Anesthetic management of a patient with dilated cardiomyopathy for left ventricular pacing lead insertion under video-assisted thoracic surgery

A 54-year-old man with dilated cardiomyopathy treated with diuretics, alpha-beta blockers, antiarrhythmics for the previous 5 years, had the indication for biventricular pacing and was scheduled for placing of pacing leads in his left ventricular wall under video-assisted thoracic surgery. Preoperative tests revealed first degree A-V block with left bundle branch block and left ventricular dilation with an ejection fraction of 0.11 on echocardiography. Anesthesia was induced with ketamine and midazolam. Endotracheal intubation was facilitated by administration of vecuronium. Anesthesia was maintained with oxygen-sevoflurane and fentanyl. One lung ventilation was carried out during surgery and the arterial oxygen saturation was kept satisfactory with the intermittent insuffilation of oxygen to the non ventilated lung. The procedure was completed uneventfully while ventricular tachycardia was observed. Biventricular pacing increased the ejection fraction from 0.11 to 0.27. We conclude that any special monitoring such as TEE would be helpful to evaluate the cardiac function during the operation.