Arrhythmic Storm Research Articles

Long-term outcomes of cardiogenic shock survivors: a contemporary retrospective analysis from a tertiary center

Abstract Background Cardiogenic shock (CS) is a complex syndrome that still portends a dismal short-term prognosis. However, in patients that survive the initial admission and are later discharged, the long-term prognosis remains ill-characterized. Aim We aimed to describe the long-term morbidity and mortality outcomes of patients surviving the index admission for CS. Methods Retrospective analysis of all consecutive patients admitted to a cardiac intensive care unit (CICU) between December 2016 and December 2022 with a diagnosis of CS. All etiologies were included and further categorized as: acute myocardial infarction (AMI-CS), acute-on-chronic heart failure (HF-CS) and secondary causes [(S-CS): myocarditis, arrhythmic storm, acute pulmonary embolism, among others]. Our primary endpoint was defined as all-cause death, conditional to being discharged alive. Secondary endpoints comprised heart transplant, durable left ventricular assist device (LVAD) implantation, implantable cardioverter-defibrillator (ICD) insertion and hospital readmission during follow-up. Results A total of 208 patients were included [median age 68 years (IQR 57-80), 66% males, mean Charlson comorbidity index 4±3], of whom 52% (n=108) had AMI-CS, 27% (n=56) HF-CS and 21% (n=44) S-CS. During the index admission, mean SAPS II score was 49±18 and most patients were in SCAI-C (66%, n=137) stage. Organ support in the form of invasive mechanical ventilation, renal replacement therapy or temporary mechanical circulatory assist devices was necessary in 62% (n=129), 27% (n=56) and 26% (n=55) of patients, respectively. 53% of patients (n=110) survived the index admission [median CICU length of stay 8 (IQR 3-15) days; median hospital length of stay 13 (IQR 4-25) days]. At discharge, mean left ventricular ejection fraction was 38±16% and 28% (n=26) of patients underwent ICD implantation. Median follow-up after discharge was 679 (IQR 373-1056) days, with 4 (4%) patients lost to follow-up. Overall mortality was 22% (n=24) and was numerically higher for AMI-CS when compared to HF-CS and S-CS (9% vs 7% vs 6% respectively, p=0.640). Secondary endpoint analysis showed that 10% (n=11) had a heart transplant, 2% (n=2) received a durable LVAD, 9% (n=10) received an ICD and 26% (n=28) were re-hospitalized during that period. Conclusions Although the long-term mortality of patients discharged alive after the index admission for CS is not overwhelming, one in every four will be readmitted and a small proportion will be eligible for advanced heart failure therapies. Healthcare strategies to improve the morbidity and mortality of many CS survivors should be devised.

Efficacy of early use of Percutaneous Stellate Ganglion Block for electrical storms.

Electrical Storm (ES) is a life-threatening condition requiring a rapid management. Percutaneous Stellate Ganglion Block (PSGB) proved to be safe and effective on top of standard therapy, but no data are available about its early use. We considered all patients enrolled from 1st July 2017 to 30th April 2024 in the STAR registry (STellate ganglion block for Arrhythmic stoRm), a multicentre, international, observational, prospective registry. We aimed to assess the effectiveness of the first PSGB only. Patients were divided into two groups depending on whether they received PSGB before (Early-PSGB, often due to AAD contraindication) or after (Delayed-PSGB) intravenous antiarrhythmic drugs (AADs other than beta-blockers). We considered 180 PSGB (26 Early-PSGB and 154 AAD-first). In the early-PSGB group we observed a statistically significant reduction of treated arrhythmic events in the hour after PSGB compared to the hour before: 0 (0-0) vs 4.5 (1-10), p<0.001 and the extent of the reduction was similar in the Early-PSGB and delayed-PSGB group [-4.5 (-7 to -2) vs. -2.5 (-3.5 to -1.5), p=ns]. The percentage of patients free from arrhythmias was similar in the two groups up to 12 hours after PSGB (81%vs 84%, p=0.6 after one hour; 77% vs 79%, p=0.8 at three hours and 65% vs 69%, p= 0.7 after 12 hours). PSGB proved to be effective also when used early in the treatment of ES. Due to its rapidity of action, our results may suggest its early use to reduce the number of defibrillations and possibly to reduce the likelihood of a refractory ES.

Arrhythmic Storm as a Cause of Sudden Cardiac Death: Effectiveness of Catheter Ablation

Arrhythmic Storm as a Cause of Sudden Cardiac Death: Effectiveness of Catheter Ablation

Percutaneous stellate ganglion blockade as an add-on therapy for the treatment of arrhythmic storm

Abstract Introduction Arrhythmic storm (AS) due to repetitive ventricular arrhythmias (VA) is a life-threatening condition that can be resistant to antiarrhythmic therapy. Sympathetic nervous system plays an important role in triggering and maintaining VA. Reducing sympathetic activity by percutaneous stellate ganglion blockade (SBG) may improve outcomes in treating AS. Purpose To evaluate the effect of SBG on outcomes of AS. Methods In this retrospective study, we analyzed 18 patients treated with SBG for AS from August 2017 to May 2022. All patient experienced VA while on antiarrhythmic drug therapy. SBG was performed under ultrasound guidance to avoid vascular structures. Either 0.75% levobupivacaine or 0.5% ropivacaine were applied to block the stellate ganglion after negative aspiration. The decision to perform unilateral or bilateral SBG was left to the operator. Results The majority of patients were male (17/18, 94.4%), mean age was 61.8 ± 13.4 years, mean BMI 28.1 ± 5.39 kg/m2, mean LVEF was 34.4 ± 12.2%, majority had an ischemic cardiomyopathy (12/18, 66.7%). Half of the patients had monomorphic VA (9/18, 50.0%), the other half had polymorphic VA (9/18, 50.0%). Majority of patients were hemodynamically unstable (13/18, 72.2%) and more than a third had a cardiac arrest (7/18, 38.9%). Half of the patients had unilateral SBG (9/18, 50.0%), and the other half bilateral SBG (9/18, 50.0%). SBG was repeated in two patients (2/18, 11.1%). On the repeat procedure, both had bilateral SBG. There were 4 minor complications (4/18, 22.2%) and no major complications. Two patients had intermittent Horner’s syndrome, one had a small hematoma on the puncture site, and one had small hematoma in the mediastinum. All complications resolved on their own and did not require an intervention. In the 72 hours after SBG, 5 patients had a recurrence of VA (5/18, 27.8%). After the discharge, 6 patients also had a recurrence of VA (6/18, 44.4%). SBG significantly reduced mean number of VA episodes in the next 72 hours (12.3 ± 11.1 vs 4.3 ± 10.6; P=0.007) with a mean difference of 8.0 VA episodes (95% CI, 4.5 - 14.0; P=0.007) (Figure 1). One patient died due to recurrent VA leading to ischemic brain damage (1/18, 5.6%). Four patients died due to non-VA related causes (4/18, 22.2%). Two deaths were due to septic shock, the other two due to cardiogenic shock. Details of baseline characteristics and outcomes are in the Figure 2. Conclusion SBG significantly reduces episodes of VA after failed antiarrhythmic drug therapy in patients presenting with AS.A before-after graph of VA after SBG.Baseline and outcomes table.

Application of artificial intelligence in predicting major arrhythmic events based on clinical and left ventricular electro-anatomical mapping data

Abstract Introduction Artificial intelligence (AI) is a ground-breaking frontier in the analysis of intricate and extensive datasets, also within the medical domain. AI can be used to meticulously and systematically analyse data derived from electro-anatomical mapping, scrutinizing the numerical data extracted from the mapping engineering files. Purpose The primary objective of the project is to utilize machine learning methods to identify potential correlations between clinical, procedural, and substrate-mapping variables with major arrhythmic cardiac events (MaCE). Methods Machine learning algorithms were implemented using a database of 220 patients who underwent endocardial left ventricular electro-anatomical mapping (EAM). A total of 223 clinical-procedural variables were collected (analysis conducted for the 61 most interesting variables) and substrate mapping engineering files/data were extrapolated for analysis. Combinations of 4 and 5 variables are explored, resulting in 487,635 and 5,461,512 combinations, respectively. All the results obtained from all the combinations and different methods were evaluated by calculating the AUC (parameter indicating the probability that the prediction is in the correct order). For each patient, the numerical data extracted from the EAM files were assessed, specifically focusing on: 1. The late potentials extension and dispersion (%LatArea). 2. Point-to-point difference of the bipolar potential compared to the unipolar potential, with identification of regions where multiple points with high differences are clustered (%UniBip) 3. Areas of deceleration, characterized by very early and very late potentials within a short range, indicating a substantial difference in the activation timing (GradVal). Results Analyzing the best six 4-variable logistic regression models, we note that the variables that are most frequently correlated with a MaCE during follow-up are "NYHA class", "PAPs" and "GradVal" (AUC of the best models was: 0,96; 0,94; 0,91; 0,90; 0,90; 0,90). Analyzing the best six 5-variable logistic regression models emerges that the variables most frequently correlated with a MaCE during follow-up are "NYHA class", "PAPs", "GradVal", "Arrhythmic Storm", "TAPSE" and "%UniBip" (AUC of the best models was: 0,97; 0,93; 0,92; 0,92; 0,92; 0,92). EAM data added to clinical data increases the number of regression variables and the model complexity; "GradVal" and "%UniBip" seem to have greater relevance. Conclusion The study successfully employs machine learning algorithms to identify key variables influencing the prediction of MaCE. The analysis of EAM numerical data through AI can allow for the stratification of MaCE risk. The application of artificial intelligence allows to analyse a large amount of computer data that would not be analysable by human capabilities alone. Ongoing refinement and expansion of the dataset can enhance the models' predictive capabilities for clinical applications.

THerapy Efficacy in Short or long-coupled idiopathic ventricular fibrillation: an International Survey (THESIS)

Abstract Background A recent review of 86 patients with short or long-coupled premature ventricular complex (SLC-PVC) initiating idiopathic ventricular fibrillation (IVF) found high success rate in arrhythmia control with quinidine (QND) (83%) or radiofrequency ablation (RFA) (70.8%). Purpose To compare the efficacy of QND vs. RFA therapy in a large patient cohort with SLC-IVF. Methods THESIS included 287 patients with SLC-IVF screened from 58 centers and 1 multicenter group in 22 countries across 4 continents. The study cohort included 146 (50.9%) males, aged 39+14 years at the time of IVF documentation. Therapy groups were defined according to the first therapy given. Therapy success was defined as no VF recurrence. Results Patients presented after aborted cardiac arrest, ICD shocks, syncope, aborted cardiac arrest + arrhythmic storm, arrhythmic storm, palpitations, seizures or were asymptomatic in 121 (42%), 51(18%), 42(14.6%), 27 (9.4%), 23 (8%), 8 (2.8%), 6 (2.1%) and 9 (3.1%), respectively. Fifty-three patients (18.5%) had a prior history of syncope. Eleven (3.8%) patients required ECMO support. Mean shortest and longest coupling interval which triggered VF in the same patient were 304.9+82ms and 341.2+94.1ms, respectively. VF initiation with "long" coupled PVC (coupling interval &amp;gt;350ms) was observed in 41 (18.1%) patients, and VF initiation with both short and long coupled PVC was documented in 30 (13.2%) others. RFA was performed in 112 patients and QND was given to 68 patients. Patients were followed during a mean follow-up of 84.8+64.5 months. Therapy success was achieved in the RFA or QND group in 69 (62.2%) and 49 (71%) patients, respectively (p=0.29). The RV Purkinje was the main targeted ablation site in 46 (47.4%) patients. Treatment success varied according to the site of origin (SOO) of the PVC which triggered VF. Therapy success was higher with QND when PVC SOO based on ECG, was the RV inflow tract (81.3% vs. 57.7%, p=0.048) or when the SOO was not available (67.9% vs 36.4%, p=0.064), and when the coupling interval/QT ratio was &amp;lt;1 (75.5% vs. 57.5%, p=0.03), Figures 1,2. A higher success rate with ablation compared with QND was seen with LV- SOO compared with RV-SOO (82.1% vs 60.3%, p=0.019). Similarly, successful ablation was achieved in 83.3% (n=24) vs. 55.9% (n=68) patients with LV and RV-SOO respectively; p=0.004. One patient expired of sudden cardiac death due to misdiagnosis, while wearing a subcutaneous -ICD, without any drug or ablation therapy. Conclusions SLC-IVF strikes males and females equally. SLC-PVCs triggering the arrhythmia mainly arise from the RV Purkinje system. QND and RFA have similar efficacy in arrhythmia control. Quinidine has a higher treatment success rate in patients with PVC-SOO in the RV inflow area and in those with coupling interval/QT&amp;lt;1.Figure 1Treatment success by SOOFigure 2Treatment success by CI/QT

Preserving active lifestyle: subcutaneous defibrillators in young patients engaged in recreational sports. Insights from a multicenter study

Abstract Background Leading an active lifestyle and participating in recreational sports are crucial for overall well-being and cardiovascular health. Many young patients with implantable defibrillators engage in these activities, but the safety for subcutaneous defibrillator (S-ICD) recipients is unknown. Purpose Evaluate how lifestyle and recreational sports affect the risk of appropriate (AS) and inappropriate shocks (IAS) in S-ICD recipients. Methods We enrolled consecutive young S-ICD recipients (14-65 years) from 19 Italian centers and assessed their physical activity with the International Physical Activity Questionnaire (IPAQ). During follow-up, we analyzed the impact of lifestyle and recreational sports on AS and IAS. Results We enrolled 602 S-ICD recipients (77% males; age: 46±14 years). Common diagnoses included hypertrophic cardiomyopathy (24%), ischemic heart disease (20%), and idiopathic dilated CM (17%). IPAQ was administered 47 months (IQR: 26-68) post-SICD implantation. According to the IPAQ, patients were categorized as inactive subjects (IS; 27.9%), minimally active subjects (MAS; 43.7%), or highly active subjects (HAS; 28.4%). Patients with progressively higher activity levels had, in parallel, younger age (48±14 vs. 45±13 vs. 44±13 years; p=0.02) and higher ejection fraction (EF, %) (46±16 vs. 48±15 vs. 49±16; p=0.09). 163 patients (27.1%) regularly participated in recreational sports, with fitness/gym (25.2%), walking (20.9%), and cycling (14.1%) as the most common choices. As compared to patients not engaged in sports, recreational athletes were younger (43±13 vs 47±14 years; p&amp;lt;0.01) and had higher EF (52±14 vs 46±16; p&amp;lt;0.01). During follow-up (32 months; IQR 19-54), there were 77 discrete VT/VF episodes and 10 storms in 44 patients treated with AS. Also, there were 38 discrete IAS and 7 inappropriate shock storms in 39 patients. IS, MAS and HAS had similar rates of AS (9.5% vs 6.8% vs 5.8%, respectively; p=0.39) and IAS (4.8% vs 6.5% vs 8.2%, respectively; p=0.44). Kaplan-Meier curves showed similar cumulative rate of first AS (p= 0.12) or IAS (p= 0.74) for the 3 groups (Figures 1 and 2). Recreational athletes and non-athletes were propensity matched for age, sex, heart disease, EF, and primary/secondary prevention ICD implantation. Non-athletes and recreational athletes had similar risk of AS (HR: 1.78; 95% CI: 0.75-4.41; p=0.20) and IAS (HR: 1.20; 95% CI: 0.55-2.64; p=0.64). Out of 163 recreational athletes, 7 (4.3%) experienced 12 distinct AS, of which 3 (25%) occurred during sport activities. There were no arrhythmic storms while engaging in sports. Additionally, 15 patients (9.2%) had 17 episodes of IAS, with 3 (17.6%) occurring during sport practice. Conclusions In young S-ICD recipients, those leading more active lifestyle and commonly engaged in recreational sports were not exposed to a higher risk neither of appropriate, nor of inappropriate shocks. However, shocks related to sport practice were not uncommon.AS-free survival according to IPAQIAS-free survival according to IPAQ

Ventricular arrhythmias associated with electrical cardioversion for atrial fibrillation, a multicenter study

Abstract Background Cases of ventricular arrhythmias (VAs) associated with QT prolongation after electrical cardioversion (ECV) for atrial fibrillation have been reported. Purpose To assess the incidence, timing and clinical characteristics of patients with VAs post-ECV for AF. Methods This is a multicenter international study. Seventy-seven centers were approached. Data was received from 13 worldwide centers. VAs included were torsades de pointes (TdP), NSPVT&amp;gt;3 beats or SCD within 7 days of ECV. The total number of ECVs performed at each center during the time period for which data was sent was provided. Results VAs occurred after ECV at an estimated incidence of 0.16%, range 0- 1.3% at different centers. Twenty-three patients with VAs were identified from 8 European centers, from 2008-2023, of whom 18 (78%) were from 2019-2023. There were 13 (56.5%) females, aged 71+11 years, mean LVEF=45+9%. AF duration prior to ECV was 72+65 days. Antiarrhythmic drugs (AADs) used prior to ECV were amiodarone in 9 (39%), sotalol in 4 (17%), class Ic in 3 (13%), beta blockers in 19 (83%), CCB in 1(4%) and digoxin in 4 (17%) patients. Five (22%) patients received QT prolonging drugs other then AADs. Baseline hypokalemia &amp;lt;3.5mmol/L was seen in 3(13%) patients (range 2.9-3.4mmol/L). ECV was elective, urgent and emergent in 10 (43%), 12 (52%) and 1(4%) patient, respectively. The arrhythmias documented were TdP in 17(74%), NSPVT &amp;gt;3 beats in 5(22%) and 1(4%) SCD. Arrhythmia documentation was available in 19 (83%) patients. Baseline mean HR pre-ECV was 115+30bpm and QT 388+61ms, both significantly differed from post-ECV mean HR which was 58+11bpm and QT 469+63ms, P&amp;lt;0.0001. Arrhythmia occurred 45+54 hours post-ECV, median 28.5 hours, range 5 minutes- 10 days. Figure 1 demonstrates an example of serial ECG changes from baseline to TdP occurrence. An arrhythmic storm occurred in 11 (48%) patients. Arrhythmia reoccurred in 9 (39%) patients, mean 13.25 + 15 (range 0.5-48) hours after the index event. The arrhythmias which reoccurred were TdP in 5 (22%), VF in 2 (9%), NSPVT in 1 (4%) and monomorphic VT in 1 (4%) patient. Acute therapy with DCCV was needed in 10 (43%) patients. AADs were discontinued in 16 patients. IV electrolytes were helpful in arrhythmia control in 16 (89%) of 18 patients, IV isoproterenol was helpful in 1 (25%) of 4 patients, temporary pacing with arrhythmia control in 2(40%) of 5 patients in whom it was used. ICD was implanted in 7 patients and a pacemaker in 4 others. Two (8.7%) patients expired, 1 died suddenly at home 12 hours after ECV and 1 suffered from acute heart failure and fatal TdP 72 hours after ECV while hospitalized. Conclusion VAs associated with QT prolongation after ECV for AF occur mainly 24-48 hours after ECV and may reoccur. Prolonged monitoring prior to discharge should be considered for prevention of fatal outcomes in patients with any evidence of QT prolongation following ECV.Figure 1

The Role of the Immune System in Pathobiology and Therapy of Myocarditis: A Review.

The role of the immune system in myocarditis onset and progression involves a range of complex cellular and molecular pathways. Both innate and adaptive immunity contribute to myocarditis pathogenesis, regardless of its infectious or non-infectious nature and across different histological and clinical subtypes. The heterogeneity of myocarditis etiologies and molecular effectors is one of the determinants of its clinical variability, manifesting as a spectrum of disease phenotype and progression. This spectrum ranges from a fulminant presentation with spontaneous recovery to a slowly progressing, refractory heart failure with ventricular dysfunction, to arrhythmic storm and sudden cardiac death. In this review, we first examine the updated definition and classification of myocarditis at clinical, biomolecular and histopathological levels. We then discuss recent insights on the role of specific immune cell populations in myocarditis pathogenesis, with particular emphasis on established or potential therapeutic applications. Besides the well-known immunosuppressive agents, whose efficacy has been already demonstrated in human clinical trials, we discuss the immunomodulatory effects of other drugs commonly used in clinical practice for myocarditis management. The immunological complexity of myocarditis, while presenting a challenge to simplistic understanding, also represents an opportunity for the development of different therapeutic approaches with promising results.

A VENTRICULAR TACHYCARDIA CASE NOT TREATABLE WITH TRANSCATHETER ABLATION DUE TO APICAL THROMBOSIS OF THE LEFT VENTRICLE RESOLVED WITH RADIOTHERAPY BASED ON THE NON–INVASIVE MAPPING SYSTE

Abstract The clinical case focuses on a 52–year–old man smoker, heavy alcohol consumer. In 2017 he began with sustained ventricular tachycardia (VT) effectively treated with DC–shock. The following ECG showed signs of anterior necrosis. Severe left ventricular (LV) dilatation, apical thrombosis and severe impairment of LV function were found on echocardiogram. Angiography was performed and LAD occlusion was found. Since of 68% necrosis of the LV at myocardial scintigraphy, no revascularization was performed. He underwent to a dual chamber ICD implantation and started oral anticoagulation therapy. In the following years recurrence of arrhythmic episodes, despite the optimization of antiarrhythmic therapy, led the patient to numerous hospitalizations. Unfortunately the persistence of the apical thrombosis, made transcatheter ablation NOT possible. The only chance for the patient remained stereotactic arrhythmia radioablation. But which area of the LV to highlight as responsible for the arrhythmia and how to program the radiotherapy treatment plan was a challenging problem. We proposed in March 2023 non–invasive mapping of arrhythmia using Cardioinsight. The patient performed heart high–resolution computed tomography (CT) for the anatomical reconstruction with precise spatial resolution of all LV aereas and surrounding structures. A 252–electrode vest is applied to the patient’s torso and connected to the system Cardioinsight. A programmed ventricular stimulation was performed using ICD inducing two VT morphologies. Through electroanatomical mapping we identified the mid LV antero–septal and infero–septal sites as target areas. Thanks to multidisciplinary team a personalized treatment plan was created to deliver an effective lesion in the target area and minimize exposure to nearby organs at risk. The treatment was generated, optimized and delivered by TrueBeam, lasted 3 minutes and no complications arose. The patient was quickly discharged in good clinical condition. After 3 months of clinical well–being he was hospitalized for a single episode of VT. Up to now no hospitalizations occurred. This treatment may represent a "bail–out" choice in patients with advanced heart failure with arrhythmic storm who have exhausted all other therapeutic options.

AUTOIMMUNE MYOCARDITIS IN MELANOMA IMMUNOTHERAPY–COMPLEX CLINICA PRESENTATION AND ADVERSE THERAPEUTIC RESPONSE

Abstract A 68–year–old Caucasian female presented to the ED with cardiac chest pain and dyspnea. The patient had a history of arterial hypertension and was equipped with a biventricular pacemaker due to atrial fibrillation with low ventricular response. She had recently been diagnosed with metastatic melanoma and initiated treatment with nivolumab and ipilimumab two weeks prior. Troponin levels were elevated (700 ng/ml), and no ST–segment elevation was observed on the electrocardiogram (ECG). In suspicion of NSTEMI–ACS, coronary angiography was performed, revealing an intact epicardial coronary circulation without stenotic lesions. The echocardiogram showed borderline left ventricular systolic function (EF 50%), and the right ventricle exhibited initial signs of reduced systolic function (TAPSE, 15 mm; S RV, 9.5 m/s). The following day, there was a deterioration in hemodynamics and respiratory exchange, with evidence of apical and mid–distal interventricular septum hypokinesia of the left ventricle (EF 40%) and dilated right ventricle (BD 4.8 cm; MD 4 cm) with severely reduced systolic function (TAPSE 10 mm, S RV 7 m/s, FAC, 20%), and severe tricuspid regurgitation. Urgent computed tomography pulmonary angiography (CTPA) excluded pulmonary embolism. Additionally, there was a new troponin increase (5000 ng/ml) and elevated hepatic biomarkers. The clinical picture raised suspicion of myocarditis related to immune checkpoint inhibitor therapy. Corticosteroid therapy was initiated with a daily administration of methylprednisolone 1000 mg. Diagnostic confirmation was sought through autoimmune panel and viral marker assessments, which yielded negative results. Endomyocardial biopsy (EMB) revealed CD4 and CD8–positive lymphocytic infiltration and myocardial necrosis. Despite initial clinical improvement, an arrhythmic storm developed. Despite treatment with a defibrillator, intravenous antiarrhythmic therapy (beta–blocker, amiodarone, and lidocaine), and sedation, the patient unfortunately succumbed. Immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of many solid tumors. However, the dysregulation of immune mechanisms can rarely (2%) lead to autoimmune events involving multiple organs. Myocarditis, despite optimal treatment, is characterized by a mortality rate exceeding 50%, representing a significant challenge in the Intensive Care Unit.

STELLATE GANGLION BLOCK: CLINICAL MONITORING AFTER INJECTION

Abstract 70–year–old man with chronic coronaric syndrome (CABG x 6 in 2006) and HFrEF. ICD implant in primary prevention in 2011. He was admitted for arrhythmic storms refractory to IV lidocaine therapy. Following sedation with midazolam, a left stellate ganglion block was performed using the ultrasound–guided lateral approach, injecting 200 mg of Lidocaine and 200 mg of Mepivacaine. After a few minutes, there was the appearance of anisocoria, different thermotouch in the upper limbs, ptosis, dysphonia, as an effect of local anesthetics on the sympathetic nervous system fibers and on the recurrent laryngeal nerve, near the stellate ganglion. At the same time, the arrhythmias did not recur. Among the rare complications described in the literature (usually transient) arising after stellate ganglion block for the treatment of various chronic pain syndromes or refractory ventricular arrhythmias, we find: hoarseness, stridor, confusion, cough, severe hypertension, subdural/intrathecal block with respiratory arrest, loss of consciousness and paralysis of the four limbs, epileptic seizures, transient locked–in syndrome, headache, visual hallucinations, myoclonus, Horner‘s syndrome, diaphragmatic palsy (phrenic nerve injury), allergic reactions, bleeding and hematoma formation, dural puncture, pneumothorax, local infections. Serious adverse effects described include cases of death or tetraplegia following epidural abscess. For this reason, it is of utmost importance monitoring after the procedure and the availability of the equipment necessary for a possible resuscitation to avoid long–term of sequelae. Conclusion In cases of arrhythmic storm refractory to antiarrhythmic therapy, percutaneous stellate ganglion block is an effective and safe procedure and serious complications are rare.

The point on the treatment of arrhythmic storm.

Arrhythmic storm is a clinical emergency associated with high mortality, which requires multi-disciplinary management. Reprogramming of the implantable cardiac defibrillator (ICD) aimed at reducing shocks, adrenergic blockade using beta-blockers, sedation/anxiolysis, and blockade of the stellate ganglion represent the first simple and effective manoeuvres, but further suppression of arrhythmias with antiarrhythmics is often required. A low-risk patient (e.g. monomorphic ventricular tachycardia, functioning ICD, and haemodynamically stable) should be managed with a beta-blocker (possibly non-selective) plus amiodarone, in addition to sedation with a benzodiazepine or dexmedetomidine; in patients at greater risk (high burden and haemodynamic instability), autonomic modulation with blockade of the stellate ganglion and the addition of a second antiarrhythmic (lidocaine) should be considered. In patients refractory to these measures, with advanced heart failure, general anaesthesia with intubation and the establishment of a haemodynamic circulatory support should be considered. Ablation, performed early, appears to be superior in terms of mortality and reduction of future shocks compared with titration of antiarrhythmics.

Stellate ganglion blockade for the management of ventricular arrhythmia storm.

Stellate ganglion blockade for the management of ventricular arrhythmia storm.

Bloqueo del ganglio estrellado como tratamiento de la tormenta arrítmica: estudio observacional

IntroductionArrhythmic storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, a stellate ganglion block can contribute to the control of the arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of the study is to assess the effectiveness and safety of stellate ganglion blocks for the treatment of refractory arrhythmic storm. MethodFollow-up of a cohort of patients with refractory arrhythmic storm that met the criteria for performing stellate ganglion blocks. The block was ultrasound-guided at C6-level using local anaesthetic and a steroid, left unilateral first, bilateral if no response, and followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse. ResultsSeven patients were included, with a mortality rate during admission of 14.29%. Four patients received unilateral and three bilateral stellate ganglion blocks. Six were ablated and one of them had an implanted cardioverter-defibrillator. Arrhythmic storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three underwent radiofrequency ablation and two underwent surgical thoracic sympathectomy. The only side effect was Horner's syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two died after discharge and four are still at home, three of them without further admission due to ventricular events for more than two years. ConclusionAn ultrasound-guided stellate ganglion block is an effective and safe technique in the treatment of refractory arrhythmic storm as a complement to the usual cardiological treatment.

Stellate ganglion block for the management of electrical storm: An observational study

IntroductionElectrical storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, stellate ganglion block can help control arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of this study is to assess the effectiveness and safety of stellate ganglion block in the management of refractory arrhythmic storm. MethodFollow-up of a cohort of patients with refractory electrical storm that met the criteria for performing stellate ganglion block. The block was ultrasound-guided at C6 using local anaesthetic and a steroid – left unilateral first, bilateral if no response, followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse. ResultsSeven patients were included. The in-hospital mortality rate was 14.29%. Four patients received unilateral and 3 bilateral stellate ganglion block. Six were ablated and 1 received an implantable cardioverter-defibrillator. Electrical storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three patients underwent radiofrequency ablation and 2 underwent surgical thoracic sympathectomy. The only side effect was Horner’s syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two patients died after discharge and 4 are alive at the time of writing, 3 of them have not been re-admitted for ventricular events for more than 2 years. ConclusionUltrasound-guided stellate ganglion block is an effective and safe complement to standard cardiological treatment of refractory electrical storm.

Emergency out-of-hours catheter ablation for ventricular arrhythmia storm: a UK and Australian experience.

There are limited data on emergency catheter ablation (CA) for ventricular arrhythmia (VA) storm. We describe the feasibility and safety of performing emergency CA in an out-of-hours setting for VA storm refractory to medical therapy at 2 tertiary hospitals. Twenty-five consecutive patients underwent out-of-hours (5pm-8am [weekday] or Friday 5pm-Monday 8am [weekend]) CA for VA storm refractory to anti-arrhythmic drugs and sedation. Baseline and procedural characteristics along with outcomes were compared to 91 consecutive patients undergoing weekday daytime-hours (8am-5pm) CA for VA storm. More patients undergoing out-of-hours CA had a left ventricular ejection fraction ≤35% (68% vs. 42%, P = 0.022), chronic kidney disease (60% vs. 20%, P < 0.001), and presented following a resuscitated out-of-hospital cardiac arrest (56% vs. 5%, P < 0.001), compared to the daytime-hours group. During median follow-up (377 [interquartile range 138-826] days), both groups experienced similar survival free from recurrent VA and VA storm. Survival free from cardiac transplant and/or mortality was lower in the out-of-hours group (44% vs. 81%, P = 0.007), but out-of-hours CA was not independently associated with increased cardiac transplant and/or mortality (hazard ratio 1.34, 95% confidence interval 0.61-2.96, P = 0.47). Of the 11 patients in the out-of-hours group who survived follow-up, VA-free survival was 91% and VA storm-free survival was 100% at 1-year after CA. Out-of-hours CA may occasionally be required to control VA storm and can be safe and efficacious in this scenario. During follow-up, cardiac transplant and/or mortality is common but undergoing out-of-hours CA was not predictive of this composite endpoint.

Printzmetal angina complicated by arrhythmic storm

Printzmetal angina complicated by arrhythmic storm

Prognosis of patients undergoing catheter ablation of arrhythmic storm in patients with and without history of previous ICD interventions

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation (CA) improves prognosis in patients with electrical storm (ES). However, its effectiveness and timing in patients with ventricular tachycardia and appropriate ICD therapies remain a matter of debate. Purpose Our aim was to investigate whether patients with history of discrete ventricular tachycardia episodes had different clinical features and outcome compared to patients with ES as first arrhythmic occurrence. Methods We enrolled 57 consecutive patients undergoing CA for ES and collected clinical, echocardiographic and electroanatomic mapping data. The primary end point was a composite of death from any cause and recurrences of sustained VT or ventricular fibrillation, appropriate ICD therapy, or ES. Results During a median follow up of 39 months, 28 patients (49%) met the primary end point of arrhythmic recurrence or death from any cause. There were no significant differences between clinical, electrocardiographic and echocardiographic parameters in the two groups. Regarding ICD therapies, patients with who met the primary end point had a higher number of ATP/shock episodes preceding the ES event: 15 (52%) vs 25 (89%), p=0.002. At Cox regression analysis, NIDCM, previous ATP and/or shock and ≥3 ATP were associated with arrhythmic recurrences and/or death. At multivariate analysis, ≥3 ATP was the only predictor that met statistical significance for the primary end point: HR was 30.41, CI 4.42 – 209.12, p=0.001. When dividing our population in patients and without ventricular arrhythmias (VAs) with appropriate device intervention before ES, thoses with VAs arrhythmias before ES had a higher percentage of presence of late potentials (80% vs 55%, p=0.041) and a greater unipolar scar (59.2±41.6 vs 30.2±21.6, p=0.001). At univariate analysis the presence of late potentials was associated with ventricular arrhythmias before ES (OR 3.33, CI 1.03-10.84, p=0.045). Conclusions CA in patients with a long arrhythmia history, recurrent ICD therapies and presence of late potentials at electroanatomic mapping, may yield worse outcomes and therefore our results support an early referral for CA of VT to improve prognosis in these subjects.

P242 CARDIOGENIC SHOCK WITH ISCHEMIC PHENOTYPE SECONDARY TO INCESSANT VENTRICULAR TACHYCARDIA: A CALL FOR IMPLEMENTATION OF HUB–AND–SPOKE MODEL

Abstract A 55–years–old patient presents to emergency room with extensive anterior STEMI, complicated by acute pulmonary edema. The ECG showed sinusal tachycardia, Q waves in V1–V3, ST elevation &amp;gt;2mm V2–V6. The echocardiogram showed akinesia of the apex and anterolateral wall with severe reduction of contractile function (LVEF 30%). The patient was treated with CPAP, dual antiplatelet therapy and diuretics; the urgent coronary angiography showed three–vessel disease with occlusion of the proximal LAD, treated with PCI and two drug–eluting stents implantation. 48 after admission to ICU, the patient developed "combined" shock (IC↓ RVS↓ WP↑), sustained by both severe cardiac dysfunction and a septic complication, requiring inotropes and targeted antibiotic therapy (noradrenaline 0.02 gamma/Kg/min and piperacillin/tazobactam i.v). At 96 hours there was a recovery of contractile function and haemodynamics (CI from 1.8 to 2.7). Weaned from inotropes, he began therapy with low doses of ACE inhibitor, beta blocker, antialdosteronic. On the 7th day of hospitalization, without ischemic and/or electrolyte "triggers", the patient developed "arrhythmic storm" with incessant sustained ventricular tachycardias. Arrhythmias persisted despite antiarrhythmics (magnesium sulfate, amiodarone, lidocaine), IOT, sedation, mechanical ventilation. The temporary pacemaker for overdrive pacing was placed in. After placement of IABP, the patient underwent revascularization of residual coronary artery stenosis. Despite 1 hour of assistance (ABLS), incessant ventricular tachycardia persisted; a third–level center for VA–ECMO inside support was called. After positioning VA–ECMO there was progressive clinical stabilization and –concomitantly– a progressive reduction of ventricular tachycardias. ECMO support was needed for over 7 days due to persistence of arrhythmic storm; it was slowly weaned with stabilization of the patient; an AICD was implanted. Residual function of the left ventricle was mild reduced (LVEF40%) despite protracted CPR. There wasn’t residual cognitive impairment. Implementation of multidisciplinary teams in the spoke centers would improve protocols and early treatments in patients with cardiogenic shock; spoke centers would provide early access to life–saving therapies and safe transfer to hub centers.