STORMS-A-BREWIN: USE OF SYMPATHECTOMY IN TREATMENT OF REFRACTORY VENTRICULAR TACHYCARDIA STORM PROVOKED BY THYROID STORM IN A PATIENT WITH STRUCTURAL HEART DISEASE

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sympathectomy has been used since the 1960s for treatment of refractory ventricular tachycardia (VT)(1). However, the procedure has not been studied with a randomized controlled trial; clear indications and outcome data remain unclear. In this case report, we describe the use of sympathectomy in the treatment of a patient with refractory VT storm provoked by thyroid storm in the setting of underlying structural heart disease. CASE PRESENTATION: The patient is a 60-year-old male with a history of biventricular systolic failure secondary to ischemic cardiomyopathy (ICM). In addition to ICM, he had a history of VT for which he underwent two prior ablations (20 months and 2 months prior to admission) as well as permanent pacemaker implantation. One month prior to presentation, he was diagnosed with hyperthyroidism which was treated with methimazole. He presented to our institution for a clinic appointment but collapsed in our hospital parking garage. He was shocked by his pacemaker 4 times before being brought to our ED where he received an additional 10 shocks. ED staff determined the patient was in VT storm. He was sedated with propofol and intubated for airway protection before admission to the ICU. Thyroid stimulating hormone was found to be undetectable at this time, and free T4 was significantly elevated. Given his presentation and clinical history, he was diagnosed with refractory VT storm secondary to thyroid storm in the setting of structural heart disease. Thyroid storm was treated with standard therapies and VT storm was adequately suppressed with propofol. On hospital day 2, sedation was discontinued, and he was extubated without complication. Unfortunately, he continued to have runs of VT on hospital days 2-6. Given his history of previous ablations and thyroid storm, we elected to pursue bilateral VATS sympathectomy (hospital day 6) before attempting a third ablation (hospital day 10). The ablation was complicated by RV perforation requiring pericardiocentesis. The patient remained VT free from hospital day 6 until discharge on hospital day 12. He has been VT free at subsequent follow up appointments. DISCUSSION: To our knowledge, this is the first reported case involving the use of sympathectomy in the treatment of VT storm provoked by thyroid storm. Arrhythmias caused by thyroid storm are typically atrial in nature, with few reports of primary ventricular arrhythmias. Ventricular arrhythmias in thyroid storm are classically thought to be associated with structural heart disease. CONCLUSIONS: Sympathectomy has been shown to be an effective treatment in refractory VT, but more research is needed in this area to better characterize indications and outcomes(2,3). REFERENCE #1: Estes EH Jr., Izlar HL Jr. Recurrent ventricular tachycardia. A case successfully treated by bilateral cardiac sympathectomy. Am J Med. 1961;31:493-497. REFERENCE #2: Vaseghi M, Gima J, Kanaan C, et al. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm. 2014;11(3):360-366. doi:10.1016/j.hrthm.2013.11.028 REFERENCE #3: Vaseghi M, Barwad P, Malavassi Corrales FJ, et al. Cardiac Sympathetic Denervation for Refractory Ventricular Arrhythmias [published correction appears in J Am Coll Cardiol. 2017 Aug 8;70(6):811]. J Am Coll Cardiol. 2017;69(25):3070-3080. doi:10.1016/j.jacc.2017.04.035 DISCLOSURES: No relevant relationships by James Collins, source=Web Response No relevant relationships by John Tepper, source=Web Response