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Review
. 2023 Jun 6;81(22):2189-2206.
doi: 10.1016/j.jacc.2023.03.424.

Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review

Jacob C Jentzer  1 , Peter A Noseworthy  2 , Anthony H Kashou  2 , Adam M May  3 , Jonathan Chrispin  4 , Rajesh Kabra  5 , Kelly Arps  6 , Vanessa Blumer  7 , James E Tisdale  8 , Michael A Solomon  9 ; American College of Cardiology Critical Care Cardiology and Electrophysiology Sections
Affiliations
Review

Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review

Jacob C Jentzer et al. J Am Coll Cardiol. .

Abstract

Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of underlying arrhythmogenic cardiac substrate and reversible triggers is essential, as is interrogation and programming of an implantable cardioverter-defibrillator, if present. Medical management includes antiarrhythmic drugs, beta-adrenergic blockade, sedation, and hemodynamic support. The initial intensity of these interventions should be matched to the severity of ES using a stepped-care algorithm involving escalating treatments for higher-risk presentations or recurrent ventricular arrhythmias. Many patients with ES are considered for catheter ablation, which may require the use of temporary mechanical circulatory support. Outcomes after ES are poor, including frequent ES recurrences and deaths caused by progressive heart failure and other cardiac causes. A multidisciplinary collaborative approach to the management of ES is crucial, and evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode.

Keywords: cardiomyopathy; heart failure; implantable cardioverter-defibrillator; myocardial infarction; shock; sudden cardiac death; ventricular fibrillation; ventricular tachycardia.

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Conflict of interest statement

Funding Support and Author Disclosures No extramural funding was directly involved in the conduct of this research. Dr Noseworthy has received research funding from National Institutes of Health (including the National Heart, Lung, and Blood Institute [R21AG 62580-1, R01HL 131535-4, R01HL 143070-2] and the National Institute on Aging [R01AG 062436-1]), Agency for Healthcare Research and Quality (R01HS 25402-3), U.S. Food and Drug Administration (FD 06292), and the American Heart Association (18SFRN34230146); he and Mayo Clinic have filed patents related to the application of artificial intelligence to electrocardiography for diagnosis and risk stratification and have licensed several artificial intelligence–electrocardiography algorithms to Anumana; he and Mayo Clinic are involved in potential equity/royalty relationship with AliveCor; he has served as a study investigator in an ablation trial sponsored by Medtronic; and has served on an expert advisory panel for OptumLabs. Dr Kashou is supported by the National Institutes of Health (T32 HL007111) and the Department of Cardiovascular Medicine at Mayo Clinic. Dr May has equity rights and possibly royalties received by the Mayo Clinic from Anumana Inc. Dr Chrispin has served on the Advisory Board for Biosense Webster; and has received honorarium from Abbott for educational activities. Dr Tisdale is supported by the National Heart, Lung, and Blood Institute, the American Heart Association, and the Indiana Clinical and Translational Sciences Institute. Dr Solomon is employed by the National Institutes of Health; and has received research support from the National Institutes of Health Clinical Center intramural research funds; this written work does not represent the official opinion of the U.S. government. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1:
Figure 1:
Mechanisms of arrhythmogenesis in ES. Triggers such as myocardial ischemia, inflammation, or hemodynamic decompensation, as well as drug and electrolyte effects, often with accompanying autonomic nervous system imbalance, can lead to sustained VA due to reentry and/or after depolarizations in those with vulnerable anatomic or electrical substrates (e.g., myocardial scar). Perpetuation of the inciting trigger and the resulting sympathetic nervous system response leads to recurrent VA and ES.
Figure 2:
Figure 2:
A patient with an ICM presenting with ES secondary to inferior MI, resulting in inferior left ventricular scar as shown by (A) late gadolinium enhancement on cardiovascular magnetic resonance imaging. (B) The imaging correlated with areas of low voltage (red circle) on electroanatomical mapping during VT ablation in the inferior left ventricle. (C) Activation mapping in sinus rhythm demonstrated areas of late activation and slow conduction (red circle) that corresponded to the area of scar.
Figure 3:
Figure 3:
Diagnostic and clinical assessment and risk stratification for patients with electrical storm.
Figure 4:
Figure 4:
Stepped-care algorithm for rational escalation of medical therapy in ES. Higher-risk presentations may justify starting at step 2 and increasing to the next step is warranted in case of recurrent VA.
Figure 5:
Figure 5:
Risk stratification using the PAINESD score (left) and procedural checklist (right) for planning prior to catheter ablation.
Central Illustration:
Central Illustration:
Global approach to the evaluation and management of ES including diagnostic assessment, risk stratification, medical therapy, and catheter ablation.
See this image and copyright information in PMC

References

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