Original Publication
Open Access

Simulation Scenario- Myocardial Ischemia in a Patient With a Cardiac Transplant After Subarachnoid Block

Published: November 21, 2011 | 10.15766/mep_2374-8265.9029

Included in this publication:

  • MI OHT 9 12 2011.doc

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Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.


This resource is a simulation scenario originating from a case experienced in the operating room. In this scenario, an 80-year-old male, who had a cardiac transplant 13 years prior, undergoes a spinal anesthetic for a wide local excision of Merkel cell carcinoma in his right thigh and thereafter develops refractory hypotension and subsequent myocardial ischemia. Sympathectomy and hypotension are well-known complications of a subarachnoid block. Identification and treatment of these common occurrences are considered basic principles in the use of neuraxial blocks. In a patient with a transplanted heart, the physiology involved can be further complicated as patients are preload dependent. This scenario exposes participants to the extreme complications of a subarachnoid block (hypotension and myocardial ischemia) in a patient with a cardiac transplant, as well as to the complicated responses to different treatments.

Educational Objectives

By the end of this resource, learners will be able to:

  1. Identify sympathectomy as the cause of hypotension immediately following subarachnoid block.
  2. Discuss the diagnosis and treatment of myocardial ischemia.
  3. Describe the appropriate selection of medications in a cardiac transplant patient experiencing severe refractory intraoperative hypotension.
  4. Demonstrate effective communication with operating room staff during a crisis and delegate tasks effectively.
  5. List the differential diagnosis of intraoperative hypotension.
  6. Describe the physiology of a patient with a transplanted heart and the effect of a subarachnoid block.
  7. Describe the preoperative evaluation of a patient with a transplanted heart.

Author Information

  • Daniel Chun, MD: University of California, Irvine, School of Medicine
  • Pablo Gavazza, MD: University of California - Irvine
  • Christine Hollister, MD: University of California - Irvine
  • Cecilia Canales, MPH: University of California - Irvine
  • Sharon Lin, MD: University of California - Irvine

None to report.

None to report.


Chun D, Gavazza P, Hollister C, Canales C, Lin S. Simulation scenario- myocardial ischemia in a patient with a cardiac transplant after subarachnoid block. MedEdPORTAL. 2011;7:9029. https://doi.org/10.15766/mep_2374-8265.9029