo, Università - Policlinico di Bari, Piazza G. Cesare, 11, 70100 - Bari, Italy. Fax +39.080.5478735; e-mail:
[email protected] or
[email protected]
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However, it cannot be regarded as a permanent treatment for obesity, because it must be removed after a maximum of 6 months, as specified by the manufacturer.4,5 Use of the BIB is contraindicated in patients with previous resection of the gastro-enteric tract, and in the presence of esophagitis or gastritis, peptic ulcer, hiatal hernia >4 cm, hemorrhagic diatheses, and patients under treatment with anticoagulant or psychotic drugs. The possible complications that can arise with the use of the BIB include: nausea, persistent vomiting, cramping pain, ulceration, gastric perforation, bowel obstruction due to collapse of the device, as well as complications due to the endoscopic and anesthesiological procedures. The efficacy of the BIB in reducing weight in patients with non-morbid obesity may depend in part on the filling volume of the balloon.6 No cardiac complications have been previously described with the use of the BIB. However, the association of obesity and altered cardiac function such as a longer QTc interval and reduction of the left ventricular systolic function, is well known, as is the fact that weight loss has positive effects on these conditions. A significant reduction in the duration of the QT interval and improvement of abnormally prolonged baseline QTc intervals suggests that there is improved cardiac repolarization even with early weight loss.7-9 It is known that arrhythmia may be the only, or the most noticeable, expression of silent cardiac ischemia.10 © FD-Communications Inc.
Atrial Fibrillation and Intragastric Balloon
Case Report A 39-year-old morbidly obese male (weight 130 kg, height 1.63 cm, BMI 49), with diabetes, mild arterial hypertension and osteoarthritis of weight-bearing joints, was selected for positioning of the BIB after endocrinological, psychological and cardiological consultations (clinical examinations and ECG within normal range). At referral for BIB insertion, BP was 150/100 mmHg with pulse 68 beats/minute. The BIB was positioned with anesthesiological assistance, induction with propofol and intranasal administration of O2, with continuous monitoring of SpO2, ECG and arterial pressure. With the patient in the left lateral decubitus position, a diagnostic esophagogastroduodenoscopy was performed. Then, the balloon was filled with physiological solution (600 ml) and methylene blue. The patient was discharged on the second postoperative day and underwent follow-up consisting of a clinical examination and ultrasound scan every 20 days to check the BIB parameters.11 At 1 month, the patient had lost 9 kg and at 2 months 14 kg. At 75 days after positioning of the BIB, he dined normally but then developed a feeling of malaise, palpitations and severe asthenia during the night. On urgent admission to the emergency-room, tachyarrhythmia due to atrial fibrillation was diagnosed, with a ventricular frequency of 130-140 beats/minute and hypotension (80/65 mmHg). He was treated with an amiodarone infusion (30 mg in 250 mg of 5% glucose, at 10 drops per minute). The arrhythmia regressed after 24 hours, with disappearance of the symptoms. After 48 hours, he was discharged with a prescription for 1 tablet of amiodarone per day. The patient had never noted an arrhythmia before its occurrence 75 days after insertion of the balloon. The BIB remained in situ for the planned term and was removed after 175 days, by which time the patient had lost 22 kg (BMI 41).
Discussion Arrhythmic events can be the only or, at any rate, the most prominent, symptoms of a silent cardiac ischemia condition. In obese patients, weight loss
can effectively reduce QTc; when the concomitant arterial hypertension disappears, weight loss can also reduce the prevalence of left ventricular hypertrophy. In obese patients in whom hypertension persists, aggressive pharmacological treatment is therefore indicated to correct the left ventricular hypertrophy.12 Cardiac complications are a frequent cause of morbidity and mortality in patients undergoing surgery or invasive medical treatments, and have a 30% incidence with vascular surgery procedures.13 It is estimated that in the U.S.A., 4% of patients undergoing general surgery are affected by ischemia and 8% to 12% have several risk factors for heart disease.14 Projections of these figures forecast that in the next 30 years, the incidence will rise to 35% in patients >55 years of age. Moreover, surgical procedures will account for >80% of those suffering perioperative cardiovascular complications: patients with cardiac arrhythmia (even of a fatal nature), cardiac failure, ischemia, degenerative valve diseases.15 Atrial fibrillation is characterized by a totally irregular arrhythmia, that has a spontaneous onset generally from a premature ectopic beat. The pulmonary veins are important sites of ectopic beats. The arrhythmia is then perpetuated by a mechanism of multiple wave re-entry.16 The triggering foci may respond to radiofrequency ablation treatment. The existence of an occult anomalous pathway allows only retrograde conduction, while anterograde conduction is blocked. Any ventricular ectopic beat can therefore be conducted to the atria through the accessory fascia. If the impulse reaches the atria while they are vulnerable, it can completely de-synchronize the electrical activity of the atria and trigger atrial fibrillation. This can then be maintained by the reentry circuits. This mechanism also explains socalled idiopathic fibrillation (“lone fibrillation”). The tachyarrhythmic episode observed in our patient containing a BIB and with no history of arrhythmia or cardiac ischemia raises the question of a relationship between the presence of the intragastric balloon and the onset of the cardiac arrhythmia, especially since the pre-procedure ECG was negative. Apart from all other considerations, there could be serious medico-legal consequences if such a relationship were proven to exist. Limiting preoperative investigations to a clinical examination and ECG may not be sufficient to identify mild cardiac complaints or problems underestimated by the Obesity Surgery, 15, 2005
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patient him/herself. Thus, non-invasive investigations such as dynamic 24 or 48 hour Holter ECG may be indicated in addition. While analysis of the ST segment may not be highly predictive of cardiac ischemia with this method, any evidence of arrhythmia is an important diagnostic factor, as preoperative treatment can reduce the later risks. Finally, dynamic ECG can also guide the choice of more targeted investigations, such as myocardial scintigraphy, if alterations of the repolarization phase are observed, as well as in silent forms of ischemia. We therefore believe that dynamic ECG should be performed as a routine investigation before positioning the BIB. Preoperative cardiological examinations must not be performed purely for medico-legal reasons, but can provide an opportunity to assess the cardiovascular apparatus and identify heart diseases causing only mild symptoms, often underestimated by the patient him/herself. In fact, cardiac arrhythmia (ventricular and supraventricular extrasystoles, atrial fibrillation, non-sustained ventricular tachycardia) frequently goes unnoticed or unmentioned, despite the fact that such patients are often in treatment for arterial hypertension and diabetes mellitus.
Conclusions Atrial fibrillation is characterized by a totally irregular arrhythmia, that has a spontaneous onset generally from a premature ectopic beat. Arrhythmic events can be the only, or the most prominent symptoms of a silent cardiac ischemic condition. Cardiac complications are a frequent cause of morbidity and mortality in patients undergoing surgery or invasive medical treatments such as BIB positioning. The tachyarrhythmia episode observed in our patient carrying a BIB and with no history of arrhythmia or cardiac ischemia raises the question of a relationship between the presence of the intragastric balloon and the onset of the cardiac arrhythmia, especially since the work-up ECG was negative. We therefore believe that dynamic ECG should be performed as a routine investigation before inserting the BIB. Preoperative cardiological examinations should assess the cardiovascular apparatus and identify heart diseases causing only mild symptoms, often underestimated by the patient. 718
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(Received February 2, 2005; accepted March 30, 2005)
