Favorable Safety Experience of Local Dental Anesthesia in ICD Recipients with Cardiac Channelopathies

Abstract Background Dental anesthetic management in implantable cardioverter defibrillator (ICD) recipients with cardiac channelopathies (CCh) can be challenging due to the potential risk of life-threatening arrhythmias and appropriate ICD therapies during procedural time. Objectives The present study assessed the hypothesis that the use of local dental anesthesia with 2% lidocaine with 1:100,000 epinephrine or without a vasoconstrictor can be safe in selected ICD and CCh patients, not resulting in life-threatening events (LTE). Methods Restorative dental treatment under local dental anesthesia was made in two sessions, with a wash-out period of 7 days (cross-over trial), conducting with a 28h - Holter monitoring, and 12-lead electrocardiography, digital sphygmomanometry, and anxiety scale assessments in 3 time periods. Statistical analysis carried out the paired Student's t test and the Wilcoxon signed-rank test. In all cases, a significance level of 5% was adopted. All patients were in stable condition with no recent events before dental care. Results Twenty-four consecutive procedures were performed in 12 patients (9 women, 3 men) with CCh and ICD: 7 (58.3%) had long QT syndrome (LQTS), 4 (33.3%) Brugada syndrome (BrS), and 1 (8.3%) Catecholaminergic polymorphic ventricular tachycardia (CPVT). Holter analysis showed no increased heart rate (HR) or sustained arrhythmias. Blood pressure (BP), electrocardiographic changes and anxiety measurement showed no statistically significant differences. No LTE occurred during dental treatment, regardless of the type of anesthesia. Conclusion Lidocaine administration, with or without epinephrine, can be safely used in selected CCh-ICD patients without LTE. These preliminary findings need to be confirmed in a larger population with ICD and CCh.

Is It Safe for Patients With Cardiac Channelopathies to Undergo Routine Dental Care? Experience From a Single-Center Study.

Background Brugada syndrome and long-QT syndrome may account for at least one third of unexplained sudden cardiac deaths. Dental care in patients with cardiac channelopathies is challenging because of the potential risk of life-threatening events. We hypothesized that the use of local dental anesthesia with lidocaine with and without epinephrine is safe and does not result in life-threatening arrhythmias in patients with channelopathies. Methods and Results We performed a randomized, double-blind pilot trial comparing the use of 2% lidocaine without a vasoconstrictor and with 1:100 000 epinephrine in 2 sessions of restorative dental treatment with a washout period of 7 days (crossover trial). Twenty-eight-hour Holter monitoring was performed, and 12-lead electrocardiography, digital sphygmomanometry, and anxiety scale assessments were also conducted at 3 time points. Fifty-six dental procedures were performed in 28 patients (18 women, 10 men) with cardiac channelopathies: 16 (57.1%) had long-QT syndrome, and 12 (42.9%) had Brugada syndrome; 11 (39.3%) of patients had an implantable defibrillator. The mean age was 45.9±15.9 years. The maximum heart rate increased after the use of epinephrine during the anesthesia period from 82.1 to 85.8 beats per minute (P=0.008). In patients with long-QT syndrome, the median corrected QT was higher, from 450.1 to 465.4 ms (P=0.009) at the end of anesthesia in patients in whom epinephrine was used. The other measurements showed no statistically significant differences. No life-threatening arrhythmias occurred during dental treatment. Conclusions The use of local dental anesthesia with lidocaine, regardless of the use of a vasoconstrictor, did not result in life-threatening arrhythmias and appears to be safe in stable patients with cardiac channelopathies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03182777.

Holter monitoring in Chagas' heart disease

Electrocardiographic rythm disturbance evaluation by Holter monitoring is increasingly becoming a useful methodologic tool for risk stratification as well as for therapeutic assessment in patients with Chagas' disease. Furthermore, late potential analyses, now being directly obtained from Holter recording has promising perspectives in enhancing identification of patients with high risk profiles for development of malignant ventricular arrhythmias. In addition, recently incorporated to Holter studies, heart rate variability analysis will certainly contribute to a better understanding of the characteristic autonomic nervous system disarray that commonly affects chagasic patients.

O eletrocardiograma de longa duraçäo (Holter) na doença de Chagas / Holter monitoring in Chagas'disease

A utiliazaçäo do método de Holter na doença de Chagas tem permitido melhor conhecimento das suas anormalidades elétricas e do comportamento das alteraçöes eletrocardiográficas transitórias, colaborando no estabelecimento do grau de risco e no controle de procedimentos terapêuticos. a introduçäo de nvoas tecnologias ao método, como a análise da variabilidade da frequência cardíaca com possibilidade de avaliar a atividade autonômica sobre o nó sinusal, poderá permitir avaliaçäo näo-invasiva desse aspecto täoimportante da doença. A possibilidade da aquisiçäo do eletrocardiograma de alta resoluçäo a partir de gravaçöes de Holter poderá ampliar a avaliaçào do risco desses pacientes.

Arritmias cardíacas na hipertrofia ventricular

A hipertrofia ventricular esquerda é um fator de risco independente bem documentado para eventos cardiovasculares, como o infarto do miocárdio e a morte súbita. Esse fato tem gerado vários estudos que correlacionam as arritmias cardíacas, principalmente ventriculares, com a hipertrofia ventricular esquerda quanto aos aspectos epidemiológicos, seus mecanismos, avaliaçäo e tratamento. A prevalência das arritmias ventriculares varia de acordo com o subgrupo de pacientes estudados, sendo que formas "complexas" podem ser encontradas em 36 por cento a 75 por cento dos doentes e a frequência e a complexidade säo progressivamente maiores quanto maior a massa ventricular esquerda. Os mecanismos ainda näo estäo completamente esclarecidos e parecem ser múltiplos, nos quais se incluem os fatores estruturais miocárdicos que interagiriam com perturbaçöes funcionais. Entre essas últimas enfatiza-se o papel da isquemia transitória (assintomática em 93 por cento dos casos de uma série) e a hipopotassemia induzida por diuréticos. O eletrocardiograma de longa duraçäo (Holter) é o exame de eleiçäo para o diagnóstico das arritmias cardíacas assim como para o controle do tratamento antiarrítmico; está indicado em especial quando há sinais eletrocardiográficos ou ecocardiográficos de hipertrofia ventricular esquerda moderada ou importante. O Tratamento deve ser dirigido basicamente para a prevençäo ou reduçäo precoce da hipertrofia ventricular esquerda, näo se recomendando o uso de diuréticos e preferindo-se os betabloqueadores de cálcio, que também säo eventualmente antiarrítmicos. Quando outros medicamentos estäo indicados o uso deve ser cauteloso pelo risoco de efieot pró-arrítmicos; as drogas de classe I deve ser evitadas e preferidas às de classe III. Casos selecionados podem se beneficiar de cardioversor-desfibrilador implantável ou de ablaçäo por cateter. O assunto, como um todo, ainda necessita mais pesquisas.