Management of Seizures After Mitral Repair and Maze Procedure
For patients who experience seizures after cardiac surgery (mitral repair and maze procedure), initiate levetiracetam as first-line antiseizure medication and continue treatment for a minimum of 1-2 years given the established epilepsy from the seizure event. 1
Immediate Post-Operative Management
If Seizure Has Already Occurred
- Start antiseizure medication immediately as the patient now has established epilepsy requiring secondary prophylaxis, not primary prophylaxis 1
- Levetiracetam is the preferred first-line agent due to superior tolerability, minimal drug interactions, and favorable side effect profile compared to older antiepileptic drugs 2, 3
- Avoid phenytoin, which is associated with excess morbidity and mortality in post-surgical patients 2
Dosing and Monitoring
- Continue current levetiracetam dosing without interruption in the immediate post-operative period 1
- Assess seizure control at each follow-up visit 1
- Consider serum levetiracetam levels if breakthrough seizures occur to assess compliance and therapeutic adequacy 1
Duration of Treatment
Do not discontinue antiseizure medication prematurely - this is a critical pitfall that increases seizure recurrence risk 1
Minimum Treatment Duration
- Continue levetiracetam for at least 1-2 years seizure-free on medication before considering tapering 1
- This extended duration is necessary because the patient has experienced actual seizures (secondary prophylaxis), not just prophylactic coverage 1
Criteria Before Considering Tapering
- Minimum 1-2 years completely seizure-free on medication 1
- No evidence of recurrent structural abnormality on imaging 1
- Shared decision-making with patient regarding recurrence risk versus medication burden 1
Why Levetiracetam Over Other Options
Advantages Over Phenytoin
- Phenytoin should be avoided - it is associated with excess morbidity, mortality, and poorer cognitive outcomes in post-surgical patients 2
- Levetiracetam has significantly fewer adverse effects (8% vs 21% in comparator groups) 4
- In cardiac surgery neonates, phenobarbital caused hypotension in 7 of 8 adverse events, while levetiracetam had zero adverse events 5
Non-Enzyme-Inducing Properties
- Levetiracetam is a non-enzyme-inducing antiepileptic drug, avoiding drug interactions with other cardiac medications 2
- This is particularly important given the complex medication regimens typical after cardiac surgery 2
Common Pitfalls to Avoid
Do Not Use Prophylactic Guidelines
- This patient has HAD seizures - prophylactic guidelines (which recommend against routine antiseizure medication) do not apply 2, 1
- Prophylactic antiseizure medication is not effective for patients who have never seized, but this patient requires treatment for established epilepsy 2
Do Not Stop Medication at 7 Days
- The 7-day perioperative recommendation applies only to prophylaxis in patients who have NOT seized 2
- For patients with actual seizures, treatment must continue for 1-2 years minimum 1
Do Not Use Valproic Acid
- While valproic acid is non-enzyme-inducing, it carries risks of thrombocytopenia and hepatotoxicity requiring regular monitoring 2, 6
- Levetiracetam is generally better tolerated with lower risk of hematologic toxicities 6
Efficacy Expectations
- Levetiracetam achieves seizure cessation in approximately 55-58% of post-cardiac surgery patients when used as first-line therapy 5
- Combined cessation rates when used as first- or second-line therapy approach 47-58% 5
- These rates are comparable to phenobarbital but with significantly better safety profile 5