Extreme bradycardia and transient asystole after massive gastric air entrapment

A 72 year old male was scheduled for radiofrequency ablation of persistent atrial fibrillation under general anesthesia. After induction, and before orotracheal intubation, he developed severe bradycardia with a 4.3 second asystole and hypotension requiring atropin and external chest compressions (Panel A). Fluoroscopy revealed massive air entrapment inside the gastric cavity probably owing to ventilation with a facemask prior to intubation (Panel B, supplementary material video S1). Following gastric exsufflation, the patient regained hemodynamic stability and underwent successful isolation of the four pulmonary veins, and ablation of a typical and atypical left atrial flutter.

Panel A.

Surface ECG showing pause and beginning of external chest compressions.

Panel B.

Fluoroscopy depicting air entrapment inside the gastric cavity.

Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.ipej.2016.05.003.

The following is the supplementary data related to this article:

Video S1

Fluoroscopy showing massive air entrapment on the gastric cavity and drainage with nasogastric tube.

We hypothesized that the patient presented a cardioinhibitory response mediated by vagal afferent terminals originating either from gastric muscular tension receptors or from cardiac sensory receptors in the inferior wall of the left ventricle via the Bezold-Jarisch reflex. An additional mechanical component related to pressure from the distended stomach obstructing/affecting venous return and/or ventricular filling cannot be excluded.