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Could Brugada Syndrome complicate anesthesia?
Journal of Clinical Anesthesia 39 (2017) 105
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Could Brugada Syndrome complicate anesthesia?
Dear Editor, We read with great interest the article with title “Near miss in a patient with undiagnosed Brugada syndrome: a case report and literature review” [1]. We would like to thank the author for reporting this case, as up to date, safe anesthesia in patients with Brugada Syndrome (BrS) remains controversial. We completely agree that adequate preoperative evaluation is extremely important, especially when history of adverse events during previous anesthesia has been identified. Furthermore, it is not clear in this case which arrhythmia occurred prior to the resuscitation, since a figure is not available for the readers. We presume than cardiac ischemia was excluded, but this is not clear. Could an anesthetic agent, or maybe other factors, such as ionic imbalance, fever or other conditions played a role in this event? Malignant arrhythmias in patients with BrS under general anesthesia have been scarcely reported. Nevertheless studies still fail to demonstrate a clear causative relation with the reported anesthetic agents administered in this case report. Although propofol has been a matter of discussion in patients with BrS it is still one of the most commonly administered anesthetic agents for inducing safe anesthesia [2]. In a recent study, propofol was administered in patients with established BrS, permitting unremarkable anesthetic procedures [3]. We believe that we should not discharge propofol yet from our pharmacological armamentarium for this pathology. In expectation of more studies, we should remain critical and vigilant when administering anesthetic agents in patients with BrS or other
http://dx.doi.org/10.1016/j.jclinane.2017.03.037 0952-8180/© 2017 Elsevier Inc. All rights reserved.
channelopathies. Moreover, although technically challenging, in terms of adequate monitoring, patients diagnosed with BrS might benefit more from a 12-lead ECG monitoring during the perioperative period, with specific focus on the right precordial leads (V1–V3) [4,5]. Those are more sensitive for ST-segment patterns seen in BrS than the IIand V-lead. Finally, eliminating and treating all known arrhythmic triggers should be part of the broader perioperative plan. References [1] Alzahrani T. Near miss in a patient with undiagnosed Brugada syndrome: a case report and literature review. J Clin Anesth 2016;35:427–9. [2] Biebuyck JF, Smith I, White PF, Nathanson M, Gouldson R. Propofol an update on its clinical use. J Am Soc Anesthesiol 1994;81(4):1005–43. [3] Flamee P, De Asmundis C, Bhutia JT, Conte G, Beckers S, Umbrain V, et al. Safe singledose administration of propofol in patients with established Brugada syndrome: a retrospective database analysis. Pacing Clin Electrophysiol 2013;36(12):1516–21. [4] Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111(5):659–70. [5] Govindan M, Batchvarov VN, Raju H, Shanmugam N, Bizrah M, Bastiaenen R, et al. Utility of high and standard right precordial leads during ajmaline testing for the diagnosis of Brugada syndrome. Heart 2010;96(23):1904–8.
Panagiotis Flamée, MD* Jan Poelaert, MD, PhD Department of Anesthesiology, Universitair Ziekenhuis Brussel, Vrije Universitet Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium *Corresponding author. E-mail address: panagiotis.fl[email protected] 20 February 2017
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Could Brugada Syndrome complicate anesthesia?
Dear Editor, We read with great interest the article with title “Near miss in a patient with undiagnosed Brugada syndrome: a case report and literature review” [1]. We would like to thank the author for reporting this case, as up to date, safe anesthesia in patients with Brugada Syndrome (BrS) remains controversial. We completely agree that adequate preoperative evaluation is extremely important, especially when history of adverse events during previous anesthesia has been identified. Furthermore, it is not clear in this case which arrhythmia occurred prior to the resuscitation, since a figure is not available for the readers. We presume than cardiac ischemia was excluded, but this is not clear. Could an anesthetic agent, or maybe other factors, such as ionic imbalance, fever or other conditions played a role in this event? Malignant arrhythmias in patients with BrS under general anesthesia have been scarcely reported. Nevertheless studies still fail to demonstrate a clear causative relation with the reported anesthetic agents administered in this case report. Although propofol has been a matter of discussion in patients with BrS it is still one of the most commonly administered anesthetic agents for inducing safe anesthesia [2]. In a recent study, propofol was administered in patients with established BrS, permitting unremarkable anesthetic procedures [3]. We believe that we should not discharge propofol yet from our pharmacological armamentarium for this pathology. In expectation of more studies, we should remain critical and vigilant when administering anesthetic agents in patients with BrS or other
http://dx.doi.org/10.1016/j.jclinane.2017.03.037 0952-8180/© 2017 Elsevier Inc. All rights reserved.
channelopathies. Moreover, although technically challenging, in terms of adequate monitoring, patients diagnosed with BrS might benefit more from a 12-lead ECG monitoring during the perioperative period, with specific focus on the right precordial leads (V1–V3) [4,5]. Those are more sensitive for ST-segment patterns seen in BrS than the IIand V-lead. Finally, eliminating and treating all known arrhythmic triggers should be part of the broader perioperative plan. References [1] Alzahrani T. Near miss in a patient with undiagnosed Brugada syndrome: a case report and literature review. J Clin Anesth 2016;35:427–9. [2] Biebuyck JF, Smith I, White PF, Nathanson M, Gouldson R. Propofol an update on its clinical use. J Am Soc Anesthesiol 1994;81(4):1005–43. [3] Flamee P, De Asmundis C, Bhutia JT, Conte G, Beckers S, Umbrain V, et al. Safe singledose administration of propofol in patients with established Brugada syndrome: a retrospective database analysis. Pacing Clin Electrophysiol 2013;36(12):1516–21. [4] Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111(5):659–70. [5] Govindan M, Batchvarov VN, Raju H, Shanmugam N, Bizrah M, Bastiaenen R, et al. Utility of high and standard right precordial leads during ajmaline testing for the diagnosis of Brugada syndrome. Heart 2010;96(23):1904–8.
Panagiotis Flamée, MD* Jan Poelaert, MD, PhD Department of Anesthesiology, Universitair Ziekenhuis Brussel, Vrije Universitet Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium *Corresponding author. E-mail address: panagiotis.fl[email protected] 20 February 2017