Management of ventricular electrical storm: a contemporary appraisal

EP Europace ◽  
2020 ◽  
Vol 22 (12) ◽  
pp. 1768-1780
Author(s):  
Gurukripa N Kowlgi ◽  
Yong-Mei Cha
Keyword(s):  
Arrhythmogenic Right Ventricular Cardiomyopathy ◽  
Stellate Ganglion ◽  
Stellate Ganglion Block ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Polymorphic Ventricular Tachycardia ◽  
Electrical Storm ◽  
Management Approach ◽  
Left Ventricular Assist Devices ◽  
Ganglion Block

Abstract Ventricular electrical storm (VES) is a clinical scenario characterized by the clustering of multiple episodes of sustained ventricular arrhythmias (VA) over a short duration. Patients with VES are prone to psychological disorders, heart failure decompensation, and increased mortality. Studies have shown that 10–28% of the patients with secondary prevention ICDs can sustain VES. The triad of a susceptible electrophysiologic substrate, triggers, and autonomic dysregulation govern the pathogenesis of VES. The rate of VA, underlying ventricular function, and the presence of implantable cardioverter-defibrillator (ICD) determine the clinical presentation. A multi-faceted approach is often required for management consisting of acute hemodynamic stabilization, ICD reprogramming when appropriate, antiarrhythmic drug therapy, and sedation. Some patients may be eligible for catheter ablation, and autonomic modulation with thoracic epidural anesthesia, stellate ganglion block, or cardiac sympathetic denervation. Hemodynamically unstable patients may benefit from the use of left ventricular assist devices, and extracorporeal membrane oxygenation. Special scenarios such as idiopathic ventricular fibrillation, Brugada syndrome, Long and short QT syndrome, early repolarization syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy, and cardiac sarcoidosis have been described as well. VES is a cardiac emergency that requires swift intervention. It is associated with poor short and long-term outcomes. A structured team-based management approach is paramount for the safe and effective treatment of this sick cohort.

Anatomical-based percutaneous left stellate ganglion block in patients with drug-refractory electrical storm and structural heart disease: a single-centre case series

EP Europace ◽  
2020 ◽  
Author(s):  
Simone Savastano ◽  
Veronica Dusi ◽  
Enrico Baldi ◽  
Roberto Rordorf ◽  
Antonio Sanzo ◽  
...  
Keyword(s):  
Stellate Ganglion ◽  
Case Series ◽  
Stellate Ganglion Block ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Electrical Storm ◽  
Ganglion Block ◽  
Ventricular Ejection Fraction ◽  
Left Stellate Ganglion ◽  
Stellate Ganglion Blockade

Abstract Aims The adoption of percutaneous stellate ganglion blockade for the treatment of drug-refractory electrical storm (ES) has been increasingly reported; however, the time of onset of the anti-arrhythmic effects, the safety of a purely anatomical approach in conscious patients and the additional benefit of repeated procedures remain unclear. Methods and results This study included consecutive patients undergoing percutaneous left stellate ganglion blockade (PLSGB) in our centre for drug-refractory ES. Lidocaine, bupivacaine, or a combination of both were injected in the vicinity of the left stellate ganglion. Overall, 18 PLSGBs were performed in 11 patients (age 69 ± 13 years; 63.6% men, left ventricular ejection fraction 31.6 ± 16%). Seven patients received only one PLSGB; three underwent two procedures and one required three PLSGB and two continuous infusions to control ventricular arrhythmias (VAs). All PLSGBs were performed with an anatomical approach; lidocaine, alone, or in combination was used in 77.7% of the procedures. The median burden of VAs 1 h after each block was zero compared with five in the hour before (P < 0.001); 83% of the patients were free from VAs; the efficacy at 24 h increased with repeated blocks. The anti-arrhythmic efficacy of PLSGB was not related to anisocoria. No procedure-related complications were reported. Conclusion Anatomical-based PLSGB is a safe and rapidly effective treatment for refractory ES; repeated blocks provide additional benefits. Percutaneous left stellate ganglion blockade should be considered for stabilizing patients to allow further ES management.

P5698What predicts the inefficiency of stellate ganglion block in the treatment of electrical storm?

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
R Spacek ◽  
O Jiravsky ◽  
M Hudec ◽  
J Fismol ◽  
L Sknouril
Keyword(s):  
Ventricular Arrhythmias ◽  
Stellate Ganglion ◽  
Case Series ◽  
Stellate Ganglion Block ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Electrical Storm ◽  
Acute Ischemia ◽  
Ganglion Block ◽  
Ventricular Ejection Fraction

Abstract Introduction Electrical storm (ES) is an emergent condition which requires a sofisticated approach. Massive sympathetic surge almost always connected with ES precipitates recurrent ventricular arrhythmias. Performing stellate ganglion block (SGB) to alleviate the sympathetic activity on myocardium is becoming a standard of care in many centers. However, there is no clear data to predict in which patients the SGB will be ineffective. Purpose To identify predictors of SGB failure in patients with ES. Methods We analyzed our case series of SGB – the procedure was performed in 31 patients with ES in our center from March 2017 to December 2018. Results Mean left ventricular ejection fraction was 27% (±9%), 74% of patients had ischaemic cardiomyopathy. The most frequent type of arrhythmia was monomorphic ventricular tachycardia (VT), occurring in 71% of patients, followed by polymorphic VT in 13% of cases. After SGB, the burden of ventricular arrhythmias failed to decrease by at least 50% in 10% of cases - these patients were marked as non-responders. Slow monomorphic VT (under 160/min) was observed in all of these patients. On the other hand, fast monomorphic VT or polymorphic VT seemed to respond very well to SGB. We also observed, that patients with ES after acute coronary syndromes were good responders as well. The effect of SGB was not related to age, gender, EF LK or the etiology of cardiomyopathy. Conclusions According to our experience, the failure of SGB in the treatment of ES is not frequent. It typically occurs in patients with slow monomorphic VT. It is probable that such arrhythmias are sustained primarily due to the extensive myocardial substrate, and not because of the sympathetic surge. The situation is quite the opposite in patients with fast VT and acute ischemia.

scholarly journals Arrhythmic storm in the acute coronary care unit

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
D Garcia-Arribas ◽  
S Rosillo ◽  
J Caro ◽  
E Armada ◽  
I Carrion ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Antiarrhythmic Drugs ◽  
Beta Blockers ◽  
Acute Myocarditis ◽  
Stellate Ganglion ◽  
Left Ventricular ◽  
Ventricular Assist Devices ◽  
Channel Blockers ◽  
Left Ventricular Assist Devices ◽  
Vt Ablation

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Beca para la Formación e Investigación en Cuidados Críticos Cardiológicos concedida por la Asociación de Cardiopatía Isquémica y Cuidados Críticos Cardiológicos de la SEC Introduction Available data on arrhythmic storm (AS) is usually obtained from retrospective observational studies based on series of patients (pts) with ICD or who undergo ablation. Therefore, selection bias limits the evidence regarding mortality and prognosis of this entity. Purpose/ Methods Describe epidemiological and clinical characteristics, as well as therapeutic strategies and in-hospital mortality as main outcome of pts admitted between 2006 and 2020 for AS in the Acute Cardiac Care Unit (ACCU) of 2 tertiary hospitals in Madrid, Spain. Results A total of 190 episodes of AS in 169 pts were analysed. Baseline characteristics are depicted in Figure 1. Cardiovascular targeted treatments of pts included: betablockers (68.7%), ACEi or ARB (53.2%), ARNI (6.5%), AA (38.5%), group III antiarrhythmic drugs (27.1%) and digoxin (5.9%). Aetiology of the AS was determined in 68.6% of the episodes: myocardial ischemia 25.1%, STEMI 22.5%, acute myocarditis 0.5%, heart failure or cardiogenic shock 28.8%, infection 11%, Bradycardia and long QT interval 10%, ionic disturbances 6.3%, others 11.5%. Antiarrhythmic drugs used for the acute episode were: amiodarone (73.3%), procainamide (27.2%), sotalol (5.7%), other beta blockers (75.9%), calcium channel blockers (3.1%), quinidine (2.1%). Other therapies were performed as follows: sedative drugs 50.3%, endotracheal intubation 39,9%, correction of electrolyte disturbances 51.8%, therapeutic hypothermia 13.6%, intravenous temporary pacemaker insertion or ICD reprogramming (9.9%). In 45% of pts coronary angiography was performed, but only 25.7% required revascularization. Vasopressors and inotropic drugs were used in 51% of pts. Regarding mechanical support intra-aortic balloon pump was implanted in 16.2% of episodes, ECMO in 3.7% and other left ventricular assist devices in 3.1%. One patient was transplanted. Ventricular tachycardia (VT) ablation was performed in 38.7% of episodes and its efficiency was 69.4%. Three pts underwent stellate ganglion ablation and surgical sympathectomy, and in one pt sympathectomy alone was performed. ICD was implanted in 23 pts after the AS episode. Survival at discharge was 81.1%. Mortality in STEMI related AS was 44.2%, while in the rest of aetiologies was 6.1%. Mortality among patients with an ICD was 6.3%. Conclusion Patients with AS requiring admission to an ACCU have predominantly ischemic background (both acute and chronic). Most common therapeutics are beta-blockers, amiodarone, sedation and VT-ablation. In-hospital mortality differs depending on the aetiology being worst in STEMI related AS. Abstract Figure 1

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