# Ventricular Asystole During Le Fort I Orthognathic Surgery: A Case Consistent with Trigeminocardiac Reflex and a Mini Review

## TL;DR

A patient undergoing Le Fort I surgery experienced ventricular asystole, likely due to a trigeminocardiac reflex triggered by lateral nasal osteotomy.

## Contribution

This case highlights lateral nasal osteotomy as a potential trigger for TCR during orthognathic surgery, expanding the understanding of high-risk maneuvers.

## Key findings

- Ventricular asystole occurred during lateral nasal osteotomy in a Le Fort I surgery, consistent with a TCR-type event.
- Lateral nasal wall manipulation may be an under-recognized trigger for TCR in orthognathic procedures.
- Prompt management with epinephrine and cessation of the stimulus restored circulation within a minute.

## Abstract

Introduction: The trigeminocardiac reflex (TCR) is a brainstem reflex in which trigeminal stimulation precipitates abrupt vagally mediated cardiovascular changes, ranging from bradycardia to asystole. While classically described during down-fracture or pterygomaxillary disjunction in Le Fort I osteotomy, rhinocardiac events from lateral nasal wall manipulation are less emphasized in orthognathic surgery. Case presentation: A 32-year-old man undergoing Le Fort I osteotomy developed ventricular asystole during lateral nasal osteotomy. The maneuver was stopped immediately; chest compressions and a single dose of epinephrine were administered, with return of spontaneous circulation within approximately one minute. Surgery was aborted and the patient was transferred to the surgical ICU. Clinical discussion: The temporal association with lateral nasal wall manipulation, in the setting of controlled hypotension and multimodal anesthesia, is most compatible with a peripheral (V2) TCR-type event, although drug-related and hemodynamic contributors cannot be excluded. A mini review of orthognathic TCR reports underscores recurring high-risk steps (down-fracture, pterygomaxillary disjunction, mandibular maneuvers) and highlights lateral nasal osteotomy as a potential additional trigger. Management principles remain the immediate cessation of the stimulus, optimization of oxygenation and ventilation, anticholinergics for bradycardia, and epinephrine/advanced cardiac life support for instability or arrest. Conclusion: Lateral nasal osteotomy may trigger a TCR-like event with severe bradyarrhythmia or asystole during Le Fort I osteotomy, particularly in hemodynamically vulnerable patients. Anticipation, swift recognition, and prompt, protocolized management are essential for favorable outcomes.