Perioperative torsade de pointes: a systematic review of published case reports

Anesth Analg. 2013 Sep;117(3):559-564. doi: 10.1213/ANE.0b013e318290c380. Epub 2013 Jun 6.


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.

Publication types

  • Meta-Analysis
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Child
  • Data Interpretation, Statistical
  • Electrocardiography
  • Female
  • Humans
  • Intraoperative Complications / therapy*
  • Long QT Syndrome / physiopathology
  • Long QT Syndrome / therapy
  • Male
  • Middle Aged
  • Perioperative Care*
  • Postoperative Complications / epidemiology
  • Postoperative Complications / therapy
  • Predictive Value of Tests
  • Torsades de Pointes / chemically induced
  • Torsades de Pointes / drug therapy
  • Torsades de Pointes / therapy*
  • Young Adult