Perioperative management of hereditary arrhythmogenic syndromes

Smooth Emergence from General Anesthesia after Deep Extubation in a Pediatric Patient Diagnosed with Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report

Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare genetic disorder where catecholamine causes bidirectional ventricular tachycardia, potentially leading to cardiac arrest. In patients undergoing surgery, sympathetic responses can be triggered in situations associated with surgical stimulations as well as high anxiety before the surgery, anesthetic maneuvers such as endotracheal intubation and extubation, and postoperative pain. Therefore, planning for surgery demands meticulous attention to anesthesia during the perioperative period in order to prevent potentially life-threatening arrhythmias. Case: We discuss a case of an 11-year-old male pediatric patient with known CPVT who required elective strabismus surgery for exotropia involving both eyes. After thorough planning of general anesthesia to minimize catecholamine response, sufficient anesthesia and analgesia were achieved to blunt the stressful response during intubation and maintained throughout the surgical procedure. Complete emergence was achieved after deep extubation, and the patient did not complain of pain or postoperative nausea and vomiting. Conclusions: Anesthesiologists should not only be able to plan and manage the catecholamine response during surgery but also anticipate and be prepared for situations that may lead to arrhythmias before and after the procedure. In certain cases, deep extubation can be beneficial as it reduces hemodynamic changes during the extubation process.

Anesthetic Management for Dental Extraction in a Patient With Catecholaminergic Polymorphic Ventricular Tachycardia Syndrome: A Case Report

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited genetic disorder that predisposes patients to potentially fatal arrhythmia when under physical or emotional stress. Anesthetic management of patients with CPVT poses a huge challenge as physical and emotional stressors are common in the operating room. Stressors, such as pain and anxiety, must be carefully controlled to prevent life-threatening tachyarrhythmias. Currently there is a paucity of data on the anesthetic management of patients with CPVT. Herein, we present the anesthetic management that was implemented to ensure a safe perioperative course for a 16-year-old male with a history of CPVT who underwent dental extraction under general anesthesia.

Total Intravenous Anaesthesia for Laparoscopic Cholecystectomy in a Patient With Congenital Long QT Syndrome: A Case Report

Long QT syndrome (LQTS) is characterised by QT interval prolongation and ventricular arrhythmia, leading to sudden cardiac death. Patients with acquired or congenital LQTS pose special challenges to anaesthetists perioperatively due to the risk of developing life-threatening arrhythmia. A variety of medications, including commonly used volatile anaesthetic agents are known to prolong QT interval and there has been growing evidence of using total intravenous anaesthesia (TIVA) instead of volatile agents for such patients.  This is a case report of a 30-year-old patient with congenital LQTS and subcutaneous implantable cardioverter defibrillator (SICD) in situ who underwent laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) under TIVA safely within two months. There were no arrhythmic events observed perioperatively.  This case highlights the importance of comprehensive planning and meticulous preparation to avoid all possible QT-prolonging conditions during the perioperative period, especially in patients with acquired or congenital LQTS.

Anesthetic management for inhibiting sympathetic activation in an adolescent patient diagnosed with catecholaminergic polymorphic ventricular tachycardia and undergoing left cardiac sympathetic denervation: A case report

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder in which catecholamine release during exercise or emotional stress cause fatal tachyarrhythmias. In this paper, we discuss methods to minimize the sympathetic stimulation that can occur during the perioperative period in patients undergoing left cardiac sympathetic denervation to surgically treat CPVT.

Anesthesia in patients with Brugada syndrome: two case reports

BACKGROUND

Brugada syndrome is a rare disease. It causes sudden cardiac arrest, which is a serious life-threatening event. Sudden cardiac death mostly results from coronary artery disease. However, patients with Brugada syndrome show normal cardiac anatomy and no evidence of ischemia or electrolyte imbalance. Anesthesia in patients with Brugada syndrome is challenging due to its unpredictable nature, and is worth our attention.

CASE PRESENTATION

We report two cases of Brugada syndrome during anesthesia. In case one, a 31-year-old Filipino laborer was scheduled for laparoscopic appendectomy. The patient denied any preexisting cardiac disease. The preoperative vital signs were stable, with mild fever of 37.9 °C. The operation was smooth. During the emergence period, the patient suffered from sudden onset of ventricular tachycardia. After resuscitation, the cardiac rhythm returned to normal. Later, he was confirmed to have a genetic trait of Brugada syndrome. In case two, a young Taiwanese patient with pre-diagnosed Brugada syndrome underwent an operation. The perioperative precautions were taken to prevent the occurrence of ventricular arrhythmia. The surgery was uneventful.

CONCLUSIONS

Brugada syndrome, although rare, has the highest incidence in South East Asian healthy young males. It brings attention to possible fatal cardiac arrhythmia in this population. Careful preoperative evaluation and perioperative management can help reduce the harmful outcome of the disease and prevent any untoward events.

Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review

Catheter ablation procedures for arrhythmias or implantation and/or extraction of cardiac pacemakers can present many clinical challenges. It is imperative that there is clear communication and understanding between the anesthesiologist and electrophysiologist during the perioperative period regarding the mode of ventilation, hemodynamic considerations, and various procedural complications. This article provides a comprehensive narrative review of the anesthetic techniques and considerations for catheter ablation procedures, ventilatory modes using techniques such as high-frequency jet ventilation, and strategies such as esophageal deviation and luminal temperature monitoring to decrease the risk of esophageal injury during catheter ablation. Various hemodynamic considerations, such as the intraprocedural triaging of cardiac tamponade and fluid administration during catheter ablation, also are discussed. Finally, this review briefly highlights the early research findings on pulse-field ablation, a new and evolving ablation modality.

Labor Analgesia in Brugada Syndrome and the Importance of Contingency Planning

Brugada syndrome is an autosomal dominant disorder that affects cardiac sodium channels and predisposes patients to an increased risk of sudden cardiac death. Obstetric anesthesia management in patients with Brugada syndrome poses a challenge due to the prevalence of local anesthetic use for labor analgesia or cesarean section. However, central neuraxial techniques and local anesthetics have been used safely in parturients with this syndrome and may be offered to patients during preadmission counseling. We present the case of a primigravida who opted for further labor analgesia via a combined spinal-epidural technique. To our knowledge, this is the first case report of a lidocaine infusion administered via an epidural catheter to a laboring parturient with Brugada syndrome. We further discuss the use of local anesthetics, other medications, and central neuraxial techniques in those with Brugada syndrome to assist anesthesiologists caring for expectant mothers.

Anesthetic Management of a Patient With Catecholaminergic Polymorphic Ventricular Tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited arrhythmogenic disorder induced by adrenergic stress. Electrophysiologically, it is characterized by emotional stress- or exercise-induced bidirectional ventricular tachycardia that may result in cardiac arrest. Minimizing perioperative stress is critical as it can reduce fatal arrhythmias in patients with CPVT. Dexmedetomidine (DEX), a centrally acting sympatholytic anesthetic agent, was used in the successful intravenous (IV) moderate sedation of a 27-year-old female patient with CPVT, a history of cardiac events, and significant dental fear and anxiety scheduled to undergo mandibular left third molar extraction. Oral surgery was successfully performed under DEX-based IV sedation to reduce stress, and no arrhythmias were observed. IV sedation with DEX provided a sympatholytic effect with respiratory and cardiovascular stability in this patient with CPVT who underwent oral surgery.

Elevation of propofol sensitivity of cardiac IKs channel by KCNE1 polymorphism D85N

BACKGROUND AND PURPOSE

The slowly activating delayed rectifier K⁺ channel (I_Ks ), composed of pore-forming KCNQ1 α-subunits and ancillary KCNE1 β-subunits, regulates ventricular repolarization in human heart. Propofol, at clinically used concentrations, modestly inhibits the intact (wild-type) I_Ks channels and is therefore unlikely to appreciably prolong QT interval in ECG during anaesthesia. However, little information is available concerning the inhibitory effect of propofol on I_Ks channel associated with its gene variants implicated in QT prolongation. The KCNE1 single nucleotide polymorphism leading to D85N is associated with drug-induced QT prolongation and therefore regarded as a clinically important genetic variant. This study examined whether KCNE1-D85N affects the sensitivity of I_Ks to inhibition by propofol.

EXPERIMENTAL APPROACH

Whole-cell patch-clamp and immunostaining experiments were conducted in HEK293 cells and/or mouse cardiomyocyte-derived HL-1 cells, transfected with wild-type KCNQ1, wild-type or variant KCNE1 cDNAs.

KEY RESULTS

Propofol inhibited KCNQ1/KCNE1-D85N current more potently than KCNQ1/KCNE1 current in HEK293 cells and HL-1 cells. Immunostaining experiments in HEK293 cells revealed that pretreatment with propofol (10 μM) did not appreciably affect cell membrane expression of KCNQ1 and KCNE1 proteins in KCNQ1/KCNE1 and KCNQ1/KCNE1-D85N channels.

CONCLUSION AND IMPLICATIONS

The KCNE1 polymorphism D85N significantly elevates the sensitivity of I_Ks to inhibition by propofol. This study detects a functionally important role of KCNE1-D85N polymorphism in conferring genetic susceptibility to propofol-induced QT prolongation and further suggests the possibility that the inhibitory action of anaesthetics on ionic currents becomes exaggerated in patients carrying variants in genes encoding ion channels.

Anaesthetic Management of a Patient with Brugada Syndrome in Total Knee Arthroplasty

We report the case of a 52-year-old female diagnosed with Brugada syndrome (BrS) scheduled to undergo right total knee arthroplasty. General anaesthesia was induced and maintained with thiopental intravenous sodium + remifentanil and sevoflurane + remifentanil infusion, respectively. Rocuronium bromide was used as the muscle relaxant. The defibrillator was ready for use with the electrodes on the patient. Sugammadex was used for muscle relaxant antagonization. Postoperative analgesia was provided by intermittent morphine HCL via an epidural catheter, intravenous patient-controlled analgesia (Meperidine), and intravenous tenoxicam. The patient was discharged on the 6th day without any problem. Anaesthetic management of patients with BrS is challenging for anaesthesiologists, because fatal cardiac arrhythmias can be triggered by many drugs commonly used in the perioperative period such as bupivacaine, lidocaine, neostigmine, propofol, succinylcholine, ketamine, and tramadol. In these cases, a detailed preoperative evaluation including family history, avoidance of drugs triggering arrhythmia, taking precautions against arrhythmia, and using the agents that are reported to be safe are essential for patient safety.

Infraclavicular Brachial Plexus Block and Sugammadex Use in a Paediatric Patient with Wolff-Parkinson--White Syndrome

Background

Wolff–Parkinson–White (WPW) syndrome is a rare disease that can cause various patterns of tachyarrhythmias. The main goal of anaesthesiologists for the perioperative anaesthetic management of WPW patients must be to avoid sympathetic stimulation and prevent tachyarrhythmias.

Case

A 9-year-old male patient with a diagnosis of WPW syndrome, who underwent emergency surgery for supracondylar humerus fracture, is presented. General anaesthesia in combination with infraclavicular brachial plexus (ICBP) block was performed successfully without any complications. For the reversal of neuromuscular block, sugammadex was uneventfully used. Intraoperative sympathetic discharge due to surgical intervention was prevented with ICBP block. The ICBP block has also provided good postoperative analgesia.

Conclusions

Sugammadex is a good alternative for the reversal of neuromuscular blocks to avoid the undesirable effects of cholinergic drugs. Peripheral regional blocks that require relatively large doses of local anaesthetics can be safely performed with utmost attention in paediatric WPW patients.

Effect of pretreatment with magnesium sulphate on the duration of intense and deep neuromuscular blockade with rocuronium: A randomised controlled trial

BACKGROUND

Magnesium sulphate is an important adjuvant drug in multimodal anaesthesia. In combination with rocuronium it can enhance neuromuscular blockade (NMB). Limited data exist concerning the effect of magnesium sulphate on the duration of deep or intense NMB and the period of no response.

OBJECTIVE(S)

To determine the role of magnesium sulphate on the duration of rocuronium-induced deep and intense NMB, and the period of no response to nerve stimulation.

DESIGN

A randomised controlled trial.

SETTING

A public tertiary care hospital, Rio de Janeiro, Brazil, from February 2017 to March 2018.

PATIENTS

All patients between 18 and 65 years of age scheduled to undergo elective otorhinolaryngological surgery, with a BMI between 18.5 and 24.9 kg m and an American Society of Anesthesiologists physical status classification of I or II.

INTERVENTION(S)

Before induction of anaesthesia 60 patients were pretreated with an intravenous infusion of either 100 ml 0.9% saline (saline group), or 60 mg kg magnesium sulphate (magnesium group). After loss of consciousness, a bolus of rocuronium (0.6 mg kg) was administered. Neuromuscular function was measured by TOF-Watch SX monitor.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were the duration of the period of no response to nerve stimulation and intense and deep NMB, respectively. An additional outcome was the NMB onset time.

RESULTS

Median [IQR] durations of deep NMB were 20.3 [12.0 to 35.4] and 18.3 [11.2 to 26.3] min in the magnesium and saline groups, respectively (P = 0.18). Median durations of intense NMB were 21.7 [0.0 to 32.2] min and 0.0 [0.0 to 6.2] min (P = 0.001) in the magnesium and saline groups, respectively. Median durations of the period of no response were 40.8 [51.4 to 36.0] min and 28.0 [21.9 to 31.6] min (P = 0.0001) in the magnesium and saline groups, respectively.

CONCLUSION

Magnesium sulphate increased both the duration of intense NMB and the period of no response. The duration of deep NMB was similar in the magnesium sulphate group and saline group.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02989272.

Anesthetic management of a child with catecholaminergic polymorphic ventricular tachycardia undergoing insertion of implantable cardioverter defibrillator : a case report

Background

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a fatal cardiac ion channelopathy that causes sudden unexpected death in the young.

Case presentation

The patient was a 3-year-old girl with CPVT. Insertion of an implantable cardioverter defibrillator (ICD) using epicardial pacing was scheduled. After premedication of rectal midazolam was given, general anesthesia was induced with midazolam, fentanyl, and rocuronium, and maintained with midazolam, fentanyl, remifentanil, and rocuronium. The operation was performed without any complications. Dexmedetomidine and fentanyl were continuously infused after the operation until she was extubated in the morning of postoperative day 1. Fatal arrhythmia due to perioperative stress did not occur.

Conclusions

We report the anesthetic management of a child with CPVT who underwent insertion of an ICD. CPVT-induced fatal arrhythmia did not occur perioperatively by carefully avoiding perioperative stress with premedication and post-operative sedation.

Anaesthetic management of C-section in Brugada syndrome: When less is more

Brugada Syndrome (BrS) is a rare and high risk condition, seldom encountered in the delivery room. Pregnant patients with BrS benefit from the lowest possible doses of arrhythmogenic drugs such as local anesthetics. Based on this premise, the following case report exposes how a subarachnoid approach might be a desirable technique in C-section procedures for BrS patients. Pain and anxiety management are priorities in this specific population. Peri-partum planning, with a previous anesthesiology appointment and mutidisciplinary care in tertiary hospital facilities are crucial to avoid complications.

Brugada Syndrome: anesthetic considerations and management algorithm

Brugada Syndrome is characterized by arrhythmogenic risk that may be exacerbated by different metabolic and pharmacological factors. Since its first description, knowledge of this syndrome and its detection by physicians belonging to different specialties have gradually increased. The risk of arrhythmias is well known to increase in the postoperative period, and this risk is particularly accentuated in patients with Brugada Syndrome. The purpose of this review is to analyze the relationship between this syndrome and anesthesia; establish recommendations for the safe management of these patients in the surgical setting; and update the relevant concepts regarding the safety of drug administration in individuals with Brugada Syndrome.

Perioperative management of patients with pre-excitation syndromes

Patients with pre-excitation abnormalities are at a high risk for life-threatening perioperative arrhythmias. In Wolff-Parkinson-White syndrome, the anaesthetics used for invasive diagnostic testing/ablation, should not affect cardiac electrophysiology; propofol, sevoflurane, fentanyl, sufentanil, alfentanil are suitable. In non-ablative surgery, propofol, sevoflurane, isoflurane, fentanyl, alfentanil, sufentanil have been used safely. Among neuromuscular blockers, cis-atracurium, rocuronium and vecuronium are good choices. Ketamine, pancuronium and pethidine should be avoided because of their sympathomimetic actions. Anticholinergic/ anticholinesterase combinations for neuromuscular block reversal should preferably be omitted, while sugammadex seems more attractive. In regional anaesthesia, addition of epinephrine and high sympathetic blocks should be avoided. Hypotension should be treated with pure alpha-adrenergic agonists. Other pre-excitation abnormalities associated with different accessory pathways are the Mahaim Fiber and Lown-Ganong-Levine syndrome. Sympathetic activation should be avoided. Total intravenous anaesthesia with propofol probably represents the safest option. A careful anaesthetic plan and close cooperation with cardiologists are mandatory for successful management.

Cochlear implantation in children with congenital long QT syndrome: Introduction of an evidence-based pathway of care

Congenital long QT syndrome (cLQTS) is an inherited cardiac ion channelopathy characterized by a long corrected-QT interval on the ECG, associated with a risk of syncope and sudden death as a result of arrhythmias. The archetypal arrhythmia associated with cLQTS is torsade de pointes which may degenerate into ventricular fibrillation. Children with Jervell and Lange-Neilsen syndrome have the combination of cLQTS and congenital sensorineural deafness and may present for cochlear implantation (CI). Sympathetic stimulation and administration of QT-prolonging medications may trigger arrhythmias in children with cLQTS and thus the perioperative period is a time of increased risk of adverse events, with deaths reported in the CI literature. Our Paediatric Cochlear Implant Programme had previously elected to discontinue offering CI to children with cLQTS following a perioperative death. However, subsequent demand for this service by parents led us to develop and introduce a multidisciplinary, evidence-based pathway of care. This pathway modifies the perioperative management of these children to reduce the associated risk. We present the cases of four children with cLQTS who underwent CI in our specialist children's hospital.

Peripartum anaesthetic management of a patient with Brugada syndrome and myoadenylate deaminase deficiency

Brugada syndrome is a rare electrophysiological cardiac disease which can result in serious arrhythmias and sudden cardiac death. Peripartum management is centred around avoiding arrhythmogenic drugs, including high doses of sodium channel blocking drugs such as bupivacaine. Myoadenylate deaminase deficiency, also known as adenosine monophosphate deaminase deficiency, is the commonest cause of myopathy in Caucasians. There is evidence that myoadenylate deaminase deficiency can predispose patients to developing malignant hyperthermia when exposed to specific anaesthetic agents. We present a case of a pregnant patient with both Brugada syndrome and myoadenylate deaminase deficiency, in which analgesic and general anaesthetic options for each condition presented potentially conflicting dilemmas for the delivery of intrapartum care.

Magnesium sulfate in pediatric anesthesia: the Super Adjuvant

Magnesium is an essential chemical element in all organisms, intervening in most cellular enzymatic reactions; thus, its importance in homeostasis and as a therapeutic tool in highly challenging patients such as pediatrics. The primary purpose of this paper was to review the role of magnesium sulfate as an adjuvant drug in pediatric anesthesia. This compound already has the scientific backing in certain aspects such as analgesia or muscle relaxation, but only theoretical or empirical backing in others such as organ protection or inflammation, where it seems to be promising. The multitude of potential applications in pediatric anesthesia, its high safety, and low cost make magnesium sulfate could be considered a Super Adjuvant.

Intraoperative management of critical arrhythmia

The incidence of intraoperative arrhythmia is extremely high, and some arrhythmias require clinical attention. Therefore, it is essential for the anesthesiologist to evaluate risk factors for arrhythmia and understand their etiology, electrophysiology, diagnosis, and treatment. Anesthetic agents reportedly affect normal cardiac electrical activity. In the normal cardiac cycle, the sinoatrial node initiates cardiac electrical activity through intrinsic autonomous pacemaker activity. Sequential atrial and ventricular contractions result in an effective cardiac pumping mechanism. Arrhythmia occurs due to various causes, and the cardiac pumping mechanism may be affected. A severe case may result in hemodynamic instability. In this situation, the anesthesiologist should eliminate the possible causes of arrhythmia and manage the condition, creating hemodynamic stability under proper electrocardiographic monitoring.

Anaesthesia for patients with arrhythmogenic right ventricular dysplasia

Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited heart muscle disease. Myocyte apoptosis and fibro-fatty scar tissue predisposes patients to malignant ventricular arrhythmias. Patients may present to variety of surgical procedures with diagnosed ARVD. Surgical insult, catecholamine surge and physiological disturbance can be hazardous on the vulnerable myocardium and may result in life-threatening ventricular tachycardia or sudden cardiac death in the perioperative period. Anaesthetists have particular role in perioperative management of this patient population, meticulous perioperative planning, close haemodynamic monitoring and maintenance of physiological stability throughout helps to avoid devastating perioperative loss.

Sudden Cardiac Arrest in Pediatrics

Sudden cardiac arrest (SCA) in the pediatric population is a rare and potentially devastating occurrence. An understanding of the differential diagnosis for the etiology of the cardiac arrest allows for the most effective emergency care and provides the patient with the best possible outcome. Pediatric SCA can occur with or without prodromal symptoms and may occur during exercise or rest. The most common cause is arrhythmia secondary to an underlying channelopathy, cardiomyopathy, or myocarditis. After stabilization, evaluation should include electrocardiogram, chest radiograph, and echocardiogram. Management should focus on decreasing the potential for recurring arrhythmia, maintaining cardiac preload, and thoughtful medication use to prevent exacerbation of the underlying condition. The purpose of this review was to provide the emergency physician with a concise and current review of the incidence, differential diagnosis, and management of pediatric patients presenting with SCA.

Synergistic restoring effects of isoproterenol and magnesium on KCNQ1-inhibited bradycardia cell models cultured in microelectrode array

OBJECTIVES

Bradycardia is caused by loss-of-function mutations in potassium channels that regulate phase 3 repolarization of the cardiac action potential. The purpose of this study is to monitor the effects of potassium channel (KCNQ1) inhibition and to evaluate the effects of isoproterenol (ISO) and MgSO4 in restoring sinus rhythm in atrial cells.

METHODS

Microelectrode array was used to analyze conduction velocity, voltage amplitude and cycle length of atrial cells (HL-1). A combination of ISO and MgSO4 was used to restore sinus rhythm in these cells.

RESULTS

mRNA expression levels of KCNQ1 (42.2 vs. 100%, p < 0.0001), connexin 43 (29.6 vs. 100%, p = 0.0033), atrial natriuretic peptide (31.0 vs. 100%, p = 0.0030), cardiac actin (38.2 vs. 100%, p < 0.0001) and α-myosin heavy chain (31.2 vs. 100%, p = 0.00254) were significantly lower in the KCNQ1 gene-inhibited group compared to the control group. When treated with MgSO4 (1 mM) and ISO (10 μM), conduction velocity (0.0208 ± 0.0036 vs. 0.0086 ± 0.0014 m/s, p = 0.0004) and voltage amplitude (1,210.78 ± 65.81 vs. 124.1 ± 13.30 μV, p < 0.0001) were higher, and cycle length (431.55 ± 2.05 vs. 1,015.15 ± 4.31 ms, p < 0.0001) was shorter than in the gene-inhibited group.

CONCLUSION

Inhibition of sinus rhythm in the bradycardia cell model was recovered by treatment with ISO and MgSO4, demonstrating the potency of combination therapy in the treatment of bradycardia.

Torsade de pointes in liver transplantation recipient after induction of general anesthesia: a case report

Torsade de pointes (TdP) is an uncommon and specific form of polymorphic ventricular tachycardia, associated with a prolonged QT interval. Prolongation of the QT interval is the most widely recognized electrophysiological abnormality in patients with liver cirrhosis. We observed a case of TdP leading to cardiopulmonary resuscitation after the induction of general anesthesia, in a patient with liver cirrhosis scheduled for emergency cadaveric donor liver transplantation. The patient had mild QT prolongation on preoperative electrocardiography with a corrected QT (QTc) interval of 455 ms. Drugs used in the preoperative period can elongate cardiac repolarization. Sevoflurane and 5-hydroxytryptamine type 3 receptor antagonists such as palonsetron, used during general anesthesia may have triggered further QT prolongation, producing a fatal condition such as TdP. More caution and consideration in selecting drugs for anesthetic management are necessary for liver cirrhosis patients, especially in patients with preoperative QT prolongation.

A novel anaesthetical approach to patients with brugada syndrome in neurosurgery

Brugada syndrome (BrS) is one of the most common causes of sudden death in young people. It usually presents with life-threatening arrhythmias in subjects without remarkable medical history. The need for surgical treatment may unmask BrS in otherwise asymptomatic patients. The best anaesthesiological treatment in such cases is matter of debate. We report a case of neurosurgical treatment of cerebello pontine angle (CPA) tumor in a BrS patient, performed under total intravenous anesthesia (TIVA) with target controlled infusion (TCI) modalities, using midazolam plus remifentanil and rocuronium, without recordings of intraoperative ECG alterations in the intraoperative period and postoperative complications.

Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management

Long QT syndrome incidence is increasing in general population. A careful pre-, peri- and post-operative management is needed for patients with this syndrome because of the risk of Torsades de Pointes and malignant arrhythmias. The available data regarding prevention of lethal Torsades de Pointes during anesthesia in patients with long QT syndrome is scant and conflicting: only case reports and small case series with different outcomes have been published. Actually, there are no definitive guidelines on pre-, peri- and post-operative anesthetic management of congenital long QT syndrome. Our review focuses on anesthetic recommendations for patients diagnosed with congenital long QT syndrome furnishing some key points for preoperative optimization, intraoperative anesthetic agents and postoperative care plan, which could be the best for patients with c-long QT syndrome who undergo surgery.