Torsade de pointes during sevoflurane anesthesia and fluconazole infusion in a patient with long QT syndrome. A case report.

We present the occurrence of 'torsade de pointes' induced by the combination of peroperative fluconazole administration and sevoflurane anesthesia in a patient with 'long QT syndrome' (LQTS) scheduled for resection of a sacral abscess. Eight minutes following uneventful induction of anesthesia 'torsade de pointes' occurred, terminated by a counter shock. At this time the end-tidal concentration of sevoflurane was 2%. The fluconazole infusion was disconnected and the operation was continued. Post-operatively the patient awakened uneventfully. The direct postoperative ECG showed a QTc of 531 ms (preoperative QTc of 442 ms.) and remained prolonged afterwards. A long QT syndrome was the most likely diagnosis. LQTS is classified as either congenital or acquired. Patients with acquired LQTS may have an underlying predisposition for QT prolongation. Many drugs have shown to be associated with a prolonged QT interval (1). The syndrome in this particular patient was unmasked by sevoflurane. Concomitant administration of fluconazole might have further predisposed the patient to the development of 'torsade des pointes'. Although LQTS is relatively rare, it is important for the anesthesiologist to be familiar with the disease because of the associated morbidity and mortality and the potential for anesthesia to induce malignant arrhythmias in asymptomatic carriers.

Primary prevention with the ICD in clinical practice: not as straightforward as the guidelines suggest?

At first sight, guidelines for implantation of an implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular systolic dysfunction seem unambiguous. There are clear cut-off values for ejection fraction, and functional class. However, determination of the ejection fraction itself is not unambiguous, and other risk factors for sudden death that may have a profound effect on risk are not used for decision-making. Furthermore, to obtain a clinically significant impact on survival, expected longevity is important as it can greatly compromise the benefit in elderly patients but underestimate the long-term potential of ICD therapy in younger patients. (Neth Heart J 2009;17:107-10.).

Lead extraction for device related infections: a single-centre experience.

AIMS: We report a single-centre experience of extraction of infected pacing and ICD leads. METHODS: Retrospective study of consecutive lead extractions for infection. Lead extraction was by traction, or, if unsuccessful, a laser sheath was used. All procedures were performed in the operating room. RESULTS: Leads were extracted in 82 patients including 66 patients (80%) with infection occurring after replacement of the generator or revision of the leads. Previous treatment, without lead extraction, had failed in 51 patients (62%). Major complications (tamponade or haemothorax) occurred in 6 patients, 2 patients died despite emergency surgery. One patient succumbed to ongoing sepsis. Of the patients alive, a follow-up of at least 6 months (27 +/- 17 months) was available in 76 patients. All patients were cured; none had a recurrence. In 31 patients (41%) pacing was abandoned after lead extraction; all remained asymptomatic. CONCLUSION: Lead extraction is effective in curing pacemaker or ICD related infection, even after failed conservative therapy, but with a significant complication rate. The routine replacement of the generator should be reconsidered in patients in whom the indication for pacing is no longer valid, as the majority of infections occurred after revision of the system.

Malfunction of endocardial defibrillator leads and lead extraction: where do they meet?

AIMS: The development of new extraction techniques has improved the success rate of intravascular extraction of pacemaker and defibrillator leads, and hence the practice of extraction is expanding. However, the indications for lead extraction of malfunctioning leads in patients with an implantable cardioverter defibrillator (ICD) are still not well established. METHODS AND RESULTS: We reviewed the literature concerning structural complications of ICD leads. The clinical presentation and detection of malfunction is discussed as well as the consequences for adequate defibrillation therapy. An overview of the current published experience of intravascular extraction of ICD leads is provided including a brief discussion of our own experience. CONCLUSION: From this overview we conclude that malfunctioning pace-sense or ICD leads can be left in situ if there are no uncovered insulation defects. Inserting a new pace-sense or ICD lead is preferable in this situation given the current known complication rate of lead extraction. Lead extraction should be reserved for damaged leads in which interference with proper detection or defibrillation of newly inserted leads cannot be excluded.

Use of a laser sheath to obtain venous access in pacemaker lead-related obstruction without extraction of the lead.

AIMS: Occlusion of the subclavian vein resulting from pacemaker leads prohibits insertion of new leads. We describe the ipsilateral insertion of a new lead without extracting the old lead using a laser sheath in a pacemaker patient with an obstructed vein. METHODS AND RESULT: A laser sheath together with an outer sheath were advanced over the malfunctioning lead just beyond the occlusion. The laser sheath was pulled back and a guide wire inserted through the outer sheath kept in position distal of the occlusion. After removal of the outer sheath a peel-away sheath was introduced and a new lead implanted next to the malfunctioning lead that was abandoned and not extracted. CONCLUSION: By avoiding using the laser along the whole length of the lead we greatly reduced the risk of the procedure but were still able to recanalize the obstructed vein. A risk of bilateral occlusion is avoided and the contralateral site saved as an entry point for future needs.