Severe Post-cardioversion Bradycardia: A Case Report Highlighting the Anesthesiology Perspective

Electrical cardioversion is commonly used to restore sinus rhythm in atrial fibrillation but can rarely precipitate clinically significant bradycardia. We present the case of an 83-year-old female with atrial fibrillation, severe mitral regurgitation, heart failure with preserved ejection fraction (HFpEF), hypertension, gout, and hypothyroidism who was recently admitted with acute decompensated heart failure. She underwent synchronized cardioversion under procedural sedation with propofol and ketamine. Immediately after conversion, she developed symptomatic bradycardia with heart rates in the 30s and hypotension. Multiple doses of atropine and vasopressor support provided only transient improvement. Temporary pacing was attempted but proved insufficient, and an isoproterenol infusion was initiated, stabilizing both heart rate and blood pressure. She was admitted to the ICU for monitoring and subsequently underwent permanent pacemaker implantation. This case underscores the importance of recognizing conduction abnormalities in the peri-cardioversion period, particularly in elderly patients with structural heart disease and those receiving atrioventricular (AV) nodal blocking agents. It highlights the anesthesiology perspective on acute management, emphasizing a stepwise pharmacologic approach, preparedness for pacing, and the role of isoproterenol infusion in refractory cases. Prompt recognition and escalation of therapy are essential to prevent hemodynamic compromise and improve patient outcomes.