Asystole During CT-Guided Biopsy of a Mediastinal Tumor due to Vasovagal Reflex
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LETTER TO THE EDITOR
Asystole During CT-Guided Biopsy of a Mediastinal Tumor due to Vasovagal Reflex Akitoshi Inoue1
•
Masatsugu Ohuchi2 • Shuhei Inoue2
Received: 23 April 2020 / Accepted: 28 May 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Keywords Image-guided biopsy Core needle biopsy Mediastinal neoplasms Vasovagal syncope Asystole
To the Editor CT-guided core needle biopsy for mediastinal tumor is a minimally invasive diagnostic procedure. Major complication rate was 2%, and common complications are pneumothorax, hemoptysis, and hemothorax [1]. Transient hypotension as a complication of core needle biopsy for mediastinal mass was reported, but not asystole due to vasovagal reflex [2]. A 20-year-old male with an anterior mediastinal tumor was scheduled for CT-guided core needle biopsy to obtain specimens for histopathological examination (Fig. 1a). His blood pressure was 119/65 mmHg, and his heart rate was 88 bpm before the procedure. An 18-G, 13-cm semi-automatic biopsy needle (STARCUT aspiration type, TSK Laboratory, Tochigi, Japan) was inserted through an 18-G, 10-cm coaxial needle and then fired with 2 cm of stroke length while applying aspiration (Fig. 1b). He complained of chest discomfort immediately after the first biopsy;
& Akitoshi Inoue [email protected] 1
Department of Radiology, National Hospital Organization Higashi-Ohmi General Medical Center, 255 Gochi-cho, Higashiomi, Shiga 527-8505, Japan
2
Department of General Thoracic Surgery, National Hospital Organization Higashi-Ohmi General Medical Center, 255 Gochi-cho, Higashiomi, Shiga 527-8505, Japan
however, his blood pressure and heart rate were stable. The second biopsy was performed to obtain a specimen from a different site (Fig. 1c). After that, he felt chest discomfort, he fainted, and became unconscious. Electrocardiogram (ECG) displayed bradycardia followed by asystole. Cardiopulmonary resuscitation was started. He was placed into Trendelenburg position and injected 0.5 mg of atropine sulfate intravenously; his blood pressure and heart rate were recovered to normal levels, and he had no sequelae. ECG monitoring system recorded asystole for 20 s at 100 s after the second biopsy (Fig. 2). Vasovagal reflex is physiologically characterized by overcompensation for exogenous factors by efferent vasodepressor mechanism resulting in bradycardia to decrease cerebral blood flow. The symptom included faintness, nausea, and heat or cold intolerance [3]. The prognosis is usually benign; however, syncope, arrhythmia, and transient asystole have been reported. Major risk factors of vasovagal reflex are warm environment, pain, insufficient food intake, seeing blood, and fear [4]. Although asystole caused by vasovagal reflex during CTguided core needle biopsy have not been described in the literature, patients who are on CT-guided core needle biopsy are associated to these risk factors, and vasovagal reflex with or witho
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