Anesthetic management of a patient with Brugada syndrome

Brugada syndrome is characterized by right bundle-branch block, ST elevation in leads V 1 through V 3 and normal QT interval. Ventricular fibrillation frequently occurs in patients with Brugada syndrome. There have been few reports of anesthetic management of Brugada patients. We managed a 47-year-old man with Brugada syndrome, who underwent hemilaminectomy under general anesthesia, without untoward cardiovascular events. Potential problems in anesthetic management of patients with Brugada syndrome are also discussed.     

Anesthetic management for patients with Brugada syndrome

Brugada syndrome should not be neglected in terms of anesthetic management because its perioperative autonomic imbalance may cause ventricular fibrillation and sudden cardiac arrest. Diagnosis of Brugada syndrome is easily made by unique electrocardiographic pattern of right bundle branch block and ST segment elevation in the right precordial leads. Thus the number of patients with Brugada syndrome for anesthetic management tends to increase. We review current concept of anesthetic management for patients with Brugada syndrome including fourteen cases in our institution, two out of which developed VF during operation.     

Brugada syndrome

Brugada syndrome is characterized by the right bundle branch block type electrocardiogram (ECG) with ST-segment elevation and ventricular fibrillation (Vf) attack in patients without obvious heart disease. Its background is considered to be the genetic Na channelopathy. The coved type is a typical morphology and is classified into type 1 in the European Society of Cardiology (ESC). In general, the coved type and the saddel-back type (type 2, 3 in the ESC) are interchangeable, and the latter is more frequently detected clinically. For diagnosis of the Brugada syndrome, confirmation of the type 1 morphology is needed. Administration of Na channel blocker, pilsicainide, is a sensitive test for confirmation of the type 1. When the type 1 has one of 7 items recommended by the ESC, the patient is diagnosed with Brugada syndrome. ECG finding alone is classified into patient with Brugada type ECG. As there is no reliable medical treatment, implantation of a cardioverter defibrillator is indicated in patients with Brugada syndrome, and observation alone in those with Brugada type ECG.     

Anesthetic management of two patients with Brugada-type ECG and of different clinical severity

Brugada syndrome is an arrhythmia syndrome characterized by typical electrocardiogram (Brugada-type ECG) and development of ventricular fibrillation (Vf) without any distinct structural heart diseases. The essential goal in the management of Brugada syndrome is to avoid the development of Vf. However, there has been no established consensus on pre-operative risk assessment of patients with Brugada-type ECG. We recently experienced two cases of anesthetic managements for patients with Brugada-type ECG. Based on these experiences and recent cardiological progress on the risk stratification of Brugada syndrome, we thoroughly discuss on the peri-operative managements for patients with Brugada-type ECG.     

Perioperative management of patients with Brugada syndrome

In 1992, Brugada et al. first reported eight cases of ventricular fibrillation, in which ST-segment abnormalities in leads V1 through V3 along with T-wave inversion, and complete or incomplete right bundle branch block were observed on the standard 12-leads ECG. Since then, this syndrome has been widely recognized as one of important diseases that can produce sudden death in middle aged healthy males. The ECG morphology of Brugada syndrome is believed to be caused by either an accentuation of the notch in the early phase of the action potential or loss of the action potential dome in the epicardium. Mechanisms of ventricular fibrillation in this syndrome are still unclear, but thought to be phase II re-entry caused by dispersion of the action potentials. It has been shown that mutations of the human cardiac Na+ channel gene (SCN5A) underlie multiple cardiac diseases including Brugada syndrome. In fact, single amino acid substitution within the SCN5A coding region can evoke a cardiac rhythm behavior. In this review, we will focus on recent progress of basic and clinical research of Brugada syndrome and perioperative management of this syndrome.     

The use of somtaosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in a patient with Brugada syndrome

IntroductionWe report on the use of Somastosensory Evoked Potential (SSEP) and Motor Evoked Potential (MEP) monitoring in a patient with Brugada syndrome.ObjectivesThe concern in this case was that the amount of current/voltage generated by SSEP/MEP might trigger arrhythmias in a patient with underlying Brugada syndrome.MethodsA 42 year-old male patient with Brugada syndrome underwent excision of an intramedullary tumour with the use of SSEP and MEP monitoring. Preoperatively, he was not on antiarrhythmic medication, nor had an Implantable Cardioverter Device (ICD) in-situ.ResultsThe patient remained stable & in sinus rhythm throughout the operation and was successfully extubated postoperatively.ConclusionThis case report indicates that SSEP/MEP monitoring may be used in patients with Brugada syndrome.     

Extracardiac Minimal Invasive Implantation of Cardioverter Defibrillator in Young Children

Implantable cardioverter defibrillator (ICD) placement in young children remains a challenge due to devicepatient size mismatch and the important choice between an endovenous or an epicardial approach for lead implantation. We treated three children, with respectively Long QT-syndrome, Brugada syndrome and Brugada syndrome with sick sinus syndrome, ranging from 9 months to 7 years with a subxyphoidal ICD and extracardiac lead implantation by minimally invasive techniques. In all cases the thresholds were excellent. The devices could be properly placed in the preperitoneal space without discomfort to the patients. The clinical course was uneventful and results were excellent.     

Caesarean section for twin pregnancy in a parturient with Brugada syndrome

Brugada syndrome is a common cause of sudden cardiac death. We report the anaesthetic management of a woman with Brugada syndrome for elective caesarean section of twins. There are few reports of this disease in pregnancy and we believe this is the first of elective caesarean section in a parturient with the syndrome. The characteristic electrocardiographic changes of the syndrome are linked to sodium channel blockers including local anaesthetics such as bupivacaine. The use of bupivacaine for intrathecal central neuraxial blockade as well as other drugs commonly used in obstetric anaesthesia is discussed.     

Extracardiac minimal invasive implantation of cardioverter defibrillator in young children

Implantable cardioverter defibrillator (ICD) placement in young children remains a challenge due to device-patient size mismatch and the important choice between an endovenous or an epicardial approach for lead implantation. We treated three children, with respectively Long QT-syndrome, Brugada syndrome and Brugada syndrome with sick sinus syndrome, ranging from 9 months to 7 years with a subxyphoidal ICD and extracardiac lead implantation by minimally invasive techniques. In all cases the thresholds were excellent. The devices could be properly placed in the preperitoneal space without discomfort to the patients. The clinical course was uneventful and results were excellent.     

Brugada syndrome following tricyclic antidepressant overdose

The Brugada syndrome, a pro-arrhythmogenic repolarization abnormality, is becoming increasingly recognised as a cause of collapse and sudden cardiac death. We report a case of a 48-year-old man with a tricyclic overdose and a delayed presentation of the Brugada pattern in the ICU. This case raises the need for clinicians to be aware of the Brugada pattern and those patients potentially at risk.     

Preoperative evaluation and anesthetic management of a patient with Brugada syndrome-like ECG

Brugada syndrome has been known as one of the causes of sudden death due to ventricular fibrillation. We experienced anesthetic management of seven patients with ECG showing Brugada syndrome before surgery, even though they had no symptoms nor family history. All of them showed no problems through-out the operation. Such patients are often untreated, but they have the risks of cardiac accidents such as ventricular fibrillation or sudden death. For preoperative evaluation of patients with Brugada syndrome-like ECG, it is important to ask them their experience of syncope and family history. Ultrasonic cardiography and Holter ECG recording should be done. External defibrillator should be prepared and parasympathetic dominant condition must be avoided during the anesthetic management.     

Cardiac surgery and Brugada syndrome: operative considerations

Brugada syndrome is an uncommon arrhythmic disease due to abnormality in myocardial transmembrane sodium channels and is associated with sudden death due to ventricular arrhythmias. We report our strategy and highlight precautions to reduce the risk of perioperative arrhythmias in a patient with Brugada pattern who underwent successful coronary artery bypass grafting.     

Cardiac Arrest with “Pseudo‐Brugada” ECG Pattern in the Setting of a Coronary Artery Anomaly

Abstract A 36‐year‐old Hispanic man with no prior cardiac history presented with chest pain and then ventricular fibrillation requiring defibrillation after a physical altercation. His ECG on presentation to the emergency room was suggestive of Brugada syndrome, which later normalized. Cardiac catheterization revealed anomalous origin of right coronary artery from the left coronary cusp (coursing between the pulmonary artery and the aorta) for which he underwent surgical reimplantation, and subsequent pharmacological challenge test did not provoke reappearance of a Brugada ECG pattern. A review of literature on Brugada syndrome and anomalous origin of the coronary arteries is presented. (J Card Surg 2010;25:614‐617)     

Brugada ECG disclosed by acute malaria: is it all about fever and propofol?

Brugada syndrome is an electrical cardiac disease predisposing to ventricular arrhythmias in which typical electrocardiographic (ECG) features consist of nonischemic repolarization abnormalities in the right precordial leads V1-V3. The appearance of a Brugada-ECG pattern is increasingly observed in critically ill patients and is traditionally attributed to the effect of body temperature and/or drug modulation on cardiac ion channels (“acquired Brugada syndrome”). A patient with complicated malaria in whom Brugada-ECG abnormalities appeared in concomitance with fever and propofol administration is presented. The repolarization changes did not disappear until the patient’s clinical course improved.     

Surgically Treated Primary Lung Cancer Associated with Brugada Syndrome: Report of a Case

A 71-year-old man with primary lung cancer associated with Brugada syndrome was safely oper-ated on following the placement of an implantable cardioverter defibrillator (ICD). During examinations for Brugada syndrome, a tumor in the apicoposterior segment of the left lung was incidentally detected by chest computed tomography. Following the implantation of an ICD, surgical treatment of the left lung tumor was scheduled. A lung biopsy was thoracoscopically performed and adenocarcinoma was diagnosed based on a frozen section analysis. A left upper lobectomy with lymph node dissection was performed through a standard posterolateral thoracotomy. Ventricular fibrillation, which occurred during the night of the first day following surgery, was successfully managed by the ICD. Received: September 29, 2000 / Accepted: May 15, 2001     

12-Kanal-EKG bei Brugada-Syndrom

The case of a 27-year-old male patient with syncope during an episode of fever is presented. Preclinical 12-lead ECG showed typical features of Brugada syndrome with elevated ST segments in lead V1–V3. These ECG patterns disappeared when the body temperature returned to normal after fever reduction therapy. Further diagnostics with an ajmaline test confirmed the diagnosis of Brugada syndrome, a rare disease associated in 30% of cases with mutations in genes encoding the SCN5A myocardial sodium channel with a high risk for arrhythmia. An implantable cardioverter-defibrillator (ICD) was implanted in the patient after ventricular tachycardia was inducible during electrophysiological testing.     

Perioperative approach to a patient with Brugada syndrome

Brugada syndrome is a recently described cardiac anomaly that may be responsible for up to one half of all sudden cardiac deaths in young adults without structural heart disease. It may also be worsened by beta-blockers, and it is almost unreported in the English language anesthesia literature.     

General anesthesia for patients with Brugada syndrome. A report of six cases

PURPOSE: To review six cases of Brugada syndrome presenting for insertion of a cardioverter-defibrillator under general anesthesia. CLINICAL FEATURES: All patients had a history of syncope, ST segment elevation in the right precordial lead of the electrocardiogram (ECG) which became prominent after a pilsicainide challenge test. Routine monitors, right precordial lead of the ECG and an external defibrillator were installed prior to anesthesia. We administered propofol/midazolam for induction, and propofol/sevoflurane combined with fentanyl for maintenance of anesthesia. Atropine and ephedrine were administered to decrease vagal tone. No ECG change or arrhythmia was observed perioperatively. After the successful implantation of the defibrillator, all patients were discharged without any adverse event. CONCLUSION: By avoiding agents or conditions that may exacerbate Brugada syndrome during anesthesia, we were able to manage the patients uneventfully for implantation of a cardioverter-defibrillator.     

Unmasking of Brugada syndrome by an antiarrhythmic drug in a patient with septic shock

Asymptomatic Brugada syndrome patients often display concealed Brugada-type electrocardiogram patterns that result in under-diagnosis of this syndrome. These patients include individuals of both genders and a wide range of ages. They are as likely as non-Brugada patients to have normal longevity or to suffer from a critical illness. Here we report a case of septic shock in which Brugada-type electrocardiogram patterns were induced by pilsicainide administration for the treatment of atrial fibrillation. This case report suggests that some drugs used in the treatment of septic shock can unmask the Brugada-type electrocardiogram pattern and induce lethal ventricular tachyarrhythmia.     

Brugada-type electrocardiographic pattern induced by epidural bupivacaine

IMPLICATIONS: In this case report, we describe the postoperative occurrence of electrocardiogram changes suggestive for the Brugada syndrome in a patient receiving a continuous epidural bupivacaine infusion. After withdrawal of bupivacaine, the electrocardiogram changes were reversible. The patient's history was unremarkable except for an incomplete right bundle branch block. We conclude that local anesthetics, particularly bupivacaine, have the potential to induce serious arrhythmias in patients with Brugada syndrome.