Short-Coupled Purkinje Ventricular Fibrillation Triggers Successfully Suppressed With Flecainide

Idiopathic ventricular fibrillation (IVF) affects young individuals without identifiable structural or channelopathic disease. Short-coupled premature ventricular contractions (sc-PVCs) of Purkinje origin are a recognized trigger, yet optimal pharmacotherapy remains undefined.

A 28-year-old healthy woman presented after a witnessed out-of-hospital sudden cardiac arrest. Extensive workup excluded all structural, ischemic, and inherited causes. Telemetry identified sc-PVCs of left anterior fascicle Purkinje origin, with a coupling interval of 330 ms, reproducibly triggering ventricular fibrillation. Intravenous amiodarone and esmolol failed, while flecainide achieved complete sc-PVC suppression. A subcutaneous implantable cardioverter-defibrillator was implanted.

IVF recurs in 25% to 40% of patients, mandating implantable cardioverter-defibrillator placement and trigger suppression. Quinidine holds an 83.3% efficacy rate but is limited by side effects and availability. Flecainide achieved comparable suppression with sustained benefit at 12-month follow-up on monotherapy.

Flecainide is a promising alternative to quinidine for suppressing sc-PVC-triggered IVF, offering comparable efficacy and better tolerability.