Injury, Int. J.
Care Injured 32 (2001) 335– 338
Case Report
Effect of aminophylline on complete atrioventricular block with
ventricular asystole following blunt chest trauma
Maurice Y. Khoury a,*, George V. Moukarbel a, Mounir Y. Obeid b, Samir E. Alam a
a
Department of Internal Medicine, Di6ision of Cardiology, American Uni6ersity of Beirut Medical Center, Beirut, Lebanon
b
Department of Surgery, Di6ision of Cardiothoracic Surgery, American Uni6ersity of Beirut Medical Center, Beirut, Lebanon
Accepted 17 October 2000
1. Introduction
Blunt trauma to the chest can cause a multitude of
cardiac injuries involving the pericardium, the my-
ocardium, the valvular apparatus, the coronary arteries,
as well as the conduction system [1]. We report a case
of traumatic complete atrioventricular (AV) block asso-
ciated with tricuspid insufficiency responding to intra-
venous (IV) aminophylline.
2. Case report
A 39-year-old man was the driver of a car involved in
an accident, in which he was thrown forward against the
steering wheel. On presentation to the emergency room
of a local hospital, he was hypotensive and in respiratory
distress. The electrocardiogram (ECG), as reported,
showed sinus tachycardia. He was intubated, stabilized
and transferred to our institution 5 h later. Upon arrival,
his pulse was faint and slow. The ECG showed evidence
of complete AV-block with ventricular asystole (Fig.
1A). He received 1 mg of atropine IV three times at 3
min intervals and 1 mg of epinephrine IV to no avail.
Arrangements for internal cardiac pacing were made,
however, following the administration of 500 mg of
aminophylline IV, his heart rate increased to 75 (Fig. 1B)
and then 150 beats/min (Fig. 1C), at 3 and 5 min,
respectively. His ECG reverted to normal sinus rhythm
(Fig. 2) with left anterior hemiblock (LAHB) and T-wave
inversion in I and aVL 10 min later with a blood pressure
of 120/80 mmHg. Echocardiography revealed flailing of
* Corresponding author. Tel.: + 961-1-350000; fax: + 961-1-
744464.
E-mail address: mk04@aub.edu.lb (M.Y. Khoury).
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the anterior leaflet of the tricuspid valve with severe
tricuspid regurgitation. He was admitted to the intensive
care unit with a smooth course. Two months later, he was
asymptomatic but with persistent LAHB and grade
II–III tricuspid regurgitation.
3. Discussion
Tricuspid insufficiency is rare following blunt trauma
[2]. It is thought to be secondary to a rapid, severe
increase in right ventricular pressure resulting from the
sudden impact of the heart against the sternum [3]. It has
been associated with complete AV-block in few case
reports [2], whereby involvement of either the whole
tricuspid apparatus or the septal leaflet alone in close
proximity to the membranous portion of the septum,
provided an anatomic explanation for the associated
disruption of the bundle of His. Our patient, however,
had involvement of the anterior leaflet of the tricuspid
valve only, making the concomitant AV-block, which we
estimate to have occurred a few hours following the
event, a separate consequence of the trauma. He presents
the rare occurrence of tricuspid insufficiency and com-
plete heart block without interruption of the membra-
nous portion of the interventricular septum, as evidenced
by the transient nature of the block.
The exact mechanism of heart block with an intact
septum is unknown. Trauma may induce local rhab-
domyolysis with release of metabolic depressant sub-
stances [1]. Adenosine, a metabolite with a pronounced
depressant effect on AV-nodal conduction is released
by ischemia and hypoxia to the myocardium [4,5]. The
conduction depressant effects have been attributed to
an interaction with an adenosine specific extracellular
 336
M.Y. Khoury et al. / Injury, Int. J. Care Injured 32 (2001) 335–338

Fig. 1. (A) Complete AV-block with ventricular asystole; (B) Complete AV-block with ventricular rate of 75 beats/min; (C) Complete AV-block with ventricular rate of 150 beats/min.
M.Y. Khoury et al. / Injury, Int. J. Care Injured 32 (2001) 335–338 337

Fig. 2. Normal sinus rhythm with LAHB.

338 M.Y. Khoury et al. / Injury, Int. J. Care Injured 32 (2001) 335–338
receptor that is blocked by methylxanthines such as
aminophylline but not by atropine [4,5] as in our pa-
tient. Although cardiac pacing is the treatment of
choice in atropine-resistant complete AV-block, the re-
sponse to intravenous aminophylline carries an implica-
tion for the management of similar cases.
References
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[3] van Son JA, Danielson GK, Schaff HV, Miller FA. Traumatic
tricuspid valve insufficiency. Experience in thirteen patients. J
Thorac Cardiovasc Surg 1994;108:893– 8.
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