Electrical storm – Management

Electrical storm – Management


Electrical storm: Recurrent unstable ventricular tachycardia (VT)/ventricular fibrillation (VF) requiring more than three direct current (DC) shocks per day.

  1. Beta blocker is the single most effective therapy for recurrent VT unless the person is in shock. A combination of intravenous amiodarone with oral propranolol has been found to be superior to intravenous amiodarone with oral metoprolol [1].
  2. Stellate ganglion block / ablation is being increasingly used as a modality for treatment of drug refractory ventricular tachycardia. Temporary blockage of stellate ganglion can be obtained by injection lignocaine or bupivacaine for a longer effect [2]. Sometimes a cannula can be left in situ and a local anesthetic infusion started for a prolonged effect. Ablation of stellate ganglion chemically with alcohol or surgically are feasible. Video assisted thoracoscopy is a semi invasive option which is replacing open surgery for surgical ablation of stellate ganglion.
  3. There should be a low threshold for inserting IABP in those with electrical storm. Extracorporeal membrane oxygenation (ECMO) support is useful in pediatric cases as hemodynamic protection for aggressive antiarrhythmic medical treatment giving a survival more than 80% [3].
  4. Moderate therapeutic  hypothermia has been shown to suppress electrical storms in a person with multi vessel coronary artery disease [4]. The converse is that patients with fever may have worsening of electrical storms; so the control of fever may be useful.
  5. Monomorphic ventricular premature complexes (VPC) which trigger the VF should be targeted during ablation of VF. The best time to take them up for EP study is during a storm as the tachycardia may not be inducible at other times. Marking electrode positions while taking ECG will help pace mapping at EPS to get an exact match.  Excellent outcomes for catheter ablation with resolution of storm in over 90% of patients and a complication rate as low as 2% has been mentioned [5].

References

  1. Sofia Chatzidou, Christos Kontogiannis, Diamantis I Tsilimigras, Georgios Georgiopoulos, Marinos Kosmopoulos, Elektra Papadopoulou, Georgios Vasilopoulos, Stylianos Rokas. Propranolol Versus Metoprolol for Treatment of Electrical Storm in Patients With Implantable Cardioverter-Defibrillator. J Am Coll Cardiol. 2018 May 1;71(17):1897-1906.
  2. Lingjin Meng, Chi-Hong Tseng, Kalyanam Shivkumar, Olujimi Ajijola. Efficacy of Stellate Ganglion Blockade in Managing Electrical Storm: A Systematic Review. JACC Clin Electrophysiol. 2017 Sep;3(9):942-949.
  3. Silvia Mariani, L Christian Napp, Valeria Lo Coco, Thijs S R Delnoij, Justin G L M Luermans, Rachel M A Ter Bekke, Carl Timmermans, Tong Li, Guenes Dogan, Jan D Schmitto, Jos Maessen, Bart Maesen, Roberto Lorusso. Mechanical circulatory support for life-threatening arrhythmia: A systematic review. Int J Cardiol. 2020 Jun 1;308:42-49.
  4. Aysha Arshad, Jonathan S Steinberg, Suneet Mittal. Therapeutic moderate hypothermia: a novel modality for management of electrical storm due to ventricular fibrillation. Europace. 2014 Oct;16(10):1481.
  5. Lucy Geraghty, Pasquale Santangeli, Usha B Tedrow, Kalyanam Shivkumar, Saurabh Kumar. Contemporary Management of Electrical Storm. Heart Lung Circ. 2019 Jan;28(1):123-133.