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Single copy made by ANZCA Library for private research or study on 3/09/15 Aesth Plast Surg (2012) 36:1160–1163 Asystole in Young Athletic Women During Breast Augmentation:A Report of Three Cases Asher Schusterman • Mark Schusterman Received: 10 February 2011 / Accepted: 13 June 2011 / Published online: 9 June 2012Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2012 Reported herein are three cases of spontaneous patients. This report should serve to alert the plastic surgeon bradycardia progressing to asystole during routine breast to the possibility of this situation occurring and how to treat it augmentation in healthy, adult female patients with a history successfully, especially in the outpatient or office-based of endurance training and resting bradycardia (heart rate 60 surgery setting.
beats per minute). The incidence of this phenomenon is Level of Evidence V This journal requires that authors assign minimally reported and virtually unexplained in literature.
a level of evidence to each article. For a full description of Our goal is to alert the plastic surgery community of the these Evidence-Based Medicine ratings, please refer to the possibility of these events occurring without warning in Table of Contents or the online Instructions to Authors athletic patients, attempt to explain these findings, and pro- vide a plan of action to minimize morbidity and mortality inthese patients. The most severe case was that of a 38-year-old Breast augmentation  Complications  female who became severely bradycardic progressing to Cardiac complications  Bradycardia  Aesthetic surgery asystole during routine breast augmentation. She had no history of any medical problems, but did have a resting heartrate of 60. Glycopyrrolate, an antimuscarinic agent, wasgiven and chest compressions started. After 10–20 s of chest This is a report of three cases of spontaneous bradycardia compressions the patient's normal sinus rhythm resumed.
progressing to asystole during routine breast augmentation in Two other cases are also reported, although these patients healthy, adult female patients with a history of endurance responded to antimuscarinic agents without requiring chest training and resting bradycardia (heart rate 60 beats per compressions. Both were endurance athletes with a resting minute [bpm]). The incidence of this phenomenon is mini- heart rate of 60. Bradycardia caused by a vagal response mally reported and virtually unexplained in the literature. Our during surgery is not uncommon and routinely treated suc- goal is to alert the plastic surgery community of the possibility cessfully with administration of atropine-like agents. Bra- of these events occurring without warning in athletic patients, dycardia progressing to frank asystole is rare and has not attempt to explain these findings, and provide a plan of action been reported in young, otherwise healthy, aesthetic surgery to minimize morbidity and mortality in these patients.
University of Texas Medical Branch, Galveston, TX, USAe-mail: [email protected] We report three cases of perioperative bradycardia in healthy, athletic women during breast augmentation. The Baylor College of Medicine, Houston, TX, USA first case is a 38-year-old nulliparous female with no sig-nificant past medical history, who underwent a routine M. Schusterman (&) breast augmentation. She reported a regular exercise regi- 1200 Binz Street #1200, Houston, TX 77004, USAe-mail: [email protected] men and had a history of long-distance running. On Aesth Plast Surg (2012) 36:1160–1163 preoperative consultation, the patient's resting heart rate review by Keyes et al. [analyzed 411,670 cases per- was 59 beats per minute, blood pressure was 105/73, and formed over a 2-year period and observed 29 cases (0.007 %) height and weight were 50900 and 140 pounds, respectively complicated by cardiac events, two being cardiac arrest, and (BMI = 20.7). The remainder of the physical exam was 7 cases (0.002%) complicated by notable hypotensive epi- normal and the patient was scheduled for surgery under sodes. A review of 4,778 office-based plastic surgery cases general anesthesia.
by Bitar et al. [reported a rate of hypotensive episodes of On the day of surgery, general anesthesia was successful 0.03% (one case).
and included the following agents: midazolam, fentanyl, There have been very few specific cases ever reported of lidocaine, propofol, rocuronium, Decadron, and Zofran.
perioperative hypotension and bradycardia progressing to The surgical team performed a subpectoral breast aug- asystole in patients with a history of endurance training and mentation using inframammary access. Both pockets were resting bradycardia (heart rate 60 bpm). The cardiac created successfully using the dual-plane technique and the arrest observed during the case reports in the Keyes et al.
implants were placed behind the pectoralis major muscle review [was preceded by unexplained bradycardia and without incident. The head of the bed was then raised to hypotension. Clayman and Caffee [described a case in examine the symmetry of the implants. When the patient their practice in which a healthy patient undergoing breast was situated in the sitting position, she became severely augmentation died after an onset of ventricular fibrillation.
bradycardic, which progressed to asystole. The head of the Clayman and Seagle [later reported another case from bed was immediately lowered and chest compressions were the same practice in which a similar patient underwent started simultaneously with administration of 20 mg of cardiopulmonary arrest just 20 min into breast augmenta- glycopyrrolate. After 10–20 s, heart rate resumed in sinus tion. Atropine and cardiopulmonary resuscitation were rhythm at 100 beats per minute. The case was then finished attempted in both cases but were ultimately unsuccessful.
without incident. The patient was under general anesthesia Both procedures were performed by board-certified plastic for a total time of 55 min. Upon awakening from anes- surgeons in an office setting. Rao et al. ] described two thesia, patient was alert and oriented and showed no signs cases of healthy patients with perioperative bradycardia of distress or tissue damage from hypoxia.
and hypotension progressing to asystole while undergoing The second and third cases describe similar patients tumescent liposuction. Postmortem evaluations in both (healthy, young women with a background of endurance patients could not reveal a definitive cause. While these training) who underwent the same surgical procedure and cases report similar sequelae, none include preoperative became hypotensive and asystolic during breast augmen- vital signs, most importantly heart rate or blood pressure.
tation. Again, both women had resting heart rates of 60 While these events seem extremely rare, a survey by beats per minute. In both instances, bradycardic events Rohrich et al. ] reported that 29.1 % of plastic surgeons developed simultaneously with retractor elevation of the have participated in a cardiopulmonary arrest situation and pectoralis muscle, and administration of glycopyrrolate 43.9 % had acted as code leader. Although many of these achieved restoration of resting heart rate and sinus rhythm.
events most likely occurred during general surgery train- Chest compressions were not required in either case.
ing, the rate is still high compared to the incidence of thesecases, highlighting the importance of advanced cardiac lifesupport (ACLS) certification, even in an office setting.
The pathophysiology of this reflex may be related to vasovagal Fatal outcomes in cosmetic surgery are rare and are usually syncope and the Bezold–Jarisch (BJ) reflex Vasova- associated with previously known morbidities or physio- gal syncope, or loss of consciousness caused by decreased logical responses to errors made during the procedure perfusion of the brain, is mediated by neural mechanisms that Cardiovascular complications are mostly excluded in reports are induced by stress or psychic mechanisms or decreased of complications in cosmetic or office-based procedures venous return, resulting in increased vagal (parasympathetic) [–]. A review by Morello et al. ] reported the inci- tone and reduced sympathetic firing [, The BJ reflex was dence of serious complications to be 0.5 % in office-based initially described as the onset of bradycardia and hypotension plastic surgery procedures, with hypotension occurring in following the administration of certain alkaloid substances, but 0.04 % of cases. Of the 400,000 procedures included in the it has come to include cardiac mechanoreceptor mechanisms study, only seven deaths were reported. Of those, four were caused primarily by ventricular underfilling reportedly caused by cardiopulmonary events and only one Evidence has been presented that identifies the source of described the cause of death as cardiopulmonary arrest. A reflex bradycardia and hypotension as both cardiac and Aesth Plast Surg (2012) 36:1160–1163 neural in origin, hence the relationship between vasovagal this can be done by either blocking b2 receptors, which syncope and the BJ reflex ]. With the exception of cause vasodilation, or by blocking parasympathetic activity stress-induced syncope and/or previous syncopal events, directly at muscarinic receptors. One study demonstrated however, this relationship is poorly understood in the the superiority of b-blockade with metoprolol compared to context of general anesthesia, especially since modern muscarinic blockade using glycopyrrolate in preventing anesthetic agents lack the anticholinergic or sympathomi- hypotensive/bradycardic events in the setting of shoulder metic side effects to induce a vasovagal response. Thus, in arthroscopy [In a plastic surgery setting, however, the setting of general anesthesia, the origin of the neural b-blockade should be absolutely avoided due to the lethal reflexes must be simply vagal.
combination of b-blockade and epinephrine [ Several studies have also examined the result of passive muscle stretch on autonomic nervous system tone inhumans. It seems that there is a relationship between me- chanoreceptors in skeletal muscle and increased sympa-thetic tone, as it could be seen in exercise []. There is Severe bradycardia progressing to asystole can occur in no evidence that muscle stretch increases parasympathetic young, healthy patients with a background of endurance tone, however. Thus, the theoretical possibility that pec- training and resting bradycardia. Healthy, asymptomatic toralis muscle stretch could have been the cause of hypo- patients may appear, at preoperative consultation, to be tension and bradycardia in our patients is most likely good candidates for cosmetic procedures when, in fact, inaccurate, not only for this reason but given the fact that they may possess a predisposition for cardiovascular the respective hypotensive and bradycardic events did not complications created by their years of involvement in seem to coincide with muscle stretch in the operating athletics. If during preoperative assessment the plastic surgeon finds resting bradycardia (heart rate 60 bpm) anda history of endurance exercise, he should be alert to the The Athlete's Heart possibility of a cardiovascular event occurring during whatmay seem like a rather routine, relatively innocuous aes- The activation of the aforementioned reflexes may reflect a thetic surgery procedure [ predisposition from years of endurance training, as was Plastic surgeons and anesthesiologists are encouraged to described by our patient during preoperative consultation.
be prepared for perioperative bradycardia, hypotension, Much evidence has been presented outlining certain and asystole. We recommend the administration of an an- changes that take place in the cardiovascular system of timuscarinic agent and additional chest compressions if athletes that could cause a predisposition in athletes for symptoms are severe. Aesthetic surgeons are also urged to cardiac complications during surgery.
maintain certification in basic life support and ACLS.
Most athletes, working at 75 % or less of their maximum These courses are offered by the American Heart Organi- potential, experience an increase in parasympathetic tone zation and can be completed online [ relative to sympathetic tone during training []. Over time, As this practice has encountered three separate cases of this produces certain changes, which can be observed in perioperative bradycardia and hypotension progressing to endurance athletes. Evidence from studies on long-distance asystole in patients with exercise-induced resting brady- runners has shown increased incidence of resting bradycar- cardia, it is highly suggested that further studies be dia, left ventricular hypertrophy and of all cardiac chambers, undertaken to elucidate the pathophysiology and possible and decreased orthostatic stress tolerance ]. These preoperative signs associated with increased risk of these changes could potentially set the stage for syncopal events, potentially fatal events.
namely, exercise-induced vasovagal, or vasodepressor,syncope []. Long-term, these athletes are at increased risk Conflict of interest The authors have no conflicts of interest to of sinus node disease and arrhythmias, namely, atrial fibrillation and flutter [, While no studies have linkedthe incidence of perioperative bradycardia and asystole, webelieve a theoretical relationship exists given the observed cases and the evidence presented in literature.
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