Yonsei Med J.  2007 Apr;48(2):331-336. 10.3349/ymj.2007.48.2.331.

Bupivacaine Induced Cardiac Toxicity Mimicking an Acute Non-ST Segment Elevation Myocardial Infarction

• Ryu HY
• Kim JY
• Lim HK
• Yoon J
• Yoo BS
• Choe KH
• Lee SH

• KMID: 1779541
• DOI: http://doi.org/10.3349/ymj.2007.48.2.331

Abstract

Bupivacaine is widely used as a local anesthetic. Central nervous system (CNS) and cardiovascular toxicity are well known side effects. However, there has been no report of bupivacaine-induced myocardial injury. We present a case of bupivacaine cardiac toxicity mimicking an acute non-ST segment elevation myocardial infarction, which was eventually diagnosed as bupivacaine-induced cardiac toxicity without CNS toxicity. As soon as a healthy young woman at a private clinic was given a spinal anesthesia of 6mg bupivacaine for hemorrhoidectomy, she developed arrhythmia and hypotension. She was transferred to our emergency room. There was an accelerated idioventricular rhythm with ST segment depression on electrocardiogram, coarse breathing sounds with rales on whole lung field and a butterfly sign on the chest radiograph. 2D transthoracic echocardiography (TTE) revealed reduced left ventricle systolic ejection fraction (approximately 27%). There was regional wall motion abnormality of the left ventricle on 2D TTE and the cardiac marker was increased. We diagnosed the patient as having acute non-ST segment elevation myocardial infarction but her impaired cardiac function improved gradually. On the seventh day from admission, there was a complete spontaneous recovery of cardiac function, and coronary angiography revealed a normal coronary artery. Therefore, we firmly believe that bupivacaine directly injures the cardiac cell.

Keyword

Bupivacaine; cardiac toxicity; myocardial infarction

MeSH Terms

Myocardium/*pathology
Myocardial Infarction/chemically induced/*diagnosis/etiology
Humans
Heart/*drug effects
Female
Electrocardiography
Diagnosis, Differential
Bupivacaine/*adverse effects
Adult

Figure

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  Fig. 1 (A) Patient's electrocardiogram before surgery. (B) Patient's electrocardiogram when she complained of chest discomfort, dyspnea and dizziness after spinal anesthesia. (C) Patient's electrocardiogram on discharge.

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  Fig. 2 Patient's chest radiographs on arrival (A) at emergency room and on discharge (B).

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  Fig. 3 (A) 2D TTE findings on arrival at ER. 2D Transthoracic echocardiogram (TTE) showed reduced myocardial contractility, diffuse hypokinesia of the left ventricle, especially akinesia of the anteroseptum of the mid-left ventricle and all segments of the left ventricle at the base, mitral regurgitation of grade I/IV and a reduced left ventricular systolic function (ejection fraction: 27%). (B) 2D TTE findings, 3 days after first examination. 2D TTE revealed a normal sized cardiac chamber with improved left ventricle systolic function (ejection fraction: 51%). (C) 2D TTE findings on discharge. Improved heart function (left ventricle ejection fraction: 71%) and morphologically normal heart.

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  Fig. 4 Coronary angiography. Left (A. normal) and right (B. normal) coronary arteries.

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