Dear Editor, A 63-year-old woman with recently diagnosed dilated cardiomyopathy with poor left and right ventricular function presented with an electrical storm of bradycardia-induced polymorphic ventricular tachycardia and ventricular fibrillation episodes, for which electrical defibrillation was necessary on ten occasions in the referring hospital. Coronary angiography and myocardial perfusion scintigraphy revealed no abnormalities.The patient received a temporary pacemaker lead via the right internal jugular vein. There was continuous ventricular pacing at a rate of 90/min. Polymorphic ventricular tachycardia occurred every time the pacing rate fell below 90/min. The patient was started on oral quinidine because of it's positive chronotropic (vagolytic) properties which, in this particular case, would aid in the prevention of ventricular arrhythmias.Our patient weighed 72 kg after recompensation. Heart failure therapy consisted of furosemide, spironolacton, and perindopril. Renal function was normal. Following the administration of supplementary potassium, electrolytes were also normal.The patient was transferred to our university medical center for further analysis of the ventricular arrhythmias.The rate of ventricular pacing decreased over several days without any recurrence of arrhythmias, upon which the temporary pacemaker lead was removed. The same night the patient was resuscitated because of ventricular fibrillation. A day later she underwent implantation of a twochamber implantable cardioverter-defibrillator (ICD) via the left cephalic vein. The following day the patient developed fever and elevated inflammation parameters due to an infection caused by the already removed temporary pacemaker lead. The culture of the tip of the temporary pacemaker lead and of four of the four blood cultures were positive for Staphylococcus aureus. After flucloxacillin therapy was started intravenously, the fever subsided. She was also treated for a short time with rifampicin; however this drug was discontinued because of the development of renal insufficiency and liver test abnormalities. Kidney and liver functions normalized after the discontinuation of rifampicin. Because of the colonization of the ICD with S. aureus, there was a clear indication for removal of the ICD. However, the patient still did not have sinus rhythm above the lower pacing rate of 90/min and thus needed continuous pacing to prevent ventricular tachycardia episodes, whereupon quinidine was increased to a maximum daily dose of 2800 mg. However, total quinidine plasma levels remained below the therapeutic range (1.1 mg/L; therapeutic range 2.5-5.0 mg/L) (Fig. 1). The quinidine was not further increased because of the already prolonged QTc-interval and expected side-effects with such exceptionally high doses of quinidine.After several weeks of treatment with quinidine and flucloxacillin, blood cultures were repeatedly negative for S. aureus, and the patient was no longer pacemaker dependent due to a higher heart rate (sinus rhythm). The ICD was expla...
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