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Case Reports
. 2019 Aug 30:20:1279-1283.
doi: 10.12659/AJCR.916370.

Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture

John M Suffredini  1 , Joshua Rutland  2 , Peter Akpunonu  3 , Regan Baum  3 , John Catanzaro  4 , Claude S Elayi  4
Affiliations
Case Reports

Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture

John M Suffredini et al. Am J Case Rep. .

Abstract

BACKGROUND Flecainide is a class Ic antiarrhythmic agent used in the treatment of supraventricular and ventricular arrhythmias. It is associated with a potent adverse effect profile; however, the effects of flecainide toxicity in the setting of a pacemaker have not been well described. We describe a unique case of flecainide toxicity secondary to acute kidney injury in the setting of a dual-chamber pacemaker, resulting in ventricular capture latency and intermittent failure to capture. CASE REPORT The patient was a 91-year-old female with a history of atrial fibrillation maintained in sinus rhythm on flecainide, who presented complaining of purple visual disturbances and syncope. She was found to be hypotensive and bradycardic, with a heart rate between 30 to 40 beats per minute. Lab work was notable for creatinine at 2.12 mg/dL. A 12-lead ECG demonstrated atrial and ventricular pacing with severely widened QRS complex and a significant latency between the pacemaker ventricular spike and the ventricular capture. The pacemaker was interrogated, revealing a significant increase in ventricular threshold from 0.75 V at 0.5 ms at baseline to 5.0 V at 1 ms to obtain consistent capture. After multiple boluses of IV sodium bicarbonate, the QRS acutely narrowed, latency interval improved, and consistent pacing capture was achieved. The flecainide level drawn on arrival was 3.09 mcg/mL. CONCLUSIONS Flecainide increases the ventricular capture threshold for pacemakers. Toxicity in these patients may present with pacemaker ventricular capture latency or failure to capture.

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Conflict of interest statement

Conflict of interest: None declared

Figures

Figure 1.
Figure 1.
(A) 12-lead ECG performed after the pacemaker was switched into VVI mode at a pacing threshold of 5 mV at 1 ms. Note the impressive latency between the ventricular spike and the ventricular depolarization and the QRS duration above 200 ms. (B) 12-lead ECG performed after treatment with intravenous sodium bicarbonate, demonstrating improvement of the QRS duration and disappearance of the latency interval. (C) 12-lead ECG performed a day later, demonstrating a ventricular paced rhythm with a QRS narrower than that before ECG.
Figure 2.
Figure 2.
Intracardiac electrograms from the initial pacemaker interrogation, demonstrating no ventricular escape at 40 bpm.
See this image and copyright information in PMC

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