Electrical storm management in structural heart disease

Abstract

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.

Keywords: Ablation; Electrical storm; Neuromodulation; Sedation; Ventricular arrhythmias.

Figure 1

Proposed management of patients with electrical storm and structural heart disease. ACLS, advanced cardiovascular life support; BB, beta-blocker; CSD, cardiac sympathetic denervation; ECMO, extracorporeal membrane oxygenation; HTx, heart transplant; ICD, implantable cardioverter defibrillator; LVAD, left ventricular assist device; PLSGB, percutaneous left stellate ganglion block; pVADs, percutaneous ventricular assist devices; RFCA, radiofrequency catheter ablation; SCAI, Society for Cardiovascular Angiography and Interventions; TEA, thoracic epidural anaesthesia.