Search

History: A 17-year-old female student presented in our emergency room after a seizure with motoric fits and enuresis. It was the second event of this kind within 3 weeks., Investigations: The resting ECG on admission showed sinus bradycardia at 45 bpm and a remarkable repolarisation with notched or bifurcated T waves in several leads. Further clinical investigations were unremarkable., Treatment and Course: As an arrhythmogenic syncope (bradycardia or tachycardia related) was presumed, beta-blocker therapy was initiated and an implantable loop recorder (ILR) was inserted. Approximately one year after the index event, the student was brought to the emergency room by ambulance after another seizure. Interrogation of the ILR revealed torsade de pointes tachycardia with spontaneous termination after 1 min and 24 s. A dual-chamber ICD for secondary prophylaxis of sudden cardiac death was therefore implanted and the dose of beta-blocker was increased. Genetic analysis for long-QT-syndrome (LQTS) was negative with regards to the most frequent known gene loci. For 6 months the patient has been free of symptoms., Conclusion: Arrhythmogenic syncopes can clinically resemble epileptic seizures ("convulsive syncope"). During basic work-up of syncope, the 12 lead ECG may provide valuable clues indicating an arrhythmogenic cause of syncope, showing excitation as well as repolarisation abnormalities. If an arrhythmogenic cause of syncope is suspected but ECG documentation as a proof of diagnosis is missing, implantation of an ILR can be useful. In LQTS, multiple gene mutations are known but cover only a fraction of clinical LQTS., (© Georg Thieme Verlag KG Stuttgart · New York.)

History and Admission Findings: A 69-year-old somnolent woman developed severe heart failure, aggravated by recurrent episodes of ventricular tachycardia. The patient showed central and peripheral edema. 24 hours earlier, she had suffered cerebral seizures that were successfully terminated by phenytoin. For 13 years, persistent atrial fibrillation had been frequency-controlled with antiarrhythmic drugs (verapamil and glycosides) and treated by oral anticoagulation. In addition, there had been long-term anti-depressant therapy with the tetracyclic agent maprotiline., Investigations: Torsade de pointes tachycardia was documented in the electrocardiograms. In addition, the QT interval was extensively prolonged (QTc = 0.70 sec). Neither electrolyte disturbances nor acute cardiac ischemia were seen. Echocardiography revealed a highly reduced ejection fraction of 25 % and a moderately dilated left ventricle. Angiography showed a collateralized occlusion of the right and plaques of the left coronary artery., Treatment and Course: Repeated torsade de pointes tachycardia resulted in hemodynamic compromise and were terminated by defibrillations. After intravenous magnesium and xylocaine administration as well as with termination of maprotiline and antiarrhythmic co-medication, QT prolongation decreased. In addition, the recurrent torsade de pointes tachycardia stopped. Subsequently, however, there were several bradycardia episodes, QT duration remained long. Accordingly, a VVI pacemaker was implanted. Up to now, the patient is doing well., Conclusions: With antidepressant therapy, a risky constellation including comorbidity and interactions with potentially arrhythmogenic drugs may lead to QT prolongation. Medication that delays conduction or causes bradycardia may generally favour torsade de pointes tachycardia. In case of indispensable multi-drug therapy, regular clinical as well as electrocardiographic monitoring with special emphasis on QT interval is mandatory.

A 29-year-old otherwise symptom-free patient had undergone a partial thyroidectomy 5 years ago followed by an episode of ventricular tachycardia and (after lidocaine injection) ventricular fibrillation requiring external defibrillation. No cause for the arrhythmias had been found at that time. Two subsequent syncopes led to her hospitalization. An asystole occurred while she was being monitored, and during the resuscitation there were several periods of ventricular fibrillation, which responded to external defibrillation. Subsequently several episodes of self-limiting ventricular tachycardia were recorded. A long QT syndrome with torsade-de-pointes tachycardia was diagnosed on the basis of typical ECG changes (QT interval 545 ms). Extensive diagnostic tests failed to find a cause. To prevent further tachycardias she was given propranolol, 40 mg three times daily, and an automatic defibrillator was implanted as a precaution. But no defibrillator discharge has so far been required (more than 10 months).