Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2020.04.012
Brazilian Journal of Anesthesiology
Case Report

Anesthetic management in a patient with arrhythmogenic right ventricular cardiomyopathy and an implantable cardioverter defibrillator: a case report

Anestesia para paciente com cardiomiopatia arritmogênica do ventrículo direito portador de cardioversor desfibrilador implantável: descrição de caso

Yoko Ohyama, Hiroshi Hoshijima, Jun Shimada

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Abstract

Background and objectives
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by potentially lethal ventricular tachycardia. Here we describe a patient with ARVC and an Implantable Cardioverter Defibrillator (ICD) in whom maxillary sinus surgery was performed under general anesthesia.

Case report
The patient was a 59 year-old man who was scheduled to undergo maxillary sinus surgery under general anesthesia. He had been diagnosed as having ARVC 15 years earlier and had undergone implantation of an ICD in the same year. Electrocardiography showed an epsilon wave in leads II, aVR, and V1–V3. Cardiac function was within normal range on transthoracic echocardiography. The ICD was temporarily deactivated after the patient arrived in the operating room and an intravenous line was secured. An external defibrillator was kept on hand for immediate defibrillation if any electrocardiographic abnormality was detected. Remifentanil 0.3 μg/kg/min, fentanyl 0.1 mg, propofol 154 mg, and rocuronium 46 mg were administered for induction of anesthesia. Tracheal intubation was performed orally. Anesthesia was maintained oxygen 1.0 L.min−1, air 2.0 L.min−1, propofol 5.0–7.0 mg.kg−1.h−1, and remifentanil 0.1–0.25 μg.kg−1.min−1. The surgery was completed as scheduled and the ICD was reactivated. The patient was then extubated after administration of sugammadex 200 mg.

Conclusion
We report the successful management of anesthesia without lethal arrhythmia in a patient with ARVC and an ICD. An adequate amount of analgesia should be administered during general anesthesia to maintain adequate anesthetic depth and to avoid stress and pain.

Keywords

Arrhythmogenic right ventricular cardiomyopathy;  Ventricular tachycardia;  Implantable cardioverter defibrillator

Resumo

Introdução e objetivo
A Cardiomiopatia Arritmogênica do Ventrículo Direito (CAVD) é uma cardiomiopatia genética caracterizada por taquicardia ventricular potencialmente letal. Descrevemos um paciente com CAVD com Cardioversor Desfibrilador Implantável (CDI) submetido a anestesia geral para cirurgia de seio maxilar.

Relato do caso
Paciente masculino, 59 anos, a ser submetido a anestesia geral para cirurgia de seio maxilar. O paciente foi diagnosticado com CAVD há 15 anos, momento em que foi submetido a implante de CDI. A eletrocardiografia mostrou onda épsilon nas derivações II, aVR e V1–V3. O ecocardiograma transtorácico revelou função cardíaca normal. Após a entrada do paciente na sala de cirurgia, o CDI foi temporariamente desativado e uma via intravenosa foi instalada. Um desfibrilador externo foi mantido próximo ao paciente caso fosse detectada alguma anormalidade eletrocardiográfica que indicasse desfibrilação do paciente. Foram administrados 0,3 mg/kg/min de remifentanil, 0,1 mg de fentanil, 154 mg de propofol e 46 mg de rocurônio para indução da anestesia. A intubação traqueal foi realizada por via oral. A anestesia foi mantida com 1 L/min de oxigênio, 2 L/min de ar, 5–7 mg/kg/h de propofol e 0,1–0,25 μg/kg/min de remifentanil. O procedimento cirúrgico proposto foi concluído e o CDI foi reativado. O tubo traqueal foi retirado após administração de 200 mg de sugamadex.

Conclusão
Descrevemos técnica de anestesia bem sucedida sem arritmia letal em paciente com CAVD e CDI. Analgesia adequada deve ser administrada durante a anestesia geral para manter profundidade anestésica correta e evitar estresse e dor.

Palavras-chave

Cardiomiopatia arritmogênica do ventrículo direito;  Taquicardia ventricular;  Cardioversor desfibrilador implantável

References

1. Corrado D, Link MS, Calkins H. Arrhythmogenic right ventricular cardiomyopathy. N Engl J Med. 2017;376:1489-90.

2. Marcus FI, Zareba W, Calkins H, et al. Arrhythmogenic right ventricular cardiomyopathy/dysplasia clinical presentation and diagnostic evaluation: results from the North American Multidisciplinary Study. Heart Rhythm. 2009;6:984-92.

3. Gupta R, Tichnell C, Murray B, et al. Comparison of features of fatal versus nonfatal cardiac arrest in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy. Am J Cardiol. 2017;120:111-7.

4. Mu J, Zhang G, Xue D, et al. Sudden cardiac death owing to arrhythmogenic right ventricular cardiomyopathy: two case reports and systematic literature review. Medicine (Baltimore). 2017;96:e8808.

5. Essandoh MK, Mark GE, Aasbo JD, et al. Anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: perspectives from the clinical experience of a U.S. panel of physicians. Pacing Clin Electrophysiol. 2018;41:807-16.

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