Key result
Sodium bicarbonate infusion successfully treated flecainide toxicity, resolving high pacemaker capture thresholds, toxic EKG changes, and takotsubo syndrome-like regional wall motion abnormalities.
Case Report (n=1)
Flecainide toxicity can present with high pacemaker capture thresholds and cardiogenic shock resembling takotsubo syndrome, which can be successfully reversed with sodium bicarbonate infusion.
May support sodium bicarbonate in flecainide toxicity with high thresholds and takotsubo features; hypothesis-generating pending controlled studies.
We describe a case of a woman in her 80s with persistent atrial fibrillation (AF) despite being on flecainide who was admitted for AF with rapid ventricular response. Attempts with direct-current cardioversions were unsuccessful despite increased doses of the antiarrhythmic therapy. At atrioventricular (AV) nodal ablation, very high right ventricular capture thresholds resulted in abortion of the procedure as back-up ventricular pacing could not be assured with adequate margin for safety. Shortly following the electrophysiology (EP) study, the patient developed cardiogenic shock with new apical left ventricular regional wall motion abnormality suggestive of apical ballooning and a toxic-appearing wide QRS complex electrocardiogram (EKG). The patient was successfully treated with sodium bicarbonate infusion for presumed flecainide toxicity. The regional wall motion abnormality and EKG changes resolved along with normalisation of capture thresholds after 2 days of treatment. The patient underwent an uncomplicated successful AV nodal ablation several weeks later.
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Manley-Casco et al. (2021) conducted a case report in Flecainide toxicity (n=1). Sodium bicarbonate infusion was evaluated on Resolution of clinical and electrocardiographic signs of toxicity. Sodium bicarbonate infusion successfully treated flecainide toxicity, resolving high pacemaker capture thresholds, toxic EKG changes, and takotsubo syndrome-like regional wall motion abnormalities.
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