Management Of Electrical Storm Research Articles

Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society.

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.

Electrical storm management in the cardiac care unit

Electrical storm (ES) is characterized by at least three separate episodes of ventricular arrhythmia (VA) over 24 h that require treatment or an incessant VA lasting >12 h. The incidence is higher in patients with implantable cardioverter-defibrillators (ICDs) in secondary prevention and the main manifestation is monomorphic VA. ES onset represents a major event in the history of patients with cardiomyopathies that significantly worsens prognosis. The management of ES is complex and requires a multidisciplinary approach including a comprehensive clinical assessment, resuscitation and sedation management skills, ICD reprogramming, ablation, and neuromodulation procedures. ES early recognition and prompt treatment initiation increase the chances of therapeutic success. Each one of these aspects will be properly discussed in the present decalogue. Notably, ES management remains a challenge, with only limited available evidence from small retrospective series and a substantial lack/limited number of randomized or prospective trials. The spectrum of available antiarrhythmic drugs is limited, as well as their efficacy. The future hope is that larger prospective studies will be able to answer important questions, concerning the most effective pharmacologic strategies, the timing for the invasive treatment, the indications for acute neuromodulation strategies and for the circulatory support tools.

PO-04-185 SAFETY AND EFFICACY OF BEDSIDE ULTRASOUND-GUIDED SYMPATHETIC BLOCKADE BY PROXIMAL INTERCOSTAL BLOCK IN PATIENTS WITH ELECTRICAL STORM

Electrical storm (ES) patients (pts) who fail standard therapies have a high mortality rate. Previous studies report effective management of ES with bedside, ultrasound-guided percutaneous stellate ganglion block (SGB) as single injection or continuous infusion of local anesthetics. SGB can be technically challenging by the presence of other catheters and support devices in the anatomical area. We report our experience with sympathetic blockade administered by the regional anesthesiology team via the alternative proximal intercostal block (PICB) (Figure 1A-C). This technique targets an area typically free of catheters and support devices, and may pose less strict requirements for anticoagulation interruption, along with lower risk of focal neurologic side effects. To describe safety and efficacy of PICB in patients with refractory ES. We reviewed our institutional data on ES pts who underwent PICB between 1/2019-10/2022 to analyze procedural safety, short and long-term outcome. Total of 12 pts with ES underwent PICB during this period (Table 1). Five pts initially had left SGB, but 2/5 required PICB due to need for prolonged infusion and rotating site of infusion catheter. Three pts underwent PICB due to lack of efficacy of SGB alone. Sympathetic blockade efficacy appeared higher when left SGB was combined with PICB with response rate of 71.4%. Among ten pts who presented with recurrent ICD shocks (Figure 1D), nine had no further ICD shock after PICB until discharge, heart transplant, or death (P=0.01). There was no procedure-related complication or focal neurologic symptoms. Overall, 8 (66.7%) pts had VT ablation, 9 (75%) pts survived to discharge, 2 (16.7%) pts underwent heart transplantation, 1 (8.4%) patient had ventricular assist device implanted as a bridge to transplant, and 2 (16.7%) pts died. During median of 168 +/- 148.5 days follow up on those pts who survived to discharge without heart transplant, 71.4% remain free of any VT recurrence. In patients with refractory ES, continuous PICB provided safe and effective sympathetic block with no incidence of block-related focal neurologic symptoms. In our series, overall PICB efficacy was 66.7% and the combination of PICB and left SGB appeared complementary. The potential benefits of bilateral sympathetic blocks or block combinations should be carefully weighed against patient- and technique-specific risks and side effects. Larger studies are needed to compare these treatment techniques.

Electrical storm management in structural heart disease.

Electrical storm (ES) is a life-threatening condition characterized by at least three separate episodes of ventricular arrhythmias (VAs) over 24 h, each requiring therapeutic intervention, including implantable cardioverter defibrillator (ICD) therapies. Patients with ICDs in secondary prevention are at higher risk of ES and the most common presentation is that of scar-related monomorphic VAs. Electrical storm represents a major unfavourable prognostic marker in the history of patients with structural heart disease, with an associated two- to five-fold increase in mortality, heart transplant, and heart failure hospitalization. Early recognition and prompt treatment are crucial to improve the outcome. Yet, ES management is complex and requires a multidisciplinary approach and well-defined protocols and networks to guarantee a proper patient care. Acute phase stabilization should include a comprehensive clinical assessment, resuscitation and sedation management skills, ICD reprogramming, and acute sympathetic modulation, while the sub-acute/chronic phase requires a comprehensive heart team evaluation to define the better treatment option according to the haemodynamic and overall patient's condition and the type of VAs. Advanced anti-arrhythmic strategies, not mutually exclusive, include invasive ablation, cardiac sympathetic denervation, and, for very selected cases, stereotactic ablation. Each of these aspects, as well as the new European Society of Cardiology guidelines recommendations, will be discussed in the present review.

Early ganglion stellate blockade as part of two-step treatment algorithm suppresses electrical storm and need for intubation

BackgroundFor the treatment of patients with electrical storm (ES), we established a two-step algorithm comprising standard anti-arrhythmic measures and early ultrasound-guided stellate ganglion blockade (SGB). In this single-center study, we evaluated the short-term efficacy of the algorithm and tested the hypothesis that early SGB might prevent the need for intubations. MethodsOverall, we analyzed data for 70 ES events in 59 patients requiring SGB (mean age 67.7 ± 12.4 years, 80% males, left ventricular ejection fraction 30.0% ± 9.1%), all with implantable cardioverter-defibrillators (ICDs). ResultsThe mean time from ES onset to SGB was 13.2 ± 12.3 hours. Percentage and mean absolute reduction in shocks at 48 hours after SGB reached 86.8% (−6.3 shocks), and anti-tachycardiac pacing (ATP) declined by 65.9% (−51.1 ATPs; all P < 0.001). Patients with the highest sustained ventricular arrhythmia (VA) burden (shocks ≥10/48 h; ATPs 10–99/48 h and ≥100/48 h) experienced the highest percentage decrease in ICD therapy (shocks −99.1%; ATPs −92.1% and −100.0%, respectively). For clinical response by defined criteria and two outcome periods (1/no sustained VA ≤48 hours post SGB, and 2/no ICD shock or <3 ATPs/day from day 3 to discharge/catheter ablation/day 8), 75.7% and 76.1% experienced complete response, respectively. Catecholamine support, no/low-dose β-blocker therapy, polymorphic/mixed-type VA, and baseline sinus rhythm versus atrial fibrillation were more frequent in patients with early arrhythmia recurrence. Temporary Horner's syndrome occurred in 67.1%, and no other adverse events were recorded. Intubation and general anesthesia during and after SGB were not needed. ConclusionThe presented two-step algorithm for treating ES proved efficacious and safe. The results support implementation of early SGB in routine ES management.

Management of patients with electrical storm: an educational review.

Electrical storm (ES) is a medical emergency that is defined as ≥ 3 separate ventricular tachycardia (VT) episodes causing ICD therapy within 24 h. Patients with ES have high risk for hospitalization, heart failure decompensation, in-hospital death. Furthermore, it is associated with significant anxiety and distress for the patients. Frequent triggers of ES are myocardial ischemia, acute decompensation of heart failure, metabolic and electrolyte disorders, drug side effects, increased sympathetic tone. Acute management of ES requires sedation, antiarrhythmic drugs and correction of the precipitating factors; although, in severe refractory cases, intubation, mechanical ventilation and circulatory support might be necessary. Radiofrequency catheter ablation is superior than antiarrhythmic drugs to suppress the ES and is also frequently required to terminate the ES as well as to achieve acute and long-term freedom of VT. Optimization of the ICD programming is crucial to reduce the burden of further appropriate and inappropriate shocks. Use of appropriate discrimination criteria and algorithms, ATPs and extending the detection times are important measures to reduce the burden of ES. In patients with end-stage heart failure, ES can be a sign of failing heart and can be refractory of treatment. In such cases, deactivation of the ICD therapy should be considered and discussed with patients and their care givers.

The new ESC guidelines on the management of ventricular tachyarrhythmias : Implications for daily practice

The recently published guidelines of the European Society of Cardiology (ESC) on the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death is an update of the 2015 guideline. For the first time anew section is dedicated to public basic life support. In the acute treatment of ventricular arrhythmias electrical cardioversion is upgraded, and there is anew focus on the management of electrical storm. Recommendations for the comprehensive diagnostic evaluation of patients with first manifestations of ventricular arrhythmias structured according to common clinical scenarios are also new. Both genetic testing and cardiac magnetic resonance imaging are upgraded, not only for diagnostic evaluation but also for risk stratification. In the long-term management, recommendations for pharmacotherapy are aligned with current heart failure guidelines. Catheter ablation has gained relevance not only for recurrent ventricular tachycardia under amiodarone treatment and as an alternative to implantable cardioverter defibrillation (ICD) implantation in selected patients with coronary artery disease but also particularly in the treatment of idiopathic ventricular extrasystoles and tachycardia. The ICD treatment remains an essential component of primary and secondary prevention of sudden cardiac death. Of note, the recommendation on primary preventive ICD treatment for patients with dilated cardiomyopathy and left ventricular ejection fraction (LVEF) ≤ 35% has been downgraded. In addition to LVEF acombination of risk factors and risk calculators is included in the recommendations on primary prophylactic ICD implantation. Overall, due to numerous tables and practical algorithms, the guidelines have become auser-oriented reference book.

Electrical Storm in the ICU – When all Options Run Out

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.

Outcomes of a PAINESD score–guided multidisciplinary management approach for patients with ventricular tachycardia storm and advanced heart failure: A pilot study

The management of electrical storm from ventricular tachycardia (VT-ES) in patients with structural heart disease and advanced heart failure (advanced HF) is challenging. In addition to refractory VT, the downstream sequelae of VT-ES in patients with advanced HF include further worsening of pump function and end-organ damage, often leading to early mortality.1–4 Catheter ablation is an important strategy in the management of drug-refractory VT-ES but carries a high risk of periprocedural morbidity and adverse outcomes.

Incidence and predictors of mortality after an electrical storm in the ICU.

For assessing predictors of early mortality following hospitalization for electrical storm (ES), only limited data are available. The purpose of this study was to assess the incidence and predictors of early mortality following hospitalization in the intensive care unit (ICU) for ES in a large retrospective study. In this retrospective study, we included all patients who were hospitalized for ES from July 2015 to May 2020 in our tertiary centre. A total of 253 patients were included. The median age was 66 [56; 73], and 64% had ischemic cardiomyopathy. A total of 37% of patients presented hemodynamic instability requiring catecholamine at admission. A total of 17% of patients presented an acute reversible cause for ES. The one-year mortality was 34% (95% CI, 30-43%), mostly driven by heart failure (HF). The multivariable Cox's regression model identified age, left ventricular ejection fraction, right ventricle dysfunction, haemoglobin level as independent predictors of one-year mortality. The use of catecholamine at admission was identified as the only variable related to the initial management of ES associated with an increased 30-day mortality risk (HR: 7.95 (95%CI, 3.18-19.85). In patients admitted for ES in ICU, the one-year mortality remains high and mostly driven by HF. The use of catecholamine at admission is associated with a seven-fold risk for mortality within 30 days. In such patients, the potential use of VT ablation can be questioned and a careful action plan regarding invasive HF-related therapy could be considered.

Stellate ganglion blockade with percutaneous bupivacaine injection followed with surgical denervation in the management of electrical storm

Electrical storm is a life-threatening medical emergency that requires immediate diagnosis and treatment. It can remain a clinical challenge despite anti-arrhythmic drugs and catheter ablation therapies. Autonomic modulation techniques have gained increased recognition in the treatment of refractory electrical storm cases. In our case, we present a patient with recurrent ventricular tachycardia/fibrillation episodes one week after a myocardial infarction. Patient's arrhythmia was refractory to antiarrhythmic drugs and hemodynamical status was unstable, thus catheter ablation under temporary mechanical circulatory support was the initial strategy. Ventricular fibrillation episodes relapsed 48 h after catheter ablation and we proceeded with autonomic modulation treatment options. Bilateral stellate ganglion blockade was performed under ultrasound guidance using bupivacaine. Sinus bradycardia was present and no ventricular arrhythmias were detected on post-procedure ECG. Stellate ganglion blockade was complemented with video-assisted thoracoscopic cardiac sympathetic denervation. After the last procedure, patient remained on sinus rhythm, was hemodynamically stable and extubated successfully.

Electrical storm in patients with left ventricular assist devices: Risk factors, incidence, and impact on survival

Ventricular arrhythmias (VAs) and electrical storm (ES) are recognized complications following left ventricular assist device (LVAD) implantation; however, their association with long term-outcomes remains poorly understood. The purpose of this study was to describe the clinical impact of ES in a population of patients undergoing LVAD implantation at a quaternary care center in the United States. This was an observational retrospective study of patients undergoing LVAD implantation from 2009 to 2020 at Duke University Hospital. The incidence of ES (≥3 sustained VA episodes over a 24-hour period without an identifiable reversible cause) was determined from patient records. Risk factors for ES were identified using multivariable Cox proportional hazards modeling. Among 730 patients undergoing LVAD implant, 78 (10.7%) developed ES at a median of 269 (interquartile range [IQR] 7-766) days following surgery. Twenty-seven patients (34.6%) developed ES within 30 days, while 51 (65.4%) presented with ES at a median 639 (IQR 281-1017) days after implant. Following ES, 41% of patients died within 1 year. Patients who developed ES were more likely to have a history of VAs, ventricular tachycardia ablation, antiarrhythmic drug use, and perioperative mechanical circulatory support around the time of LVAD implant than patients without ES. ES occurs in 1 in 10 patients after LVAD and is associated with higher mortality. Risk factors for ES include a history of VAs, VT ablation, antiarrhythmic drug use, and perioperative mechanical circulatory support. Optimal management of ES surrounding LVAD implant, including escalation of medical therapy, catheter ablation, or adjunctive sympatholytic therapies, remains uncertain.

Just the facts: management of electrical storm and recurrent ICD shocks in the emergency department.

Just the facts: management of electrical storm and recurrent ICD shocks in the emergency department.

Prognosis at one year after urgent catheter ablation for electrical storm in patients with scar-related left ventricular cardiomyopathy

Electrical storm (ES) is a severe event in patients with scar-related left ventricular cardiomyopathy. Prognosis factors of ventricular arrhythmias (VA) recurrence and death after catheter ablation (CA) are not clearly identified in this population. Aims of this study is to identify prognosis factor of VA recurrences and death at 30 days and one year after CA. Patients with scar-related left ventricular cardiomyopathy hospitalised for urgent CA for ES in four tertiary referral university hospitals (AP–HP, Paris) were retrospectively included. Patients’ characteristics, ES management and one-year follow-up were collected. In total, 124 patients with scar related left ventricular cardiomyopathy who underwent urgent CA for ES were included. Polymorphic VA (HR = 2.15 95% CI [1.16–3.97], P = 0.02) was independently associated with VA recurrences at 30 days. Dilated cardiomyopathy (DCM) was associated with VA recurrences (HR = 2.25 95% CI [1.31–3.87], P = 0.003) whereas beta-blockers at baseline were associated with less VA recurrences (HR = 0.46 95% CI [0.26–0.83], P = 0.01) at one year. PAINESD Score (HR = 1.09 95% CI [1.01–1.19], P = 0.04) and need for circulatory support (HR = 4.20 95% CI [1.81–9.75], P = 0.04) were associated with 30 day-mortality. PAINESD Score (HR = 1.10 95% CI [1.03–1.16], P = 0.003), DCM (HR = 3.52 95% CI [1.75–7.08], P < 0.0001) and circulatory support (HR = 3.55 95% CI [1.83–6.84], P < 0.0001) were associated with one year-mortality. At one year, 22% of patients who underwent cardiac graft and 50% with long-term LVAD died. Polymorphic VA is associated with VA recurrence at 30 days. PAINESD score was significantly associated with early and late mortality. Patients with DCM presented a higher risk of VA recurrence and death at one year.

Anatomical-based percutaneous left stellate ganglion block in patients with drug-refractory electrical storm and structural heart disease: a single-centre case series.

The adoption of percutaneous stellate ganglion blockade for the treatment of drug-refractory electrical storm (ES) has been increasingly reported; however, the time of onset of the anti-arrhythmic effects, the safety of a purely anatomical approach in conscious patients and the additional benefit of repeated procedures remain unclear. This study included consecutive patients undergoing percutaneous left stellate ganglion blockade (PLSGB) in our centre for drug-refractory ES. Lidocaine, bupivacaine, or a combination of both were injected in the vicinity of the left stellate ganglion. Overall, 18 PLSGBs were performed in 11 patients (age 69 ± 13 years; 63.6% men, left ventricular ejection fraction 31.6 ± 16%). Seven patients received only one PLSGB; three underwent two procedures and one required three PLSGB and two continuous infusions to control ventricular arrhythmias (VAs). All PLSGBs were performed with an anatomical approach; lidocaine, alone, or in combination was used in 77.7% of the procedures. The median burden of VAs 1 h after each block was zero compared with five in the hour before (P < 0.001); 83% of the patients were free from VAs; the efficacy at 24 h increased with repeated blocks. The anti-arrhythmic efficacy of PLSGB was not related to anisocoria. No procedure-related complications were reported. Anatomical-based PLSGB is a safe and rapidly effective treatment for refractory ES; repeated blocks provide additional benefits. Percutaneous left stellate ganglion blockade should be considered for stabilizing patients to allow further ES management.

Long-term follow up after renal denervation for the electrical storm management

Abstract Background/Introduction Electrical storm (ES) is a potentially lethal state developing in 4–28% of ICD patients. Neuroaxial modulation (beta-blockers, deep sedation, epidural anesthesia, stellate ganglion blockade etc) is used to decrease arrhythmogenic predisposition of ventricular myocardium to trigger and maintain ventricular arrhythmias. Catheter renal arterial denervation (RDN) is recently described to prevent atrial fibrillation recurrence after pulmonary vein isolation. We used this procedure in addition to standard care to improve the results of ES treatment. Purpose This retrospective single-center case-series is aimed to analyze ES patient population and describe the effect of RDN on the in-hospital number of ventricular tachycardia (VT) episodes and ICD shocks and on the mid-term survival. Methods Pts admitted to the CCU for more than 3 sustained VT episodes or more than 3 appropriate ICD shocks during the 24h period in 2017–18 were enrolled into study. Demographic, echocardiographic, ICD check up, renal arteries anatomy and mid-term mortality/transplant data were retrospectively analyzed. Results Twelve pts (10 male, age 69,3±9,8 years; 2 female, age 72,0±8,5) were included. Nine pts (75%) had CAD, 3 pts (25%) – DCM. Echocardiography revealed LVEF 30±9%, and LV EDV – 216±38 ml. Time from ICD implantation to ES onset was from 4 mos to 13 yrs. In 2 pts RDN was performed after VT ablation, in 1 pt – both RDN and VT ablation were performed during the same procedure, in 4 pts – RDN was done prior to VT ablation and in 5 pts - without VT ablation. Mean number of ablations was 4,8 per artery. The power was 2 to 11 Wt and lesion duration was 90 sec. In 1 pt RF-balloon-based technology was used to achieve RDN. Dramatic decrease in the number of VT episodes (49c52 vs. 6±2) was found in 6/12 pts directly after RDN procedure. In-hospital rhythm control was accessed in 10/12 pts, 1 pt with DCM was transferred for heart transplant despite VT ablation and RDN. There were no RDN procedure related complications in this group of pts. During mean 22 mos of follow-up 2/11 pts needed repeat hospitalization due to ES recurrence (VT ablation and 2-chamber ICD to CRT-D upgrade, respectively, were performed), 2/11 died (1-probably arrhythmic death, 1-other cause), 1/11 was lost for follow up. Total efficacy of RDN after almost 2 years in this study was 50%. Mean LVEF increased to 38±7%. Conclusion(s) Catheter renal artery denervation is effective and safe additional procedure to treat ES patients. It allows decreasing the number of ICD shocks and decreases arrhythmogenic potential of ventricular myocardium. Prospective registry is warranted. Funding Acknowledgement Type of funding source: None

Electrical Storm: Current Evidence, Clinical Implications, and Future Perspectives.

Electrical storm (ES) is a life-threatening medical emergency of repetitive episodes of sustained ventricular arrhythmias within a short period. Its occurrence is associated with poor short- and long-term survival, even in patients with implantable cardioverter defibrillators (ICD). Management of ES is challenging and mainly based on retrospective studies. This article reviews the existing literature on ES, presents the available data regarding its management, and proposes a new algorithm based on current evidence. Recent research could modify the management of ES supporting the role of non-selective β1 and β2 blockade and the early intervention with catheter ablation as well as strengthening the role of cardiac sympathetic denervation. A multipronged approach should be considered for the management of ES including identification and correction of reversible causes, ICD reprogramming, drug therapy (beta-blockers-especially non-selective ones-and other anti-arrhythmic drugs) and non-pharmacologic therapies such as catheter ablation and techniques of neuroaxial modulation. Although current data suggest early aggressive management, further research is required to clarify the optimal order and combination of therapies for the prevention of future events.

Update in Electrical Storm Therapy.

Electrical storm (ES) is a major life-threatening event, which announces a possible negative outcome and poor prognosis and poses challenging questions concerning etiology and management. A literature search was conducted through MEDLINE and EMBASE (past 30 years until the end of September 2018) using the following search terms: ES, ventricular fibrillation, ventricular tachycardia, ablation, and implantable defibrillator. Clinicaltrials.gov was also consulted for studies that are ongoing or completed. Additional articles were identified through bibliographical citations. There is no homogeneous attitude, and therapeutic strategies vary widely. The aim of this review is to define the concept of ES, to review the incidence and prognostic implications, and to describe the most common strategies of therapeutic advances and trends. The management strategy should be decided after an accurate risk stratification is done in initial evaluation according to hemodynamic tolerability and presence of triggers and comorbidities. General care should be provided in an intensive cardiovascular care unit. The cornerstone of acute medical therapy used in ES is mainly represented by amiodarone and beta-blockers. Deep sedation and mechanical ventilation should provide comfort for treatment administration. First-choice drugs are benzodiazepines and short-acting analgesics. General care may also include thoracic epidural anesthesia to modulate neuroaxial efferents to the heart and to decrease sympathetic hyperactivity. We include a special focus on ablation as a reliable tool to target the mechanism of arrhythmia, finally building an up-to-date standardization. ES management needs a complex assessment and interpretation of a critical situation in a life-threatening condition. Optimal implantable cardioverter-defibrillator-reprogramming, antiarrhythmic drug therapy and sedation are in first-line approach. Catheter ablation is the elective therapy and plays a central key role in the treatment of ES if possible in combination with hemodynamic support.

Management of Electrical Storm

Management of Electrical Storm

Electrical Storm in Patients with Implantable Cardioverter-defibrillators: A Practical Overview.

Electrical storm (ES) is an increasingly common medical emergency characterized by clustered episodes of sustained ventricular arrhythmias (VAs) that lead to repeated appropriate implantable cardioverter-defibrillator (ICD) therapies. A diagnosis of ES can be made with the occurrence of three or more sustained episodes of VAs, or of three or more appropriate ICD therapies within 24 hours in patients with implanted devices. ES is associated with poor outcomes in patients with structural heart disease, particularly those with severe left ventricular dysfunction. In large clinical trials involving patients with ICDs for primary and secondary prevention, ES appears to be a predictor of cardiac death, with notably higher rates of mortality soon after the event. ES management is challenging and requires special medical attention with accurate patient risk stratification and a multidisciplinary approach that includes the use of pharmacologic therapies such as antiarrhythmic drugs (AADs) and interventional approaches like catheter ablation, surgical ablation, or sympathetic neuromodulation. Initial management involves determining and addressing the underlying ischemia, any electrolyte imbalances, and/or other causative factors. Hemodynamic support needs to be considered in high-risk patients with unstable VAs or those with severe comorbidities such as low left ventricular ejection fraction, advanced New York Heart Association class, and/or chronic pulmonary disease. Following the acute phase of ES, treatment should shift towards maximizing therapeutic efforts to address heart failure, performing revascularization, and preventing subsequent VAs. In the present manuscript, we offer an overview of the most relevant clinical aspects of ES with regard to novel therapeutic strategies.