Electrical Storm in the ICU – When all Options Run Out

Abstract

The management of patients with ischaemic cardiomyopathy presenting with refractory ventricular arrhythmias may be challenging and is associated with high morbidity and mortality. The authors present the case of a 72-year-old male patient with a known history of severe ischemic cardiomyopathy and impaired left ventricular function (LVEF 29%) with a previous episode of incessant ventricular tachycardia (VT), previously submitted to VT catheter ablation and implantable cardioverter-defibrillator (ICD) implantation in secondary prevention. Due to hyperthyroidism with amiodarone, he was under dofetilide therapy. In this case report, we detail the step-by-step approach undertaken in the management of a complex case of refractory electrical storm. The therapeutic approach included the use of several anti-arrhythmic drugs (amiodarone, lidocaine and esmolol), manual ICD anti-tachycardia pacing and cardioversion, sedation and mechanical ventilation, extracorporeal life support with VA-ECMO and VT catheter ablation under VA-ECMO support. Unfortunately, despite every measure undertaken, the patient developed incessant VT culminating in haemodynamic collapse and death. The role of mechanical circulatory support in haemodynamically unstable patients with refractory ventricular arrhythmias and undergoing VT catheter ablation is also explored, as well as other treatment options that may be considered in the management of electrical storm, such as early coronary angiography, autonomic modulation, and surgical VT ablation with electroanatomical mapping.