Brugada syndrome is an inherited disease characterized by right bundle branch block and ST-segment elevation in the right precordial leads of the electrocardiogram (ECG) caused by ion channel disorders of the cardiac conduction system [1, 2]. In such patients, exacerbation of ST-segment elevation due to the heterogeneity of repolarization between the epicardium and endocardium in the right ventricular outflow tract increases the risk of ventricular tachycardia/fibrillation (VT/VF), potentially leading to sudden cardiac death [3, 4]. In some cases, the ST-segment elevation increases just prior to the onset of polymorphic VT/VF [5].

In the perioperative periods, certain drugs and conditions have been identified as triggering worsened ST-segment elevation and critical arrhythmias in Brugada syndrome patients, most notably ketamine, local anesthetics, hyperthermia, and electrolyte anomalies [6]. Sevoflurane and propofol are widely used general anesthetics in current anesthetic practice, but their use with caution in patients with Brugada syndrome is still recommended [6]. On the other hand, some studies revealed that induction with propofol bolus and volatile-based anesthesia caused reduction or no exacerbation of ST-segment elevation without VT/VF [7,8,9]. Although there may exist safe methods of anesthetic management in patients with Brugada syndrome that attenuate ST-segment elevation, to our knowledge there are no reports of ST-segment morphology throughout general anesthesia for major surgery in such patients. We report a case of sustained mitigation of ST-segment elevation during anesthesia with only sevoflurane and remifentanil in a patient with Brugada syndrome. Written informed consent was obtained from the patient for the publication of this case report. This manuscript adheres to the applicable EQUATOR guidelines.

A 63-year-old man [height 162 cm; weight 53 kg] presented to his family doctor with persistent cough and dyspnea. Chest computed tomography showed multiple pleural masses and left pleural effusion, for which a chest drain was inserted. He was scheduled for a pleural biopsy using video-assisted thoracoscopic surgery (VATS) under general anesthesia to establish the definitive diagnosis of malignant pleural mesothelioma. His preoperative electrocardiogram (ECG) showed coved-type ST-segment elevation and J-wave amplitude > 0.2 mV in the right chest leads (Fig. 1). He was diagnosed with a spontaneous Brugada type 1 pattern by our cardiologist, according to the latest modified Brugada syndrome criteria [10]. There had been no events in his family history. A prophylactic implantable cardioverter-defibrillator was not applied because he had experienced no symptoms of Brugada syndrome. Preoperative transthoracic echocardiography did not reveal any abnormal findings.

Preoperative 12-lead electrocardiogram showing coved-type ST-segment elevation and J waves amplitude > 0.2 mV in the right chest leads

We planned anesthesia with only sevoflurane and remifentanil, and postoperative intravenous patient-controlled analgesia (IV-PCA) with fentanyl to avoid local anesthetic-induced critical arrhythmias with regional anesthesia. Adhesive defibrillator pads were applied to the chest before induction of anesthesia. We used a 5-lead ECG including the right precordial leads positioned at V2 or V3 and continuously recorded ECG throughout the entire procedure. ST-segment elevation was analyzed at the J-point (J-point segment) and 60 ms from the J-point (ST-segment) in lead V2. Forced-air warming was applied to strictly control the body temperature between 36.5 and 36.8 °C during surgery because postoperative shivering can lead to fever-triggered ventricular arrhythmias. Isoproterenol was prepared for the occurrence of malignant arrhythmias.

ECG immediately before induction showed coved type J-point and ST-segment elevation of 0.40 mV and 0.28 mV, respectively in V2 leads (Fig. 2A (1)). After a right radial arterial cannula was inserted, the patient underwent 5% sevoflurane inhalational induction with continuous intravenous infusion of remifentanil at 0.2 µg/kg/min. A tracheal intubation was performed with a double-lumen endotracheal tube after rocuronium 40 mg. Anesthesia was maintained with 1.0–2.0% sevoflurane, remifentanil at 0.05–0.30 µg/kg/min, and rocuronium at 10–20 mg/h. After position adjustment of the tube using fiberoptic bronchoscopy, we found a significant reduction in J-point and ST-segment elevation of 0.35 mV and 0.26 mV (Fig. 2A (2)), which was not affected by the postural change from supine to right lateral decubitus position (Fig. 2A (3)). VATS biopsy samples were taken from the parietal pleura. J-point and ST-segment elevations of 0.18–0.28 mV and 0.12–0.15 mV remained low during surgery (Fig. 2A (4, 5)). The surgery was completed without ventricular arrhythmia. After sevoflurane was discontinued and neuromuscular blockade was reversed with sugammadex, the trachea was extubated. During emergence from anesthesia, ECG changed with a gradual increase in J-point and ST-segment elevation, subsequently returning to the initial coved-type ST elevation (Fig. 2A (6, 7)). The patient showed no postoperative shivering or electrolyte anomalies.

A Sequential electrocardiogram in lead V2 during anesthesia (red circle, J-point; blue circle, ST-segment). (1) Before induction of anesthesia. (2) After position adjustment of a double-lumen endotracheal tube. (3) After the postural change from supine to right lateral decubitus position. (4) After resection of the pleural mass. (5) At the end of surgery. (6) At eye-opening upon emergence from anesthesia. (7) Immediately before transfer to the high care unit. B Changes in the value of ST-segment (J-point) amplitudes in lead V2 in the operating room. C Anesthesia record for this case. BP, blood pressure; HR, heart rate

The patient stayed in the high-care unit without any complications including critical arrhythmia. He was transferred to a general ward on the third postoperative day.