This case report details the anesthesia management of a 21-year-old male diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) who underwent pyeloplasty. The erector spinae plane block (ESPB) was utilized as part of a multimodal analgesia strategy to reduce intraoperative stress and minimize opioid use. Administered under ultrasound guidance, 20 mL of 0.5% ropivacaine with clonidine provided effective somatic and visceral analgesia. The intraoperative period was stable, and the patient experienced a smooth recovery post-surgery. This case underscores the effectiveness of ESPB as a safe anesthesia technique for patients with ARVC, enhancing postoperative pain management and aligning with Enhanced Recovery After Surgery (ERAS) protocols.
Introduction
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a genetic heart condition marked by the replacement of right ventricular muscle cells with fibrofatty tissue. This replacement leads to electrical instability and a heightened risk of ventricular tachycardia (VT). The erector spinae plane block (ESPB) is a regional anesthesia method used for pain management. It involves injecting a local anesthetic into the space between the erector spinae muscle and the vertebrae’s transverse processes. ESPB serves as an alternative to neuraxial blocks for postoperative pain relief in renal surgeries.
This report highlights successful anesthesia management in a patient with ARVC, navigating the procedure without any lethal arrhythmias, despite the challenges posed by the condition. Enhanced Recovery After Surgery (ERAS) protocols, developed by Danish surgeon Dr. Kehler, focus on a patient-centered, evidence-based, multimodal approach to surgical recovery, including preoperative optimization, standardized anesthesia, stress reduction, early mobilization, and effective postoperative pain management.
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Case Presentation
The patient, a 21-year-old male with a four-month history of ARVC, was scheduled for right-sided pyeloplasty under general anesthesia. He had been diagnosed with ARVC after experiencing five seizure episodes with loss of consciousness. Since then, he has been on propranolol, taking 5 mg twice daily. His electrocardiogram (ECG) indicated left axis deviation, sinus tachycardia, and T-wave inversion in leads V2, V3, and V4. A preoperative echocardiogram revealed a dilated right atrium and ventricle, a dilated right ventricular outflow tract, mild tricuspid regurgitation, and an ejection fraction of 60%.
On the surgery day, the patient’s vital signs were recorded as BP 140/100 mmHg, HR 110/min, and SpO₂ 100%. After confirming the propranolol dose and obtaining written consent, he was taken to the operating theater with emergency cardiac drugs and an external defibrillator on standby. The patient received midazolam (0.02 mg/kg) for premedication, followed by general anesthesia induction with fentanyl (2 µg/kg) and etomidate (0.5 mg/kg). An 8-size endotracheal tube was inserted after administering vecuronium. To minimize the stress response, a senior anesthetist performed the intubation, using a 2% lignocaine spray to anesthetize the vocal cords beforehand.
Anesthesia was maintained with vecuronium for muscle relaxation and isoflurane as the inhalational agent, keeping ETCO₂ between 32 and 38 mmHg. An intraoperative arterial line was established for blood pressure monitoring. A multimodal analgesia approach was adopted to enhance pain relief while minimizing side effects from any single method, ultimately improving postoperative outcomes. After positioning, a right-sided ESPB was administered at the second lumbar transverse process using a low-frequency 5-10 MHz curvilinear probe.
The block consisted of 20 mL of 0.5% ropivacaine and 20 µg clonidine.
The intraoperative period was stable, with vital signs recorded as BP 104/61 mmHg, HR 71/min, mean arterial pressure (MAP) 80 mmHg, and SpO₂ 100%. The surgery proceeded as planned. To prevent extubation response, intravenous lignocaine (2 cc, 40 mg) was administered. Once spontaneous respiration resumed, extubation occurred uneventfully after decurarization with sugammadex. Post-extubation, the patient’s vital signs remained stable.
Discussion
ARVC affects approximately 1 in 3,000 individuals, with men often experiencing symptoms earlier than women. Common symptoms include palpitations, light-headedness, and syncope. Many patients may present with chest pain linked to transient ischemic changes on ECG and elevated troponin levels, mimicking myocardial infarction.
ARVC is characterized by the loss of right ventricular myocytes, replaced by fibrofatty tissue, leading to wall thinning. This condition typically manifests in individuals aged 10 to 50. Diagnostic tools for ARVC include ECG, echocardiography, angiography, computed tomography, and magnetic resonance imaging. Treatment primarily involves antiarrhythmic agents, catheter ablation, diuretics, beta-blockers, and, in severe cases, heart transplantation.
The ESPB offers numerous advantages, such as reduced opioid consumption, improved postoperative pain control, and a lower risk of complications associated with systemic opioids or other analgesics. It is particularly useful for avoiding respiratory complications and enhancing patient satisfaction. The ESPB is performed using an in-plane ultrasound-guided technique, allowing anesthetic spread that blocks both somatic and visceral pain pathways, making it effective for thoracic and abdominal surgeries.
However, ESPB is not without risks, including local anesthetic toxicity, nerve injury, or infection. Proper technique, patient selection, and monitoring are crucial to minimize these risks. ERAS protocols aim to enhance surgical outcomes through comprehensive perioperative care strategies. Multimodal analgesia in ERAS involves various combinations of opioids, non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetics, wound infiltration, and nerve blocks.
Ultrasound-guided nerve blocks are transforming perioperative care, improving patient satisfaction and recovery while significantly reducing postoperative pain, opioid use, and hospital stays.
Conclusions
ARVC is a complex condition marked by its gradual progression, unpredictable arrhythmias, and tendency to affect younger patients. The ESPB has emerged as a valuable adjunct in anesthesia for ARVC, providing a novel intraoperative approach to pain management. By alleviating pain during surgery, which can trigger tachycardia and stress responses, ESPB helps reduce ventricular stress and the risk of ARVC exacerbation.
Moreover, ESPB enhances recovery from anesthesia and postoperative pain management, leading to better patient outcomes. Integrating ESPB into the multidisciplinary management of ARVC may improve treatment efficacy, reduce complications, and enhance the quality of life for affected individuals.