Extreme bradycardia and transient asystole after massive gastric air entrapment

A 72 year old male was scheduled for radiofrequency ablation of persistent atrial fibrillation under general anesthesia. After induction, and before orotracheal intubation, he developed severe bradycardia with a 4.3 second asystole and hypotension requiring atropin and external chest compressions (Panel A). Fluoroscopy revealed massive air entrapment inside the gastric cavity probably owing to ventilation with a facemask prior to intubation (Panel B, supplementary material video S1). Following gastric exsufflation, the patient regained hemodynamic stability and underwent successful isolation of the four pulmonary veins, and ablation of a typical and atypical left atrial flutter. Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.ipej.2016.05.003. We hypothesized that the patient presented a cardioinhibitory response mediated by vagal afferent terminals originating either from gastric muscular tension receptors or from cardiac sensory