Torsades de pointes after termination of an atrial fibrillation episode

Patient

84-year-old patient with a history of paroxysmal atrial fibrillation, hospitalized for palpitations and signs of left heart failure; introduction of a loading dose of amiodarone and intravenous diuretic treatment; episodes of near-syncope;

Trace

At the beginning of the tracing, there is a narrow QRS tachycardia corresponding to a probable atrial fibrillation; spontaneous termination of arrhythmia and post-tachycardia sinus pause; signs of left atrial enlargement; on the first QRS complex following the pause, substantial prolongation of the QT interval; non-early ventricular extrasystole falling on the T wave (descending portion of the T wave); induction of an arrhythmia over 8 complexes, irregular, polymorphic, wide QRS tachycardia with characteristic torsade de pointes pattern: variable amplitude of the QRS complexes with rotation around the baseline more or less visible depending on the leads; spontaneous termination, new sinus pause, long QT and ventricular extrasystole;

Exergue

The combination of amiodarone and diuretics in an elderly patient with heart failure due to passage in atrial fibrillation may increase the likelihood of concomitant torsade de pointes in sinus rhythm.