Brugada syndrome: safe epidural anaesthesia for labour and subsequent emergency caesarean delivery

Editor, We read with great interest the article by Borrell-Vega et al., ‘Eighteen-year analysis of anaesthetic management in Brugada syndrome: the BRUGANAES study’, recently published in this journal.1 In this case series of 189 anaesthetic procedures in 111 patients, malignant ventricular arrhythmias occurred intraoperatively in only two patients (1%). Notably, no anaesthetic-related complications were reported with regional or neuraxial techniques, providing reassuring data in a population traditionally considered at risk. We would like to report an obstetric case that complements these findings. A 21-year-old primiparous woman was referred for antenatal anaesthetic assessment after the diagnosis of asymptomatic Brugada syndrome. The diagnosis was established following a positive ajmaline challenge test, performed because of a significant family history: the patient's mother had symptomatic Brugada syndrome with recurrent syncope and an implanted cardioverter-defibrillator. The patient herself had no history of syncope, presyncope or palpitations and had previously undergone several general anaesthetics without perioperative complications. Genetic testing revealed a variant of uncertain significance in the SCN5A gene. Baseline electrocardiography showed sinus rhythm with incomplete right bundle branch block and no spontaneous type 1 Brugada pattern. Cardiac imaging was unremarkable. After multidisciplinary discussion involving anaesthesiology, cardiology and obstetrics, and informed by the data published by Borrell-Vega et al., another obstetric case series in Brugada patients,2 and recommendations from the brugadadrugs.org website,3 an anaesthetic management strategy was agreed upon with senior cardiologist standby and immediate availability of an isoprenaline administration protocol. Labour analgesia was provided using epidural anaesthesia with programmed intermittent epidural boluses (8 ml every 60 min) combined with patient-controlled epidural analgesia (6 ml, lockout 20 min). The epidural solution consisted of ropivacaine 0.12% with sufentanil 0.31 μg ml−1. Continuous ECG and standard haemodynamic monitoring were applied, with active maintenance of normothermia. No arrhythmic events or conduction abnormalities were observed. An urgent caesarean delivery was subsequently indicated because of foetal heart rate abnormalities. Epidural anaesthesia was induced with 15 ml lidocaine 2% with epinephrine. Surgery proceeded uneventfully, without haemodynamic instability or electrocardiographic changes. At the end of the procedure, subcutaneous wound infiltration was performed using 20 ml ropivacaine 0.375%. Postoperative monitoring revealed no cardiac complications. Maternal and neonatal outcomes were favourable. Although local anaesthetics have historically been considered potentially arrythmogenic in Brugada syndrome because of their sodium channel blocking properties, increasing clinical experience suggests that neuraxial anaesthesia using contemporary local anaesthetics may be safe when administered under strict monitoring. This case provides specific obstetric data for Brugada patients and adds further evidence for an individualised, anticipating multidisciplinary approach rather than systematic avoidance of regional anaesthetic techniques.