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Amiodarone in Aortic Root: A Noval Approach to Treat the Refractory Ventricular Fibrillation After Release of Aortic Cross Clamp. A Review

Vishnu Datt, Datt Diksha, MA Geelani, Divya, Sneha Satya, Suman Keshav, Subodh Satyarthi

Refractory Ventricular Fibrillation (VF) is referred to as VF that persists or reappears after termination despite three successive shocks delivery, 3 mg of epinephrine, and 300 mg of amiodarone, and failure to obtain the Return of Spontaneous Circulation (ROSC) within 10 min and requires multiple Direct Current (DC) shocks. It is rare but a fatal complication after cardiac surgery. VF often occurs after the release of Aortic Cross-Clamp (ACC) in patients undergoing cardiac surgery using Cardiopulmonary Bypass (CPB). In patients with concentric Left Ventricular Hypertrophy (LVH) of severe aortic stenosis, either continuous VF occurs after release of ACC or reverts to sinus rhythm and crops up again and at times difficult to terminate. Persistent VF and repeated monophasic DC shocks can increase myocardial oxygen demand and myocardial injuries. Intravenous slow bolus or in the CPB circuit of amiodarone, a class III antiarrhythmic agent, has the prominent properties of converting VF and restoring the sinus rhythm. But at times, administration of lignocaine 100 mg, cardioversion with biphasic (10 J-20 J) DC shock and intravenous amiodarone 150 mg or 300 mg fails to revert the VF to the sinus rhythm during weaning from CPB in cardiac surgery for aortic stenosis with concentric LV hypertrophy. In this scenario, the authors have been successfully practicing amiodarone administration in the aortic root for reverting the VF and restoring the sinus rhythm. Administration of amiodarone (150-300 mg diluted in 20 ml normal saline) directly in the aortic root after reapplying a cross clamp for 15-30 seconds, helps in VF termination either reverting to the sinus rhythm or by increasing the sensitivity to DC shock. Not many clinicians have been employing amiodarone in the aortic root (coronary ostia) to manage the refractory VF during weaning off CPB till date. This review will describe the utility of amiodarone in the aortic root (coronary ostia) as a Novel approach to managing the refractory VF after the removal of ACC in patients undergoing cardiac surgery when other conventional therapies fail.