Perioperative Torsade de Pointes: A Systematic Review of Published Case Reports

Johnston, Joshua MD; Pal, Swatilika MBBS, MS; Nagele, Peter MD, MSc

Anesthesia & Analgesia:
doi: 10.1213/ANE.0b013e318290c380
Cardiovascular Anesthesiology: Research Report
Abstract

BACKGROUND: Torsade de pointes is a rare but potentially fatal arrhythmia. More than 40 cases of perioperative torsade de pointes have been reported in the literature; however, the current evidence regarding this complication is very limited. To improve our understanding, we performed a systematic review and meta-analysis of all published case reports of perioperative torsade de pointes.

METHODS: MEDLINE was systematically searched for cases of perioperative torsade de pointes. We included patients of all age groups and cases that occurred from the immediate preoperative period to the third postoperative day. Patient and case characteristics as well as QT interval data were extracted.

RESULTS: Forty-six cases of perioperative torsade de pointes were identified; 29 occurred in women (67%), and 2 episodes were fatal (case fatality rate: 4%). Craniotomies and cardiac surgery accounted for 40% of all cases. Preceding events identified by the authors were hypokalemia (12/46, 26%; 99% confidence interval [CI], 9%–43%) and bradycardia (7/46, 15%; 99% CI, 2%–28%). Drugs were implicated in approximately one third of the events (14/46, 30%; 99% CI, 13%–48%). The mean corrected QT (QTc) at baseline was 457 ± 67 milliseconds (minimum 320 milliseconds; maximum 647 milliseconds; data available in 27/46 patients). At the time of the event, the mean QTc increased to 575 ± 77 milliseconds (minimum 413 milliseconds; maximum 766 milliseconds; data available in 33/46 patients). On average, QTc increased by +118 milliseconds (99% CI, 70–166 milliseconds; P < 0.001) between baseline and after the torsade de pointes event. All patients, except for 2, had a substantial prolongation of their QTc interval at the time of the event.

CONCLUSIONS: This systematic review identified several common risk factors for perioperative torsade de pointes. Given the nearly uniform presence of a substantial QTc interval prolongation at the time of a torsade de pointes episode, increased vigilance for perioperative QTc interval prolongation may be warranted.

In Brief

Published ahead of print June 6, 2013

Author Information

From the Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri.

Accepted for publication February 26, 2013

Published ahead of print June 6, 2013

Funding: The study was supported, in parts, by grants from the National Institutes of Health, Bethesda, MD (NIHK23 GM087534 to PN and UL1RR024992 to Washington University Institute of Clinical and Translational Sciences) and the American Heart Association (9CRP2240001).

Conflict of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Peter Nagele, MD, MSc, Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave., Box 8054, St. Louis, MO 63110. Address e-mail to nagelep@wustl.edu.

© 2013 International Anesthesia Research Society