Could Brugada Syndrome Be Treated With Percutaneous Coronary Intervention?
論文ID: CJ-23-0685
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論文ID: CJ-23-0685
To the Editor:
Further to the guideline of Takase et al,1 here are 3 snippets about ventricular fibrillation (VF) and the right coronary artery (RCA). First, F. Mason Sones Jr. accidentally injected contrast down this artery in a man who went into asystole, but not VF, in 1958. Twenty-nine years prior, Werner Forssmann inserted a catheter to his right atrium from his left arm. This inspired Sones Jr., who published his thousand-patient series in 1966, but described no VF despite a 1.1% rate.
Second, VF is frequent with the RCA when contrast is injected down a wedged catheter (Figure). This man had an RCA lesion (Figure A) stented (Figure B) with a guide extension that inadvertently deep-seated following guidewire withdrawal. Contrast was transmitted down the conus as myocardial dye blushing, Thebesian venous filling and coronary sinus clearance (Figure C). The electrocardiogram (Figure D) shows progressive QTc prolongation with a rising J point, mimicking a Brugada pattern (as indicated [arrow] in V2). An R-on-T premature ventricular ectopy leads to VF and the patient was cardioverted without sequelae. The association between conus-induced right ventricular outflow tract (RVOT) ischemia, Brugada pattern and VF is fascinating. RVOT and right ventricular (RV) ablation as demonstrated by Koonlawee Nademanee in Bangkok in 2011 could “cure” Brugada syndrome.2 Speculatively, percutaneous conus and RV acute marginal branch embolization with microbeads could be an alternative technique.
Brugada pattern mimicry and right coronary artery (RCA) conus. (A) Conus (top arrow) and the mid RCA lesion (bottom arrow) just beyond the acute marginal branch. (B) Contrast injected unintentionally down the pressure-damped guideliner in the RCA following stenting and removal of guidewire for post-procedural coronary angiogram. (C) Selective dye injection down the conus, with Thebesian venous filling spilling into the coronary sinus (top arrow) and transient tissue staining (bottom arrow). Note the relative lack of myocardial blush in distal RCA territories thus excluding potentially more generalized cardiac hypoxia. (D) Contrast-related conus ischemia leading to Brugadoid ECG changes decaying into VF.
Third, women are less prone to VF with coronary angiography and during myocardial infarction.3 Sudden cardiac death from Brugada syndrome predominantly occurs in men (9 : 1 in men vs. women). It remains a mystery why women’s hearts are more electrically resilient; and this sex difference is inverse in Takotsubo syndrome. Women outlive men by an average of 5–10 years. Syllogistically, when it comes to cardiac stress, “a man’s heart stops, while a woman’s heart breaks”.
