Management of Ventricular Electrical Storm: A Contemporary Appraisal

Gurukripa N. Kowlgi; Yong-Mei Cha

Disclosures

Europace. 2020;22(12):1768-1780. 

In This Article

Abstract and Introduction

Abstract

Ventricular electrical storm (VES) is a clinical scenario characterized by the clustering of multiple episodes of sustained ventricular arrhythmias (VA) over a short duration. Patients with VES are prone to psychological disorders, heart failure decompensation, and increased mortality. Studies have shown that 10–28% of the patients with secondary prevention ICDs can sustain VES. The triad of a susceptible electrophysiologic substrate, triggers, and autonomic dysregulation govern the pathogenesis of VES. The rate of VA, underlying ventricular function, and the presence of implantable cardioverter-defibrillator (ICD) determine the clinical presentation. A multi-faceted approach is often required for management consisting of acute hemodynamic stabilization, ICD reprogramming when appropriate, antiarrhythmic drug therapy, and sedation. Some patients may be eligible for catheter ablation, and autonomic modulation with thoracic epidural anesthesia, stellate ganglion block, or cardiac sympathetic denervation. Hemodynamically unstable patients may benefit from the use of left ventricular assist devices, and extracorporeal membrane oxygenation. Special scenarios such as idiopathic ventricular fibrillation, Brugada syndrome, Long and short QT syndrome, early repolarization syndrome, catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular cardiomyopathy, and cardiac sarcoidosis have been described as well. VES is a cardiac emergency that requires swift intervention. It is associated with poor short and long-term outcomes. A structured team-based management approach is paramount for the safe and effective treatment of this sick cohort.

Introduction

Ventricular electrical storm (VES) is a clinical scenario characterized by the clustering of multiple episodes of sustained ventricular arrhythmias (VAs) over a short duration. Several definitions of VES have been proposed over the years (Supplementary material online, Table S1), but the most widely accepted one is three or more episodes of sustained VA occurring within 24 h, requiring either anti-tachycardia pacing (ATP) or implantable cardioverter-defibrillators (ICDs) shocks, with each event separated by at least 5 min.[1–5] In patients without ICDs, VES is typified by three or more discrete occurrences of sustained VA.[1,6]

Patients with VES are prone to psychological disorders, heart failure decompensation, and increased mortality.[7,8] The management of VES is genuinely multidisciplinary, including but not limited to: thorough clinical evaluation, resuscitation skills, critical care management with sedation, ICD reprogramming, medical therapies, ablation, and sympathetic modulation procedures.[9,10] Not surprisingly, VES has a tremendous impact on healthcare resources. Prompt recognition of VES and implementation of rapid treatment can be the difference between life and death. With this comprehensive review, we attempt to provide an up-to-date contemporary understanding and management of VES.

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