Management of untreatable ventricular arrhythmias during pharmacologic challenges with sodium channel blockers for suspected Brugada syndrome.

Stefano Poli, Mauro Toniolo, Massimo Maiani, Davide Zanuttini, Luca Rebellato, Igor Vendramin, Ermanno Dametto, Guglielmo Bernardi, Flavio Bassi, Carlo Napolitano, Ugolino Livi, Alessandro Proclemer

Journal: Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2018;20(2):234-242

PMID: 28521022

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Abstract

Pharmacologic challenge with sodium channel blockers is part of the diagnostic workout in patients with suspected Brugada syndrome. The test is overall considered safe but both ajmaline and flecainide detain well known pro-arrhythmic properties. Moreover, the treatment of patients with life-threatening arrhythmias during these diagnostic procedures is not well defined. Current consensus guidelines suggest to adopt cautious protocols interrupting the sodium channel blockers as soon as any ECG alteration appears. Nevertheless, the risk of life-threatening arrhythmias persists, even adopting a safe and cautious protocol and in absence of major arrhythmic risk factors. The authors revise the main published case studies of sodium channel blockers challenge in adults and in children, and summarize three cases of untreatable ventricular arrhythmias discussing their management. In particular, the role of advanced cardiopulmonary resuscitation with extra-corporeal membrane oxygenation is stressed as it can reveal to be the only reliable lifesaving facility in prolonged cardiac arrest.

Address: Cardiothoracic Department, University Hospital of Udine, P.le Santa Maria della Misericordia, 15, 33100, Udine, Italy.; Department of Medical, Surgical and Health Care Sciences, Postgraduate School in Cardiovascular Medicine, University of Trieste, Strada di Fiume, 447 34149 Trieste, Italy.; Cardiology Department, "Azienda per i Servizi Sanitari n°5", Via Montereale, 24 33170 Pordenone, Italy.; Emergency and Intensive Care Department, "Azienda per i Servizi Sanitari n°5", Pordenone, Via Montereale, 24 33170 Pordenone, Italy.; Molecular Cardiology, IRCCS Fondazione Maugeri, Via S. Maugeri, 10 27100 Pavia, Italy.

DOI: 10.1093/europace/eux092

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MeSH Terms: Action Potentials, Adolescent, Adult, Aged, Aged, 80 and over, Ajmaline, Brugada Syndrome, Cardiopulmonary Resuscitation, Child, Electrocardiography, Extracorporeal Membrane Oxygenation, Female, Flecainide, Heart Arrest, Heart Conduction System, Heart Rate, Humans, Male, Middle Aged, Predictive Value of Tests, Risk Factors, Sodium Channel Blockers, Tachycardia, Ventricular, Treatment Outcome, Ventricular Fibrillation, Young Adult