Search

Background Anti-arrhythmic drug therapy has often a narrow therapeutic index and could be responsible of toxic side effects including malignant arrhythmias and life-threatening hemodynamic deterioration. Flecainide toxicity can occur even at normal serum levels in the setting of electrolyte disturbances such as hyponatremia. We report a case of flecainide toxicity, likely due to dual mechanism: reduced excretion and potentiation of the toxic effects due to concomitant hyponatremia. Case description A 82-year-old woman was admitted to our hospital for syncope. The ECG at admission showed atrial fibrillation, complete atrio-ventricular (AV) block and a wide QRS escape rhythm. She has a history of hypertension, COPD and atrial fibrillation. She was currently taking flecainide at a dosage of 150 mg per die. Laboratory tests reported an elevated lactate concentration (4.6 mmol/L), hyponatremia (128 mmol/L), severe reduction of renal function (eGFR 19 ml/min), and NT-proB-type Natriuretic Peptide 17563 pg/ml, (ULN Discussion Flecainide toxicity is a rare but potentially life-threatening condition. The excess of sodium channel blockade causes in fact delayed conduction through the AV node, His-Purkinje system, and ventricles with possible AV block, ventricular tachycardia, ventricular fibrillation, and asystole. In addition, hemodynamic instability can develop rapidly in flecainide intoxication due to chronotropic and inotropic incompetence. The majority of flecainide intoxication reported cases are due to a drug overdose. However, flecainide toxicity can occur with serum levels within the range of normality. Particularly, this can occur in the setting of hyponatremia. The observed pacemaker malfunction was also due to flecainide intoxication. In our case, the patient was taking therapeutic doses of this drug. The toxic effect was probably due to the reduced excretion (secondary to kidney failure) and the simultaneous presence of hyponatremia. The main treatment for flecainide intoxication is sodium bicarbonate and supportive care. However, there is currently no recommended standardized protocol for flecainide toxicity. The inotropic agents could be helpful in case of cardiogenic shock, but their use may be limited by the rate-dependent effect of flecainide and the increased risk ventricular arrhythmias. Left ventricular assist devices have been also used to support hemodynamic through flecainide-induced cardiogenic shock.

Leadless pacemaker (LPs) is a safe device and the implantation rates of this device is increasing. The device extraction and replacement are today a challenging procedures especially in case of infections, fragile and older patients or in unfavorable venous anatomy; LPs can be a valid alternative strategy in these cases. We report a case of management of a patient with multiple previous device replacements and extractions, with malfunction of transvenous pacemaker and with a fibrous membrane between the walls of the ventricular lead and the superior vena cava (SVC), who underwent a successful LP implantation.