Flecainide acetate in the treatment of tachycardias associated with mahaim fibres

Patients with Mahaim fibres are susceptible to tachycardias which can be refractory to conventional drug therapy, leading to treatment with surgery and catheter ablation. The effects of flecainide acetate were studied in 3 patients (61, 21 and 35 years of age) with Mahaim fibres presenting with tachycardias refractory to beta-blockers, quinidine and verapamil. One also had ophthalmic side-effects from amiodarone. Three types of tachycardias were induced: a reentrant tachycardia with left bundle branch block morphology (LBBBM) in all 3 patients, atrial flutter in one and atrial fibrillation in another. Intravenous flecainide acetate (2 mg kg-1) terminated reentrant tachycardia and abolished duality of atrioventricular conduction in patient 1. In patient 2, it abolished preexcitation during atrial flutter prior to termination. Atrial fibrillation could not be induced in patient 3 after flecainide acetate. In all patients, retrograde conduction was blocked, preexcitation was not present with atrial pacing and no tachycardia was induced after flecainide. All have remained asymptomatic on oral flecainide acetate (100 mg bd) for a mean follow-up period of 9 months.We conclude that (1) flecainide acetate is effective for the treatment of various tachycardias associated with Mahaim fibres; (2) since different mechanisms responsible for the tachycardia with LBBBM may be present in the same patient and difficult to determine in some, treatment with flecainide acetate which affects both the atrioventricular node and Mahaim fibre conduction may be appropriate for the condition and; (3) its use should be considered before more aggressive therapies.