Abstract 11589: Total Artificial Heart Placement in a Case of Recurrent Ventricular Tachycardia Storm

Abstract

Background: Electrical storm is defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within a 24-hour period requiring termination by cardioversion, anti-tachycardia pacing (ATP) or defibrillation. It can be a particularly challenging syndrome to treat when refractory to standard of care therapies, which include antiarrhythmics, sedation, and ablation. We present a case of refractory electrical storm requiring total artificial heart placement (TAH) as a bridge to transplant. Case: A 65-year-old male with a history of idiopathic non-ischemic cardiomyopathy presented with VF arrest. After return of spontaneous circulation, he was admitted to the cardiac intensive care unit. Implantable cardioverter defibrillator (ICD) interrogation showed 38 shocks delivered over the prior two-week period. Coronary angiography showed no obstructive coronary disease and an intraaortic balloon pump (IABP) was placed for cardiogenic shock. He was intubated and sedated on fentanyl and propofol. He continued to have episodes of VT despite treatment with lidocaine, procainamide, and amiodarone drips. Further trials of paralysis and left stellate ganglion nerve block did not suppress his VT. Since the patient was refractory to all prior interventions, was deemed too unstable for VT ablation, and had a prolonged anticipated wait time for heart transplant, he underwent TAH placement as a bridge to heart transplant. He recovered well and eventually underwent successful heart transplant. Discussion: Management of electrical storm requires a stepwise approach including administration of antiarrhythmics, sedation, mechanical hemodynamic support, and catheter ablation. Our patient had incessant VT despite exhaustive medical and supportive therapies, but was too unstable to undergo VT ablation. In cases of refractory VT storm, definitive treatment with heart transplantation must be considered, but bridging patients to transplant poses a challenge. Our patient underwent TAH placement and was successfully stabilized prior to transplant. In centers with this capability, TAH should be recognized as a legitimate option in the pathway for VT, particularly with a long anticipated wait time for heart transplant.