P050: PERIOPERATIVE MANAGEMENT OF A PATIENT WITH BRUGADA SYNDROME
Cayla Y Suthumphong, MD; Nathalie Abitbol, MD
University of Miami/Jackson Memorial Hospital
Introduction/Background: Brugada syndrome is a rare but potentially life-threating cardiac conduction disorder that predisposes patients to tachyarrhythmias. Anesthesia providers must be cognizant of the appropriate perioperative management and possible complications these patients may experience.
Methods: We present a case of a 51 year-old male with a past medical history of hypertension, family history of sudden cardiac deaths and recently diagnosed Brugada syndrome, who presented for a cardiac ablation for history of supraventricular tachycardia. Months prior, he presented to an outside hospital with palpitations and found to be in sustained SVT that required adenosine 12mg IV to resolve. He soon after was diagnosed with Brugada syndrome, type I.
Preoperative evaluation included: an electrocardiogram showing sinus rhythm with type 1 Brugada syndrome (coved ST-segment elevations in V1-V2); transthoracic echocardiogram showing normal left ventricular systolic function, ejection fraction of 55-60%, no regional wall motion abnormalities; and a pharmacological stress test with no stress-induced perfusion defects.
Results: Monitored anesthesia care was provided using midazolam 2mg and a low-dose continuous propofol infusion. A radial arterial line was established for intraoperative monitoring. The electrophysiology cardiology team performed a conduction study concluding that AVNRT was the mechanism of his tachyarrhythmia with successful ablation of the slow pathway and no inducible AVNRT post ablation.
Postoperatively, the patient had no reported reoccurrence of palpitations and was planned for a preventative implantable cardioverter-defibrillator.
Discussion/Conclusion: Brugada syndrome is an autosomal dominant disorder characterized by typical (Brugada pattern) ECG features along with either sustained ventricular tachyarrhythmia or sudden cardiac death. On ECG, two distinct patterns can be seen in precordial leads V1-V2: type 1 “coved” Brugada pattern with an ST segment elevation >2 mm and concavity with an inverted T wave, or type 2 “saddle back” Brugada pattern with elevated ST segment that descends before elevating to an upright or biphasic T-wave.
While rare, perioperative management of this syndrome requires unique considerations. Preoperative evaluation should include cardiology evaluation and ICD interrogation, if present. Intraoperative management should be aimed at avoidance of ventricular tachyarrhythmias, usually precipitated by bradycardia or increased vagal tone. External defibrillator pad placement prior to induction is also recommended.
Careful medication selection and avoidance of medications known to increase risk of ventricular arrhythmias is critical in patients with Brugada syndrome. Local anesthetics should be used with caution due to effects on myocardial sodium channels; regional and neuraxial blockade should be performed with short-acting local anesthetics, with avoidance of bupivacaine. Intravenous local anesthetics should be avoided. Common induction agents have been used without issues, but prolonged propofol infusions have had conflicting reports of safety due to the medication’s effect on cardiac calcium channels. Thus, propofol infusions should be used for a limited period with lowest possible infusion rates. Additionally, cholinergic agents should be avoided when possible and sugammadex should be the reversal agent of choice.
While Brugada syndrome is uncommon, anesthesia providers should be aware of the ECG presentation and perioperative management as fatal arrhythmias can occur with commonly used anesthetics.