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Abstract
Les torsades de pointe (TdP) sont une complication immédiatement létale des blocs auriculo-ventriculaires (BAV). Il s’agit d’une tachycardie ventriculaire polymorphe qui est caractérisée sur le plan électrocardiographique par un QT long, des ventriculogrammes élargis et fluctuants de fréquence élevée (200-250/min), succédant à une extrasystole ventriculaire initiatrice ; sur le plan clinique par une inefficacité cardio-circulatoire lorsqu'elles se prolongent, à l'origine de lipothymies ou syncopes. Exceptionnellement les épisodes de TdP peuvent évoluer vers la mort subite. Nous rapportons le cas d’une patiente âgée de 55 ans, ayant présenté un BAV complet mal toléré compliqué d’arrêt cardiaque ressuscité en rapport avec des accès de TdP, pour lesquels aucune étiologie apparente ni cardiopathie structurelle n’ont pu être identifiées. La prise en charge malgré les difficultés inhérentes à notre système de soins, a toutefois pu se solder par l’implantation d’un stimulateur cardiaque double chambre. L’enquête génétique est en cours.
ABSTRACT
Torsades de pointe (TdP) is an immediately life-threatening complication of atrio-ventricular block (AVB). It is defined as a polymorphic ventricular tachycardia which is characterized on ECG by a baseline long QT, enlarged and fluctuating high rate ventriculograms (200-250 beats per min), usually initiated by ventricular premature contraction. Clinical possible consequences maybe cardio-circulatory inefficiency when they are prolonged, causing faintness or syncope. Exceptionally, episodes of TdP can lead to sudden death. We report the case of a 55-years-old female patient, who presented complete AVB with resuscitated cardiac arrests episodes due to TdP attacks. The initial cardiac evaluation excluded any structural heart disease. Isoproterenol infusion avoided any recurrence of TdP. Despite main difficulties related to our health care system, the patient could be implanted with a dual-chamber pacemaker. The genetic testing is ongoing.
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References
- - Dessertenne F, Gourgon R, Coumel P, Fabiato A. Tachycardie ventriculaire et ‘torsades de pointes’. Annales de cardiologie et d’angéiologie. 1971;20(3):243–51
- - Slama R, Coumel PH, Motte G, Gourgon R, Waynberger M, Touche S. Tachycardies ventriculaires et torsades de pointes:frontieres morphologiques entre les dysrythmies ventriculaires. Arch Mal Coeur. 1973;66:1401–1411..
- - Milon D, Daubert JC, Saint-Marc C, Gouffault J. Les torsades de pointe: A propos de 54 cas. Annales Françaises d’Anesthésie et de Réanimation. 1982;1(5):513–520.
- - Djiane P, Deharo JC. Blocs auriculo-ventriculaires. EMC-cardiologie-Angéiologie. 1999;9(2):18–22.
- - Opolski G, Kraska T, Ostrzycki A, Zielinski T, Korewicki J. The effect of infarct size on atrioventricular and intraventricular conduction disturbances in acute myocardial infarction. Int J Cardiol. 1986 ; 10(2) : 141-147.
- - Thomas D, Choussat R, Isnard R, Michel PL, Iung B, Hanania G et al. Abcès cardiaques dans l’endocardite infectieuse. Étude multicentrique à propos de 233 cas. Arch Mal CoeurVaiss. 1998;91(6):745–752.
- - Fisch C, Knoebel SB. Digitalis cardiotoxicity. J Am Coll Cardiol. 1985;5(5 Suppl A):91A-98A.
- - Kurita T, Ohe T, Marui N, Aihara N, Takaki H, Kamakura S, et al. Bradycardia-induced abnormal QT prolongation in patients with complete atrioventricular block with torsades de pointes. Am J Cardiol. 1992;69(6):628–633
- - Topilski I, Rogowski O, Rosso R, Justo D, Copperman Y, Glikson M, et al. The morphology of the QT interval predicts torsade de pointes during acquired bradyarrhythmias. J Am Coll Cardiol. 2007;49(3):320–328.
- - Wilson FN, Robinson CC. Two cases of complete heart block showing unusual features. Arch Intern Med 1918 ;21 :166-75.
- - Puech P, Gallay P. Torsades de Pointe. In: de Luna AB, Betriu A, Permanyer G, editors. Therapeutics in Cardiology. 1988. Dordrecht. Springer Netherlands: 46–58.
- - Krikler DM, Curry PV. Torsade De Pointes, an atypical ventricular tachycardia. Br Heart J. 1976;38(2):117–120..
- - ZilcherH, Glogar D, Kaindl F. Torsades de pointes: occurrence in myocardial ischaemia as a separate entity. Multiform ventricular tachycardia or not? Eur Heart J. 1980;1(1):63–71.
- - Vos MA, de Groot SH, Verduyn SC, van der Zande J, Leunissen HD, Cleutjens JP, et al. Enhanced susceptibility for acquired torsade de pointes arrhythmias in the dog with chronic, complete AV block is related to cardiac hypertrophy and electrical remodeling. Circulation. 1998;98(11):1125–1135.
- - VoldersPG, Sipido KR, Vos MA, Spätjens RL, Leunissen JD, Carmeliet E, et al. Downregulation of delayed rectifier K(+) currents in dogs with chronic complete atrioventricular block and acquired torsades de pointes. Circulation. 1999;100(24):2455–2461.
- - TsujiY, Opthof T, Yasui K, Inden Y, Takemura H, Niwa N, et al. Ionic mechanisms of acquired QT prolongation and torsades de pointes in rabbits with chronic complete atrioventricular block. Circulation. 2002;106(15):2012–2018.
- - Napolitano C, Schwartz PJ, Brown AM, Ronchetti E, Bianchi L, Pinnavaia A, et al. Evidence for a cardiac ion channel mutation underlying drug-induced QT prolongation and life-threatening arrhythmias. J CardiovascElectrophysiol. 2000;11(6):691–696.
- - Yang P, Kanki H, Drolet B, Yang T, Wei J, Viswanathan PC, et al. Allelic variants in long-QT disease genes in patients with drug-associated torsades de pointes. Circulation. 2002;105(16):1943–1948.
- - AntzelevitchC. Heterogeneity and cardiac arrhythmias: an overview. HeartRhythm. 2007;4(7):964–972.
- - AntzelevitchC. Role of spatial dispersion of repolarization in inherited and acquired sudden cardiac death syndromes. Am J PhysiolHeartCircPhysiol. 2007;293(4):H2024-2038.
- - Yoshida H, Horie M, Otani H, Kawashima T, Onishi Y, Sasayama S. Bradycardia-induced long QT syndrome caused by a de novo missense mutation in the S2-S3 inner loop of HERG. Am J Med Genet. 2001;98:348-52.
- - Chevalier P, Bellocq C, Millat G, Piqueras E, Potet F, Schott J-J, et al. Torsades de pointes complicating atrioventricular block: evidence for a genetic predisposition. Heart Rhythm. 2007;4(2):170–174.
- - Subbiah RN, Gollob MH, Gula LJ, Davies RW, Leong-Sit P, Skanes AC, et al. Torsades de pointes during complete atrioventricular block: Genetic factors and electrocardiogram correlates. Can J Cardiol. 2010;26(4):208–212.
- - Lang CN, Koren G, Odening KE. Transgenic rabbit models to investigate the cardiac ion channel disease long QT syndrome. Prog Biophys Mol Biol. 2016;121(2):142–156.
- - Schreiner KD, Voss F, Senges JC, Becker R, Kraft P, Bauer A, et al. Tridimensional activation patterns of acquired torsade-de-pointes tachycardias in dogs with chronic AV-block. Basic Res Cardiol. 2004;99(4):288–298.
- - Halkin A, Roth A, Lurie I, Fish R, Belhassen B, Viskin S. Pause-dependent torsade de pointes following acute myocardial infarction: a variant of the acquired long QT syndrome. J Am Coll Cardiol. 2001;38(4):1168–1174.
References
- Dessertenne F, Gourgon R, Coumel P, Fabiato A. Tachycardie ventriculaire et ‘torsades de pointes’. Annales de cardiologie et d’angéiologie. 1971;20(3):243–51
- Slama R, Coumel PH, Motte G, Gourgon R, Waynberger M, Touche S. Tachycardies ventriculaires et torsades de pointes:frontieres morphologiques entre les dysrythmies ventriculaires. Arch Mal Coeur. 1973;66:1401–1411..
- Milon D, Daubert JC, Saint-Marc C, Gouffault J. Les torsades de pointe: A propos de 54 cas. Annales Françaises d’Anesthésie et de Réanimation. 1982;1(5):513–520.
- Djiane P, Deharo JC. Blocs auriculo-ventriculaires. EMC-cardiologie-Angéiologie. 1999;9(2):18–22.
- Opolski G, Kraska T, Ostrzycki A, Zielinski T, Korewicki J. The effect of infarct size on atrioventricular and intraventricular conduction disturbances in acute myocardial infarction. Int J Cardiol. 1986 ; 10(2) : 141-147.
- Thomas D, Choussat R, Isnard R, Michel PL, Iung B, Hanania G et al. Abcès cardiaques dans l’endocardite infectieuse. Étude multicentrique à propos de 233 cas. Arch Mal CoeurVaiss. 1998;91(6):745–752.
- Fisch C, Knoebel SB. Digitalis cardiotoxicity. J Am Coll Cardiol. 1985;5(5 Suppl A):91A-98A.
- Kurita T, Ohe T, Marui N, Aihara N, Takaki H, Kamakura S, et al. Bradycardia-induced abnormal QT prolongation in patients with complete atrioventricular block with torsades de pointes. Am J Cardiol. 1992;69(6):628–633
- Topilski I, Rogowski O, Rosso R, Justo D, Copperman Y, Glikson M, et al. The morphology of the QT interval predicts torsade de pointes during acquired bradyarrhythmias. J Am Coll Cardiol. 2007;49(3):320–328.
- Wilson FN, Robinson CC. Two cases of complete heart block showing unusual features. Arch Intern Med 1918 ;21 :166-75.
- Puech P, Gallay P. Torsades de Pointe. In: de Luna AB, Betriu A, Permanyer G, editors. Therapeutics in Cardiology. 1988. Dordrecht. Springer Netherlands: 46–58.
- Krikler DM, Curry PV. Torsade De Pointes, an atypical ventricular tachycardia. Br Heart J. 1976;38(2):117–120..
- ZilcherH, Glogar D, Kaindl F. Torsades de pointes: occurrence in myocardial ischaemia as a separate entity. Multiform ventricular tachycardia or not? Eur Heart J. 1980;1(1):63–71.
- Vos MA, de Groot SH, Verduyn SC, van der Zande J, Leunissen HD, Cleutjens JP, et al. Enhanced susceptibility for acquired torsade de pointes arrhythmias in the dog with chronic, complete AV block is related to cardiac hypertrophy and electrical remodeling. Circulation. 1998;98(11):1125–1135.
- VoldersPG, Sipido KR, Vos MA, Spätjens RL, Leunissen JD, Carmeliet E, et al. Downregulation of delayed rectifier K(+) currents in dogs with chronic complete atrioventricular block and acquired torsades de pointes. Circulation. 1999;100(24):2455–2461.
- TsujiY, Opthof T, Yasui K, Inden Y, Takemura H, Niwa N, et al. Ionic mechanisms of acquired QT prolongation and torsades de pointes in rabbits with chronic complete atrioventricular block. Circulation. 2002;106(15):2012–2018.
- Napolitano C, Schwartz PJ, Brown AM, Ronchetti E, Bianchi L, Pinnavaia A, et al. Evidence for a cardiac ion channel mutation underlying drug-induced QT prolongation and life-threatening arrhythmias. J CardiovascElectrophysiol. 2000;11(6):691–696.
- Yang P, Kanki H, Drolet B, Yang T, Wei J, Viswanathan PC, et al. Allelic variants in long-QT disease genes in patients with drug-associated torsades de pointes. Circulation. 2002;105(16):1943–1948.
- AntzelevitchC. Heterogeneity and cardiac arrhythmias: an overview. HeartRhythm. 2007;4(7):964–972.
- AntzelevitchC. Role of spatial dispersion of repolarization in inherited and acquired sudden cardiac death syndromes. Am J PhysiolHeartCircPhysiol. 2007;293(4):H2024-2038.
- Yoshida H, Horie M, Otani H, Kawashima T, Onishi Y, Sasayama S. Bradycardia-induced long QT syndrome caused by a de novo missense mutation in the S2-S3 inner loop of HERG. Am J Med Genet. 2001;98:348-52.
- Chevalier P, Bellocq C, Millat G, Piqueras E, Potet F, Schott J-J, et al. Torsades de pointes complicating atrioventricular block: evidence for a genetic predisposition. Heart Rhythm. 2007;4(2):170–174.
- Subbiah RN, Gollob MH, Gula LJ, Davies RW, Leong-Sit P, Skanes AC, et al. Torsades de pointes during complete atrioventricular block: Genetic factors and electrocardiogram correlates. Can J Cardiol. 2010;26(4):208–212.
- Lang CN, Koren G, Odening KE. Transgenic rabbit models to investigate the cardiac ion channel disease long QT syndrome. Prog Biophys Mol Biol. 2016;121(2):142–156.
- Schreiner KD, Voss F, Senges JC, Becker R, Kraft P, Bauer A, et al. Tridimensional activation patterns of acquired torsade-de-pointes tachycardias in dogs with chronic AV-block. Basic Res Cardiol. 2004;99(4):288–298.
- Halkin A, Roth A, Lurie I, Fish R, Belhassen B, Viskin S. Pause-dependent torsade de pointes following acute myocardial infarction: a variant of the acquired long QT syndrome. J Am Coll Cardiol. 2001;38(4):1168–1174.