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Magdi, Mohamed, Mahmood Mubasher, Hakam Alzaeem, and Tahir Hamid. "Resistant Ventricular Arrhythmia and the Role of Overdrive Pacing in the Suppression of the Electrical Storm." Case Reports in Cardiology 2019 (May 22, 2019): 1–4. http://dx.doi.org/10.1155/2019/6592927.
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Ventricular arrhythmia storm is a state of cardiac instability characterized by multiple ventricular arrhythmias or multiple ICD therapies within a 24-hour duration. Management of this life-threatening state depends on the reversal of the cause besides either electrical or medical management of the arrhythmia. We report a case of a 54-year-old male who underwent a percutaneous coronary intervention following massive acute myocardial infarction. Afterwards, he developed frequent life-threatening ventricular arrhythmias that required multiple shocks and antiarrhythmic medications. Despite all these interventions, it was very difficult to control the electrical instability, but after overdrive ventricular pacing, the storm subsided and within a few days the case was stabilized. Overdrive pacing is an easy temporary modality to control the resistant arrhythmia following myocardial infarction.
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Pappone, Carlo, Gabriele Negro, and Giuseppe Ciconte. "Ventricular fibrillation ablation in cardiomyopathies and arrhythmic storm." European Heart Journal Supplements 23, Supplement_E (October 1, 2021): E112—E117. http://dx.doi.org/10.1093/eurheartj/suab104.
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Abstract Sudden cardiac death (SCD) is a relevant contributor to cardiovascular mortality, often occurring as a dramatic event. It can be the consequence of a ventricular tachycardia/fibrillation (VT/VF), a common and life-threatening arrhythmia. The underlying mechanisms of this catastrophic arrhythmia are poorly known. In fact, it can occur in the presence of a structural heart condition which itself generates the suitable substrate for this arrhythmia. Nevertheless, a VF may cause SCD also in young and otherwise healthy individuals, without overt structural abnormalities, generating difficulties in the screening and prevention of these patients. The implantable cardioverter-defibrillator represents the only therapy to contrast SCD by treating a VT/VF; however, it cannot prevent the occurrence of such arrhythmias. Catheter ablation is emerging as an essential therapeutic tool in the management of patients experiencing ventricular arrhythmias.
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Vicent, Lourdes, Miriam Juárez, Irene Martín, Jorge García, Hugo González-Saldívar, Vanesa Bruña, Carolina Devesa, Iago Sousa-Casasnovas, Francisco Fernández-Avilés, and Manuel Martínez-Sellés. "Ventricular Arrhythmic Storm after Initiating Sacubitril/Valsartan." Cardiology 139, no. 2 (2018): 119–23. http://dx.doi.org/10.1159/000486410.
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Objectives: Sacubitril/valsartan was approved recently for the treatment of patients with heart failure and reduced ejection fraction. We present 6 cases of ventricular arrhythmia, that occurred shortly after sacubitril/valsartan initiation, that required drug withdrawal. Other potential triggering factors of electrical storm were ruled out and, from the arrhythmic perspective, all of the patients were stable in the previous year. Our aim is to describe the possible association of sacubitril/valsartan with arrhythmic storm. Methods: This was an observational monocentric study performed in the first 7 months of sacubitril/valsartan commercialization in Spain (October 2016). All patients were included in the SUMA (Sacubitril/Varsartan Usado Ambulatoriamente en Madrid [Sacubitril/Valsartan Used in Outpatients in Madrid]) registry. Patients were consecutively enrolled on the day they started the drug. Ventricular arrhythmic storm was defined as ≥2 episodes of sustained ventricular arrhythmia or defibrillator therapy application in 24 h. Results: From 108 patients who received the drug, 6 presented with ventricular arrhythmic storm (5.6%). Baseline characteristics were similar in the patients with and without ventricular arrhythmic storm. The total number of days that sacubitril/valsartan was administered to each patient was 5, 6, 44 (8 since titration), 84, 93, and 136 (105 since titration), respectively. Conclusions: Our data are not enough to infer a cause-and-effect relationship. Further investigations regarding a potential proarrhythmic effect of sacubitril/valsartan are probably needed.
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Wong, Bethany, Lavanya Saiva, John Buckley, and Joseph Galvin. "A first case report of dapsone inducing recurrent ventricular arrhythmia." European Heart Journal - Case Reports 3, no. 4 (September 20, 2019): 1–6. http://dx.doi.org/10.1093/ehjcr/ytz158.
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Abstract Background Ventricular arrhythmias (VAs) are life-threatening arrhythmias which are associated with significant morbidity and mortality. Ventricular arrhythmias are induced by a change in the myocardial environment altering cardiomyocyte electrophysiology. The substrate for VA includes myocardial scar, electrolyte disturbances, and drugs altering cellular electrophysiology. Case summary Here, we present a case of a 52-year-old man with known ischaemic cardiomyopathy, presenting with VA storms secondary to dapsone, an anti-microbial used in this case for the prophylaxis of pneumocystis pneumonia. This is the first case linking dapsone to the development of VAs. Ventricular arrhythmias storm occurred towards the end of the course of anti-microbial therapy and the patient was referred for sympathectomy. However, following the end of treatment, no further VA occurred and sympathectomy was therefore avoided. Discussion The underlying mechanism for the association between dapsone treatment and VA is unclear and a prolonged QTc was not observed in our case. It is important to recognize that every drug has many physiological effects and in patients with underlying diseases whereby there is already an unfavourable environment, additional drugs can lower the threshold of triggering an arrhythmia and the result can be life-threatening. In a patient with ischaemic cardiomyopathy, where underlying substrate for VA may already exist, the introduction of dapsone could lower the threshold for development of arrhythmia.
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Sani, Huzairi, Nada Syazana Zulkufli, and Sazzli Kasim. "Malignant Ventricular Arrhythmia in a Fatal Thyroid Storm." Journal of Clinical and Health Sciences 5, no. 2 (November 1, 2020): 79. http://dx.doi.org/10.24191/jchs.v5i2.8736.
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Skoczyński, Przemysław, and Paweł Pochciał. "RECURRENT SYNCOPE AS A SYMPTOM OF ELECTRICAL STORM – CASE PRESENTATION." Emergency Medical Service 8, no. 4 (2021): 271–73. http://dx.doi.org/10.36740/emems202104111.
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Dangerous ventricular arrhythmias leading to sudden cardiac death (SCD) are some of the most diffi-cult diagnostic challenges. They are often mildly symptomatic. Their often self-limiting nature means that they are difficult to capture on ECG. A 75-year old woman with chronic heart failure due to nonis-chemic cardiomyopathy reported to the cardiology clinic for a scheduled routine follow-up of the ICD, implanted three years prior as primary prevention of SCD. The patient reported recent episodes of sud-den weakness and described the episodes as hypotension. The patient associated it with too aggressive treatment of arterial hypertension. During the visit the patient experienced one of these episodes that she had previously described. The monitoring equipment in the clinic revealed ventricular tachycardia (VT). The history of the implanted ICD revealed many similar previous episodes including 5 episodes in the last 24 hours which led to a diagnosis of electrical storm. Dangerous ventricular arrhythmias may be mildly symptomatic and they are often underestimated by the patient. Fainting, especially in situa-tions unusual for the vasovagal reflex or orthostatic hypotension, should always arouse vigilance to-wards life-threatening ventricular arrhythmia.
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Matsubara, Masaki, Tomohiro Tanaka, Akinori Wakamiya, Tamiko Tamanaha, Hisashi Makino, Tomonori Tanei, Takeshi Aiba, Kengo Kusano, and Kiminori Hosoda. "First Case Report of Arrhythmogenic Right Ventricular Cardiomyopathy Showing Refractory Ventricular Tachycardia Induced by Thyroid Storm due to Graves’ Disease." Case Reports in Endocrinology 2022 (June 23, 2022): 1–8. http://dx.doi.org/10.1155/2022/6078148.
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A 48-year-old man who was diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) due to a plakophilin 2 gene mutation developed acute both-sided heart failure with rapid atrial fibrillation and was hospitalized. After admission, sustained ventricular tachycardia, which was refractory to antiarrhythmic agents, occurred repeatedly, and required electrical cardioversion. He was diagnosed with thyroid storm due to Graves’ disease, and treatment for hyperthyroidism was initiated. After the treatment, lethal arrhythmia did not reoccur, and biventricular heart failure ameliorated. To our best knowledge, this is the first report in English of a patient with ARVC showing refractory arrhythmia induced by thyroid storm due to Graves’ disease.
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Chihara, Ray K., Edward Y. Chan, Leonora M. Meisenbach, and Min P` KIM. "Surgical Cardiac Sympathetic Denervation for Ventricular Arrhythmias: A Systematic Review." Updates in Cardiac Electrophysiology, no. 17.1 (March 25, 2021): 24–35. http://dx.doi.org/10.14797/qiqg9041.
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Ventricular arrhythmias are potentially life-threatening disorders that are commonly treated with medications, catheter ablation and implantable cardioverter defibrillator (ICD). Adult patients who continue to be symptomatic, with frequent ventricular arrhythmia cardiac events or defibrillation from ICD despite medical treatment, are a challenging subgroup to manage. Surgical cardiac sympathetic denervation has emerged as a possible treatment option for people refractory to less invasive medical options. Recent treatment guidelines have recommended cardiac sympathectomy for ventricular tachycardia (VT) or VT/fibrillation storm refractory to antiarrhythmic medications, long QT syndrome, and catecholaminergic polymorphic VT, with much of the data pertaining to pediatric literature. However, for the adult population, the disease indications, complications, and risks of cardiac sympathectomy are less understood, as are the most effective surgical cardiac denervation techniques for this patient demographic. This systematic review navigates available literature evaluating surgical denervation disease state indications, techniques, and sympathectomy risks for medically refractory ventricular arrhythmia in the adult patient population.
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Bhar-Amato, Justine, William Davies, and Sharad Agarwal. "Ventricular Arrhythmia after Acute Myocardial Infarction: ‘The Perfect Storm’." Arrhythmia & Electrophysiology Review 6, no. 3 (2017): 134. http://dx.doi.org/10.15420/aer.2017.24.1.
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Ventricular tachyarrhythmias (VAs) commonly occur early in ischaemia, and remain a common cause of sudden death in acute MI. The thrombolysis and primary percutaneous coronary intervention era has resulted in the modification of the natural history of an infarct and subsequent VA. Presence of VA could independently influence mortality in patients recovering from MI. Appropriate risk assessment and subsequent treatment is warranted in these patients. The prevention and treatment of haemodynamically significant VA in the post-infarct period and of sudden cardiac death remote from the event remain areas of ongoing study.
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Bardyszewski, Aleksander, Jacek Kuśnierz, and Paweł Derejko. "Treatment of Electrical Storm – the Electrophysiologist’s Point of View." In a good rythm 2, no. 43 (May 24, 2017): 4–8. http://dx.doi.org/10.5604/01.3001.0010.3965.
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Electrical storm is a life-threatening condition and requires immediate treatment. In most cases ventricular arrhythmia originates from previously formed lesions in the cardiac muscle. Such patients, following the necessary initial treatment, should be forwarded to catheter ablation, which is proven to reduce arrhythmia recurrence and to improve overall morbidity. Along with the technological progress related to electroanatomical mapping the growing role of meticulous substrate mapping and modification for successful ablation is being recognized.
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Looi, Khang-Li, Anthony Tang, and Sharad Agarwal. "Ventricular arrhythmia storm in the era of implantable cardioverter-defibrillator." Postgraduate Medical Journal 91, no. 1079 (August 26, 2015): 519–26. http://dx.doi.org/10.1136/postgradmedj-2015-133550.
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Steinberg, Christian, Brianna Davies, Greg Mellor, Rafik Tadros, Zachary W. Laksman, Jason D. Roberts, Martin Green, et al. "Short-coupled ventricular fibrillation represents a distinct phenotype among latent causes of unexplained cardiac arrest: a report from the CASPER registry." European Heart Journal 42, no. 29 (May 19, 2021): 2827–38. http://dx.doi.org/10.1093/eurheartj/ehab275.
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Abstract Aims The term idiopathic ventricular fibrillation (IVF) describes survivors of unexplained cardiac arrest (UCA) without a specific diagnosis after clinical and genetic testing. Previous reports have described a subset of IVF individuals with ventricular arrhythmia initiated by short-coupled trigger premature ventricular contractions (PVCs) for which the term short-coupled ventricular fibrillation (SCVF) has been proposed. The aim of this article is to establish the phenotype and frequency of SCVF in a large cohort of UCA survivors. Methods and results We performed a multicentre study including consecutive UCA survivors from the CASPER registry. Short-coupled ventricular fibrillation was defined as otherwise unexplained ventricular fibrillation initiated by a trigger PVC with a coupling interval of <350 ms. Among 364 UCA survivors, 24/364 (6.6%) met diagnostic criteria for SCVF. The diagnosis of SCVF was obtained in 19/24 (79%) individuals by documented ventricular fibrillation during follow-up. Ventricular arrhythmia was initiated by a mean PVC coupling interval of 274 ± 32 ms. Electrical storm occurred in 21% of SCVF probands but not in any UCA proband (P < 0.001). The median time to recurrent ventricular arrhythmia in SCVF was 31 months. Recurrent ventricular fibrillation resulted in quinidine administration in 12/24 SCVF (50%) with excellent arrhythmia control. Conclusion Short-coupled ventricular fibrillation is a distinct primary arrhythmia syndrome accounting for at least 6.6% of UCA. As documentation of ventricular fibrillation onset is necessary for the diagnosis, most cases are diagnosed at the time of recurrent arrhythmia, thus the true prevalence of SCVF remains still unknown. Quinidine is effective in SCVF and should be considered as first-line treatment for patients with recurrent episodes.
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Liu, Xingji, Binay Kumar Adhikari, Tianlong Chen, Yonggang Wang, Quan Liu, and Shudong Wang. "Ventricular fibrillation storm after revascularization of chronic total occlusion of the left anterior descending artery: is this reperfusion arrhythmia?" Journal of International Medical Research 49, no. 3 (March 2021): 030006052199761. http://dx.doi.org/10.1177/0300060521997618.
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Electrical storm is a life-threatening emergency condition defined as three or more episodes of ventricular tachycardia or ventricular fibrillation (VF) within 24 hours requiring anti-tachycardia therapy, electrical cardioversion, or defibrillation. However, studies of the incidence of electrical storm after chronic total occlusion-percutaneous coronary intervention (CTO-PCI) are limited, 7 and post-procedural VF after revascularization of CTO has not been described. The purpose of this article was to present a case of post-operative VF electrical storm after revascularization of CTO of the left anterior descending (LAD) artery to determine whether the electrical storm was caused by reperfusion arrhythmia or compromise of either branch vessels or the collateral circulation during intervention.
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Kabunga, Peter, Caroline Medi, Laura Yeates, and Raymond W. Sy. "Malignant Ventricular Arrhythmic Storm Triggered by Short-coupled Premature Ventricular Contractions Arising from the Anterolateral Papillary Muscle." European Journal of Arrhythmia & Electrophysiology 02, no. 01 (2016): 33. http://dx.doi.org/10.17925/ejae.2016.02.01.33.
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A case of idiopathic ventricular fibrillation (VF), triggered by ectopic beats originating from the anterolateral papillary muscle, is presented. The arrhythmia was characterised by short-coupled premature ventricular contractions (PVCs), which were resistant to isoproterenol, and ultimately treated with catheter ablation.
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De Vera, Jerome, Hyungjin Ben Kim, and Antoine E. Sakr. "A Case Report of Loperamide-Induced Ventricular Storm." Journal of Investigative Medicine High Impact Case Reports 9 (January 2021): 232470962199076. http://dx.doi.org/10.1177/2324709621990768.
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Loperamide is an easily accessible antidiarrheal medication. Unlike other medications in its class, loperamide is unique in that it causes euphoria at supratherapeutic levels due to its effect on opioid receptors. Unfortunately, with its growing abuse potential also comes increasing reports of cardiotoxicity including prolonged QT, torsades de pointes, and sudden cardiac death. We report a case of a 29-year-old female who presented with unstable arrhythmia that further progressed into electrical storm in the setting of loperamide toxicity. Due to its growing popularity and availability, it is important for clinicians to understand loperamide’s mechanisms for causing toxicity as well as how to appropriately treat its complications.
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Nayyar, S., A. N. Ganesan, A. G. Brooks, T. Sullivan, K. C. Roberts-Thomson, and P. Sanders. "Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis." European Heart Journal 34, no. 8 (December 21, 2012): 560–71. http://dx.doi.org/10.1093/eurheartj/ehs453.
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Bundgaard, Johan S., Peter K. Jacobsen, Johannes Grand, Matias G. Lindholm, Christian Hassager, Steen Pehrson, Jesper Kjaergaard, and Henning Bundgaard. "Deep sedation as temporary bridge to definitive treatment of ventricular arrhythmia storm." European Heart Journal: Acute Cardiovascular Care 9, no. 6 (March 20, 2020): 657–64. http://dx.doi.org/10.1177/2048872620903453.
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Background: Electrical storm and incessant ventricular tachycardia (VT) are characterized by the clustering of episodes of VT or ventricular fibrillation (VF) and are associated with a poor prognosis. Autonomic nervous system activity influences VT threshold, and deep sedation may be useful for the treatment of VT emergencies. Methods: We reviewed data from conscious patients admitted to our intensive care unit (ICU) due to monomorphic VT, polymorphic VT or VF at our tertiary center between 2010 and 2018. Results: A total of 46 conscious patients with recurrent ventricular arrhythmia, refractory to initial treatment, were referred to the ICU. The majority ( n = 31) were stabilized on usual care. The remaining treatment-refractory 15 patients (57 years (range 9–74), 80% males, seven with implantable cardioverter-defibrillators) with VT/VF storm ( n = 11) or incessant VT ( n = 4) due to ischemic heart disease ( n = 10), cardiomyopathy ( n = 2), primary arrhythmia ( n = 2) and one patient post valve surgery, were deeply sedated and intubated. A complete resolution of VT/VF within minutes to hours was achieved in 12 patients (80%), partial resolution in two (13%) and one (7%) patient died due to ventricular free-wall rupture. One patient with recurrent VT episodes needing repeated deep sedation developed necrotic caecum. No other major complications were seen. Thirteen (87%) patients were alive after a mean follow-up of 3.7 years. Conclusion: Deep sedation was effective and safe for the temporary management of malignant VT/VF refractory to usual treatment. In emergencies, deep sedation may be widely accessible at both secondary and tertiary centers and a clinically useful bridge to definitive treatment of VT.
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Zeppenfeld, Katja, and Martin J. Schalij. "Current Status and Future Directions of Ventricular Arrhythmia Ablation." European Cardiology Review 6, no. 3 (2010): 77. http://dx.doi.org/10.15420/ecr.2010.6.3.77.
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Ventricular tachycardia (VT) catheter ablation has evolved over the past decade, allowing effective treatment of haemodynamically unstable and epicardial VTs in patients with structural heart disease previously not amenable to ablation. Catheter ablation reduces VT recurrences and thereby implantable cardioverter–defibrillator (ICD) shocks in 67–75% of patients, with a low incidence of procedure-related complications when performed in highly experienced centres. It can be life-saving in patients with electrical storm. Early use of ablation can be considered in selected patients who receive an ICD as an alternative to drug therapy provided that the procedure can be performed safely. Although acute results are promising, outcomes over the long-term are less favourable. An improved understanding of the VT substrate is mandatory for further advancement of a substrate-based ablation approach. Pre-procedural and intra-procedural imaging are likely to contribute to this. Whether catheter ablation will become first-line treatment for VT in structural heart disease and ultimately allow ICD implantation to be avoided in selected patients needs further evaluation.
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den Uil, Corstiaan A. "Extracorporeal Life Support for Electrical Storm, or for Cardiogenic Shock With Ventricular Arrhythmia?" Critical Care Medicine 45, no. 4 (April 2017): e469. http://dx.doi.org/10.1097/ccm.0000000000002229.
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Păsăroiu, Dan, Zsolt Parajkó, Noémi Mitra, and Diana Opincariu. "Electrical Storm Due to Active Myocardial Ischemia in the Right Coronary Artery Territory – Case Report." Journal Of Cardiovascular Emergencies 5, no. 2 (June 1, 2019): 72–77. http://dx.doi.org/10.2478/jce-2019-0009.
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Abstract Electrical storm is defined by at least three episodes of sustained ventricular tachyarrhythmias or appropriate shocks given by implantable cardiac defibrillator devices (ICD), occurring within a period of 24 hours. In the present manuscript, we present the case of a 69-year-old female patient with previous aortocoronary bypass, who was admitted from the Emergency Department after presenting several episodes of syncope in prehospital settings and presented 4 episodes of sustained ventricular tachycardia which required electrical cardioversion. The arrhythmia disappeared after percutaneous revascularization of a chronic occlusion in the right coronary artery. In this case, the implantation of an ICD was avoided, as a reversible cause of ES has been identified and treated.
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Siontis, Konstantinos C., Hyungjin M. Kim, Pasquale Vergara, Giovanni Peretto, Duc H. Do, Marta de Riva, Anna Lam, et al. "Arrhythmia exacerbation after post-infarction ventricular tachycardia ablation: prevalence and prognostic significance." EP Europace 22, no. 11 (August 23, 2020): 1680–87. http://dx.doi.org/10.1093/europace/euaa169.
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Abstract Aims Catheter ablation is an effective treatment for post-infarction ventricular tachycardia (VT). However, some patients may experience a worsened arrhythmia phenotype after ablation. We aimed to determine the prevalence and prognostic impact of arrhythmia exacerbation (AE) after post-infarction VT ablation. Methods and results A total of 1187 consecutive patients (93% men, median age 68 years, median ejection fraction 30%) who underwent post-infarction VT ablation at six centres were included. Arrhythmia exacerbation was defined as post-ablation VT storm or incessant VT in patients without prior similar events. During follow-up (median 717 days), 426 (36%) patients experienced VT recurrence. Events qualifying as AE occurred in 67 patients (6%). Median times to VT recurrence with and without AE were 238 [interquartile range (IQR) 35–640] days and 135 (IQR 22–521) days, respectively (P = 0.25). Almost half of the patients (46%) who experienced AE experienced it within 6 months of the index procedure. Patients with AE had had longer ablation times during the ablation procedures compared to the rest of the patients (median 42 vs. 34 min, P = 0.02). Among patients with VT recurrence, the risk of death or heart transplantation was significantly higher in patients with than without AE (hazard ratio 1.99, 95% CI 1.28–3.10; P = 0.002) after adjusting for age, gender, ejection fraction, cardiac resynchronization therapy, post-ablation non-inducibility, and post-ablation amiodarone use. Conclusion Arrhythmia exacerbation after ablation of infarct-related VT is infrequent but is independently associated with an adverse long-term outcome among patients who experience a VT recurrence. The mechanisms and mitigation strategies of AE after catheter ablation require further investigation.
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Nof, Eyal, Petr Peichl, Predrag Stojadinovic, Martin Arceluz, Philippe Maury, Moshe Katz, Usha B. Tedrow, et al. "HeartMate 3: new challenges in ventricular tachycardia ablation." EP Europace 24, no. 4 (November 17, 2021): 598–605. http://dx.doi.org/10.1093/europace/euab272.
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Abstract Aim To describe clinical characteristics, procedural details, specific challenges, and outcomes in patients with HeartMate3™ (HM3), a left ventricular assist device system with a magnetically levitated pump, undergoing ventricular tachycardia ablation (VTA). Methods and results Data were collected from patients with an HM3 system who underwent VTA in seven tertiary centres. Data included baseline patient characteristics, procedural data, mortality, and arrhythmia-free survival. The study cohort included 19 patients with cardiomyopathy presenting with ventricular tachycardia (VT) (53% with VT storm). Ventricular tachycardias were induced in 89% of patients and a total of 41 VTs were observed. Severe electromagnetic interference was present on the surface electrocardiogram. Hence, VT localization required analysis of intra-cardiac signals or the use of filter in the 40–20 Hz range. The large house pump HM3 design obscured the cannula inflow and therefore multi imaging modalities were necessary to avoid catheter entrapment in the cannula. A total of 32 VTs were mapped and were successfully ablated (31% to the anterior wall, 38% to the septum and only 9% to the inflow cannula region). Non-inducibility of any VT was reached in 11 patients (58%). Over a follow-up of 429 (interquartile range 101–692) days, 5 (26%) patients underwent a redo VT ablation due to recurrent VTA and 2 (11%) patients died. Conclusions Ventricular tachycardia ablation in patients with HM3 is feasible and safe when done in the appropriate setup. Long-term arrhythmia-free survival is acceptable but not well predicted by non-inducibility at the end of the procedure.
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Xie, Yanan, Jingzhe Han, Jinming Liu, Jie Hao, Xiuguang Zu, and Yuming Hao. "A case of hypokalemia-induced bidirectional ventricular tachycardia." Journal of International Medical Research 48, no. 11 (November 2020): 030006052097144. http://dx.doi.org/10.1177/0300060520971440.
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Background Bidirectional ventricular tachycardia (BVT) is a rare, but serious, arrhythmia. Hypokalemia is commonly found in clinical practice, but hypokalemia-induced BVT has rarely been reported. Case presentation A 74-year-old male patient with the symptoms of chest distress and palpitations was admitted owing to frequent discharge of his implantable cardioverter defibrillator (ICD) for 4 days. Before admission, the patient experienced diarrhea after intake of crabs, and felt frequent discharge of his ICD with a total of approximately 17 discharges in 4 days. He had no history of digitalis use. The serum potassium level after admission was 3.1 mmol/L and an electrocardiogram was consistent with BVT. The diagnosis was ventricular tachycardia, electrical storm, and hypokalemia. His ventricular tachycardia was completely relieved after correction of hypokalemia. Conclusions After correction of hypokalemia in this patient, the episode of BVT was terminated and no recurrence of BVT was observed during long-term follow-up. Our findings suggest the diagnosis of hypokalemia-induced BVT.
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Knops, Reinoud E., Willeke van der Stuijt, Peter Paul H. M. Delnoy, Lucas V. A. Boersma, Juergen Kuschyk, Mikhael F. El-Chami, Hendrik Bonnemeier, et al. "Efficacy and Safety of Appropriate Shocks and Antitachycardia Pacing in Transvenous and Subcutaneous Implantable Defibrillators: Analysis of All Appropriate Therapy in the PRAETORIAN Trial." Circulation 145, no. 5 (February 2022): 321–29. http://dx.doi.org/10.1161/circulationaha.121.057816.
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Background: The PRAETORIAN trial (A Prospective, Randomized Comparison of Subcutaneous and Transvenous Implantable Cardioverter Defibrillator Therapy) showed noninferiority of subcutaneous implantable cardioverter defibrillator (S-ICD) compared with transvenous implantable cardioverter defibrillator (TV-ICD) with regard to inappropriate shocks and complications. In contrast to TV-ICD, S-ICD cannot provide antitachycardia pacing for monomorphic ventricular tachycardia. This prespecified secondary analysis evaluates appropriate therapy and whether antitachycardia pacing reduces the number of appropriate shocks. Methods: The PRAETORIAN trial was an international, investigator-initiated randomized trial that included patients with an indication for implantable cardioverter defibrillator (ICD) therapy. Patients with previous ventricular tachycardia <170 bpm or refractory recurrent monomorphic ventricular tachycardia were excluded. In 39 centers, 849 patients were randomized to receive an S-ICD (n=426) or TV-ICD (n=423) and were followed for a median of 49.1 months. ICD programming was mandated by protocol. Appropriate ICD therapy was defined as therapy for ventricular arrhythmias. Arrhythmias were classified as discrete episodes and storm episodes (≥3 episodes within 24 hours). Analyses were performed in the modified intention-to-treat population. Results: In the S-ICD group, 86 of 426 patients received appropriate therapy, versus 78 of 423 patients in the TV-ICD group, during a median follow-up of 52 months (48-month Kaplan-Meier estimates 19.4% and 17.5%; P =0.45). In the S-ICD group, 83 patients received at least 1 shock, versus 57 patients in the TV-ICD group (48-month Kaplan-Meier estimates 19.2% and 11.5%; P =0.02). Patients in the S-ICD group had a total of 254 shocks, compared with 228 shocks in the TV-ICD group ( P =0.68). First shock efficacy was 93.8% in the S-ICD group and 91.6% in the TV-ICD group ( P =0.40). The first antitachycardia pacing attempt successfully terminated 46% of all monomorphic ventricular tachycardias, but accelerated the arrhythmia in 9.4%. Ten patients with S-ICD experienced 13 electrical storms, versus 18 patients with TV-ICD with 19 electrical storms. Patients with appropriate therapy had an almost 2-fold increased relative risk of electrical storms in the TV-ICD group compared with the S-ICD group ( P =0.05). Conclusions: In this trial, no difference was observed in shock efficacy of S-ICD compared with TV-ICD. Although patients in the S-ICD group were more likely to receive an ICD shock, the total number of appropriate shocks was not different between the 2 groups. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01296022.
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Vătășescu, Radu, Cosmin Cojocaru, Alexandrina Năstasă, Sorin Popescu, Corneliu Iorgulescu, Ștefan Bogdan, Viviana Gondoș, and Antonio Berruezo. "Monomorphic VT Non-Inducibility after Electrical Storm Ablation Reduces Mortality and Recurrences." Journal of Clinical Medicine 11, no. 13 (July 4, 2022): 3887. http://dx.doi.org/10.3390/jcm11133887.
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Background: Electrical storm (ES) is defined by clustering episodes of ventricular tachycardia (VT) and is associated with severe long-term outcomes. We sought to evaluate the prognostic impact of radiofrequency catheter ablation (RFCA) in ES as assessed by aggressive programmed ventricular stimulation (PVS). Methods: Single-center retrospective longitudinal study with 82 consecutive ES patients referred for RFCA with a median follow-up (IQR 25–75%) of 45.43 months (15–69.86). All-cause mortality and VT recurrences were assessed in relation to RFCA outcomes defined by 4-extrastimuli PVS: Class 1—no ventricular arrhythmia; Class 2—no sustained monomorphic VTs (mVT) inducible, but non-sustained mVTs, polymorphic VTs, or VF inducible; Class 3—clinical VT non-inducible, other sustained mVTs inducible; and Class 4—clinical VT inducible. Results: Class 1, Class 2, Class 3, and Class 4 were achieved in 56.1%, 13.4%, 23.2%, and 7.4% of cases, respectively. The combined outcome of Class 1 + Class 2 (no sustained monomorphic VT inducible) led to improved survival (log-rank p < 0.001) and reduced VT recurrence (log-rank p < 0.001). Residual monomorphic VT inducibility (HR 6.262 (95% CI: 2.165–18.108, p = 0.001), NYHA IV heart failure symptoms (HR 20.519 (95% CI: 1.623–259.345), p = 0.02)), and age (HR 1.009 (95% CI: 1.041–1.160), p = 0.001)) independently predicted death during follow-up. LVEF was not predictive of death (HR 1.003 (95% CI: 0.946–1.063) or recurrences (HR 0.988 (95% CI: 0.955–1.021)). Conclusions: Non-inducibility for sustained mVTs after aggressive PVS post-RFCA leads to improved survival in ES, independently of LVEF.
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Tilz, Roland R., Charlotte Eitel, Evgeny Lyan, Kivanc Yalin, Spyridon Liosis, Julia Vogler, Ben Brueggemann, et al. "Preventive Ventricular Tachycardia Ablation in Patients with Ischaemic Cardiomyopathy: Meta-analysis of Randomised Trials." Arrhythmia & Electrophysiology Review 8, no. 3 (August 9, 2019): 173–79. http://dx.doi.org/10.15420/aer.2019.31.3.
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Catheter ablation of ventricular tachycardia (VT) aims to treat the underlying arrhythmia substrate to prevent ICD therapies. The aim of this meta-analysis was to assess the safety and efficacy of VT ablation prior to or at the time of secondary prevention ICD implantation in patients with coronary artery disease, as compared with deferred VT ablation. Based on a systematic literature search, three randomised trials were considered eligible for inclusion in this analysis, and data on the number of patients with appropriate ICD shocks, appropriate ICD therapy, arrhythmic storm, death and major complications were extracted from each study. On pooled analysis, there was a significant reduction of appropriate ICD shocks (OR 2.58; 95% CI [1.54–4.34]; p<0.001) and appropriate ICD therapies (OR 2.04; 95% CI [1.15–3.61]; p=0.015) in patients undergoing VT ablation at the time of ICD implantation without significant differences with respect to complications (OR 1.39; 95% CI [0.43–4.51]; p=0.581). Mortality did not differ between both groups (OR 1.30; 95% CI [0.60–2.45]; p=0.422). Preventive catheter ablation of VT in patients with coronary heart disease at the time of secondary prevention ICD implantation results in a significant reduction of appropriate ICD shocks and any appropriate ICD therapy compared with patients without or with deferred VT ablation. No significant difference with respect to complications or mortality was observed between both treatment strategies.
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Hedley, Jeffrey, Cameron Incognito, Joshua Parker, Alex Milinovic, Venu Menon, Oussama Wazni, Wilson Tang, and John Rickard. "B-PO02-122 LONG-TERM MORTALITY AND VENTRICULAR ARRHYTHMIA OUTCOMES IN ELECTRICAL STORM PATIENTS WHO UNDERGO ABLATION." Heart Rhythm 18, no. 8 (August 2021): S147. http://dx.doi.org/10.1016/j.hrthm.2021.06.376.
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Pansare, Rahul, Daniyeh Khurram, and Malika Rawal. "PSAT220 Severe Vitamin D Deficiency and Hypocalcemia during Pregnancy Masquerading as Thyroid Storm." Journal of the Endocrine Society 6, Supplement_1 (November 1, 2022): A218. http://dx.doi.org/10.1210/jendso/bvac150.448.
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Abstract Background Hypocalcemic tetany in young female patients is a clinical entity that is well-described in literature. Here we present a potentially life-threatening case of hypocalcemia secondary to severe Vitamin D deficiency and hyperemesis gravidarum mimicking thyroid storm. Case Presentation A 22-year-old Caucasian woman at 21 weeks gestation was transferred to our hospital for suspected thyroid storm with TSH <0.01 mIU/L (0.05-5.7). She had no history of nor risk factors for thyroid disease and presented with severe agitation, hallucinations, and muscle spasms after weeks of vomiting and poor oral intake. In the ambulance her temperature was 106.6F (rectal) and she was tachycardic (216/minute). EKG revealed ventricular arrhythmia with QTc 532 ms. EMS interventions included unsuccessful cardioversion with 100J and 300mg IV amiodarone bolus. In the ED, serum calcium level was 5.9 mmol/L (8.4-10.2), albumin 2.8 g/dL (3.3-4.5), magnesium 1.0 mmol/L (1.7-2.3), potassium 3.1 mmol/L (3.5-4.8), lactic acid 9.5 mmol/L (0.5-2.2), Free T4 1.36 ng/dL (0.58-1.65), troponin 2.21 ng/ml (0.00-0.03), β-hcg 48,775 mIU/ml, CK 9960 U/L (0-188), AST 171 U/L (8-34), ALT 45 (0-24). She received IV calcium gluconate, aggressive IV hydration and electrolyte repletion. Free T3 was drawn prior to initiating empiric thyroid storm treatment (hydrocortisone, propylthiouracil) returned at 3.8 pmol/L (2.5-3.9). Thyroid storm was further ruled out with negative antibodies for TPO and TSI and ultrasound revealing normal-sized gland without nodules and with normal vascularity. Hydrocortisone and Thionamide therapy were discontinued. The patient had rapid improvement in mentation and vitals with continued hydration and electrolyte repletion. 25-hydroxy-Vitamin D level was undetectable and PTH 118 pg/mL (12-88), consistent with secondary hyperparathyroidism. Celiac disease was ruled out with negative tissue transglutaminase IgA and IgG. At her follow-up clinic visit, symptoms had resolved with calcium and Vitamin D supplementation. Discussion Though a common phenomenon in pregnant women, metabolic derangements due to hyperemesis gravidarum can be quite severe and/or life-threatening, as in our case. Literature search revealed an isolated case of hyperemesis gravidarum presenting with severe electrolyte derangement and subsequent paraparesis which resolved after vitamin D and calcium supplementation. Hyperthyroidism is typically associated with hypercalcemia in the Western population. This patient's presenting features of hyperpyrexia, malignant cardiac arrhythmia, hepatitis, and altered mentation were reminiscent of thyroid storm and could easily be attributed to such in a pregnant patient with suppressed TSH. This could lead to continued use of thionamide and further hepatic damage. Thus, it is prudent to consider hypocalcemia in the differential diagnosis of thyrotoxicosis-like presentation, particularly in pregnant patients. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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Zhang, Ruiqi, Chandong Ding, and Hui Wang. "Treatment on arrhythmia electric storm in a Jervell and Lange-Nielsen syndrome patient by ablation of the triggering premature ventricular contraction: a case report." Annals of Palliative Medicine 9, no. 5 (October 2020): 5. http://dx.doi.org/10.21037/apm-19-460a.
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Chugh, Radhika, and Wiley Harkens. "RF23 | PSAT301 Plasmapheresis and Extracorporeal Membrane Oxygenation (ECMO) for Treatment of Thyroid Storm with Multiorgan Failure." Journal of the Endocrine Society 6, Supplement_1 (November 1, 2022): A858—A859. http://dx.doi.org/10.1210/jendso/bvac150.1775.
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Abstract Introduction Thyroid storm is a life-threatening condition with a high morbidity and mortality rate. It can lead to severe end organ damage including liver injury, which can preclude the use of thionamides. Therapeutic plasma exchange can be a lifesaving option for treatment of thyroid storm in such cases. Multiorgan failure can also necessitate the use of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Case Presentation A 34-year-old woman with a history of Graves’ disease, untreated for several years, presented to the emergency department with fatigue, palpitations, dyspnea, and edema which developed over 1 month. Labs showed suppressed thyroid stimulating hormone (TSH) with significantly elevated free T4 of 10.8 ng/dL (normal 0.89-1.76 ng/dL). She had evidence of atrial fibrillation and heart failure. She was started on treatment with propylthiouracil, propranolol, and hydrocortisone and then Lugol's iodine was added. However, she quickly deteriorated with worsening mentation, dyspnea, and hypotension. She progressed to multiorgan failure including significant liver injury likely due to ischemic hepatitis. Thus, thianomides could not be used any further. She was started on cholestyramine; hydrocortisone and Lugol's iodine were continued.An echocardiogram revealed global hypokinesis with a left ventricular ejection fraction of 20%. Beta blockers were discontinued due to hypotension. The cardiogenic shock worsened despite aggressive medical therapy requiring initiation of veno-arterial (V-A) ECMO. She also required CRRT due to renal failure.Plasmapheresis was initiated for treatment of thyroid storm and she received 4 treatments with normalization of free T4: 1.48 ng/dL and T3 levels: 3.4 ng/dL (normal 2.3-4.2 ng/dL). Her condition subsequently improved and she was decannulated from the ECMO device after 5 days. She was then able to receive definitive treatment with thyroidectomy 11 days following admission. The patient was discharged in improved condition after a 10-week hospital course. Discussion Thyroid storm is a rare complication of thyrotoxicosis with a mortality rate of 10-30%. Treatment classically involves inhibiting the synthesis, release, and peripheral conversion of thyroid hormone as well as supportive management. Major causes of mortality in thyroid storm, present in our patient, include cardiogenic shock, arrhythmia, and multiorgan failure. Cardiac and hepatic failure can preclude the use of beta blockers and thionamides, which may necessitate the use of extracorporeal treatments, such as plasmapheresis for clearance of high burden of circulating thyroid hormone; V-A ECMO and CRRT for end organ damage. These therapeutic measures were used in our patient and led to a favorable outcome. This case highlights the successful use of these extracorporeal treatments as a bridge to thyroidectomy when standard medical treatment is contraindicated or unsuccessful. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:42 p.m. - 12:47 p.m.
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Sipahi, Nihat Firat, Arash Mehdiani, Diyar Saeed, Udo Boeken, Hisaki Makimoto, Artur Lichtenberg, and Hannan Dalyanoglu. "Successful treatment of ventricular arrhythmic storm with percutaneous coronary intervention and catheter ablation in a patient with left ventricular assist device." International Journal of Artificial Organs 41, no. 6 (April 12, 2018): 333–36. http://dx.doi.org/10.1177/0391398818768118.
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Introduction: Ventricular arrhythmias are common in patients with advanced heart failure, which may also persist after sufficient intensive therapy for heart failure even with a left ventricular assist device. Although most ventricular arrhythmias have no hemodynamic relevance during left ventricular assist device support, some patients suffer from right ventricular decompensation due to ventricular arrhythmias resulting in severe hemodynamic deterioration and poor clinical outcomes. Methods: We describe herein an left ventricular assist device patient with refractory ventricular arrhythmic storm early after left ventricular assist device implantation. Results: The patient was admitted to our department after stenting of left anterior descending artery with subsequent polymorphic ventricular tachycardia and cardiogenic shock with ongoing multi-organ failure. After 6 days of extracorporeal life-support, a permanent left ventricular assist device was implanted. With postoperatively ongoing tachycardias, a subtotal right coronary artery occlusion was recanalized utilizing a drug-eluting stent. On the first post-intervention day, an additional catheter ablation was successfully performed. No further ventricular tachycardias were detected during the entire hospital stay and the further postoperative course was uneventful. The patient was transferred to a physiotherapy unit to improve his daily physical activities. He is currently at home and doing well 6 months after discharge. Conclusions: Our case report demonstrates the feasibility of a successful therapeutic approach with a combination of interventional therapies such as coronary stenting and catheter ablation in a patient with persistent ventricular arrhythmias after assist device implantation.
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Chlebuś, Marcin, Janusz Romanek, Włodzimierz Wnęk, and Andrzej Przybylski. "Percutaneous stellate ganglion block in the treatment of incessant ventricular tachycardia and ventricular fibrillation." In a good rythm 2, no. 47 (May 16, 2018): 22–26. http://dx.doi.org/10.5604/01.3001.0012.0394.
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Treatment of ventricular arrhythmias, especially electrical storm or incessant ventricular tachycardia (VT), remains a therapeutic challenge due to the limited possibilities of pharmacotherapy. The possibility of electrophysiological diagnostics and ablation of the arrhythmic substrate allows to effectively prevent the recurrence of VT. Often, though, a serious general condition of the patient and the progress of myocardial dysfunction prevents from conducting an effective ablation procedure. The method that can interrupt an electric storm or incessant VT is the blockade of the sympathetic nervous system, which is responsible for the adrenergic stimulation of the heart. This is achievable by blocking the stellate ganglion (SGB). The cases of sympathetic denervation described in the literature include cases of surgical excision of the ganglion or percutaneous block with the use of anesthetics. The use of SGB enables the termination of life-threatening arrhythmias and improvement of the patient’s clinical condition, which is often a prerequisite for administering electrophysiological treatment or transferring the patient to a center having the capability to apply mechanical circulatory support.
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Guzik, Tomasz J., Saidi A. Mohiddin, Anthony Dimarco, Vimal Patel, Kostas Savvatis, Federica M. Marelli-Berg, Meena S. Madhur, et al. "COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options." Cardiovascular Research 116, no. 10 (April 30, 2020): 1666–87. http://dx.doi.org/10.1093/cvr/cvaa106.
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Abstract The novel coronavirus disease (COVID-19) outbreak, caused by SARS-CoV-2, represents the greatest medical challenge in decades. We provide a comprehensive review of the clinical course of COVID-19, its comorbidities, and mechanistic considerations for future therapies. While COVID-19 primarily affects the lungs, causing interstitial pneumonitis and severe acute respiratory distress syndrome (ARDS), it also affects multiple organs, particularly the cardiovascular system. Risk of severe infection and mortality increase with advancing age and male sex. Mortality is increased by comorbidities: cardiovascular disease, hypertension, diabetes, chronic pulmonary disease, and cancer. The most common complications include arrhythmia (atrial fibrillation, ventricular tachyarrhythmia, and ventricular fibrillation), cardiac injury [elevated highly sensitive troponin I (hs-cTnI) and creatine kinase (CK) levels], fulminant myocarditis, heart failure, pulmonary embolism, and disseminated intravascular coagulation (DIC). Mechanistically, SARS-CoV-2, following proteolytic cleavage of its S protein by a serine protease, binds to the transmembrane angiotensin-converting enzyme 2 (ACE2) —a homologue of ACE—to enter type 2 pneumocytes, macrophages, perivascular pericytes, and cardiomyocytes. This may lead to myocardial dysfunction and damage, endothelial dysfunction, microvascular dysfunction, plaque instability, and myocardial infarction (MI). While ACE2 is essential for viral invasion, there is no evidence that ACE inhibitors or angiotensin receptor blockers (ARBs) worsen prognosis. Hence, patients should not discontinue their use. Moreover, renin–angiotensin–aldosterone system (RAAS) inhibitors might be beneficial in COVID-19. Initial immune and inflammatory responses induce a severe cytokine storm [interleukin (IL)-6, IL-7, IL-22, IL-17, etc.] during the rapid progression phase of COVID-19. Early evaluation and continued monitoring of cardiac damage (cTnI and NT-proBNP) and coagulation (D-dimer) after hospitalization may identify patients with cardiac injury and predict COVID-19 complications. Preventive measures (social distancing and social isolation) also increase cardiovascular risk. Cardiovascular considerations of therapies currently used, including remdesivir, chloroquine, hydroxychloroquine, tocilizumab, ribavirin, interferons, and lopinavir/ritonavir, as well as experimental therapies, such as human recombinant ACE2 (rhACE2), are discussed.
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Koenig, Sebastian, Arash Arya, Gerhard Hindricks, and Borislav Dinov. "Catheter ablation of ventricular tachycardia in the setting of electrical storm after revascularization of a chronic total occlusion of the right coronary artery: An uncommon presentation of reperfusion arrhythmia." HeartRhythm Case Reports 2, no. 6 (November 2016): 462–64. http://dx.doi.org/10.1016/j.hrcr.2016.04.008.
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Lee, Dustin, Matthew Glassy, Zenaida Feliciano, Gholam Berenji, Faisal Shaikh, and Janet Han. "A DARK AND STORMY NIGHT: METASTATIC CANCER CAUSING VENTRICULAR ARRHYTHMIC STORM." Journal of the American College of Cardiology 73, no. 9 (March 2019): 2307. http://dx.doi.org/10.1016/s0735-1097(19)32913-4.
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Khan, Muhammad H., Obadah Aqtash, David M. Harris, Alexandru I. Costea, and Myron C. Gerson. "Ventricular Tachycardia or Fibrillation Storm in Coronavirus Disease." Case Reports in Cardiology 2022 (August 18, 2022): 1–9. http://dx.doi.org/10.1155/2022/1157728.
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Ventricular tachycardia (VT) or ventricular fibrillation (VF) storm associated with severe acute respiratory syndrome coronavirus 2 infection is a potentially fatal complication; the correlation of these 2 disorders, however, has not been well studied. This retrospective case series examined outcomes of 2 patients who were admitted for repeated implantable cardioverter-defibrillator shocks with or without syncope and observed to have VT/VF storms with COVID-19. Mechanisms of VT/VF storms in COVID-19 are multifactorial including myocarditis, systemic inflammation, hyperadrenergic state, hemodynamic instability, hypoxia, acidosis, and proarrhythmic drugs. A higher incidence of VT/VF storm is observed in patients with comorbidities and those requiring critical care, with some studies reporting increased mortality. In our cohort, 1 of the 2 patients succumbed to the complications from COVID-19, and the other patient was discharged to home in stable condition. Monitoring of life-threatening arrhythmias in the setting of COVID-19 may need to be adopted to prevent morbidity and mortality.
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Viskin, Sami, Aviram Hochstadt, Ehud Chorin, Dana Viskin, Ofer Havakuk, Shafik Khoury, John K. Lee, Bernard Belhassen, and Raphael Rosso. "Quinidine-responsive out-of-hospital polymorphic ventricular tachycardia in patients with coronary heart disease." EP Europace 22, no. 2 (November 12, 2019): 265–73. http://dx.doi.org/10.1093/europace/euz290.
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Abstract Aims We recently reported that patients with coronary artery disease (CAD) who develop polymorphic ventricular tachycardia (VT) during the healing phase of an acute coronary event, generally fail to respond to revascularization or standard antiarrhythmic therapy but respond immediately to quinidine therapy. Here, we describe that CAD patients presenting with out-of-hospital polymorphic VT without a recent coronary event or an obvious precipitating factor, also respond uniquely to quinidine therapy. Methods and results Retrospective study of patients with unheralded, mainly out-of-hospital, polymorphic VT related to CAD but without evidence of acute myocardial ischaemia. We identified 20 patients who developed polymorphic VT without precipitating factors. The polymorphic VT events were triggered by extrasystoles with short (376 ± 49 ms) coupling interval. Arrhythmic storms occurred in 70% patients. These arrhythmic storms were generally refractory to conventional antiarrhythmic therapy but invariably responded to quinidine therapy. Revascularization was antiarrhythmic in 3 patients despite the absent clinical or ECG signs of ischaemia. During long-term follow-up (range 2 months to 11 years), 3 (15%) of patients not receiving quinidine developed recurrent polymorphic VT. There were no recurrent arrhythmias during long-term quinidine therapy. Conclusions Patients with CAD may develop polymorphic VT in the absence of obvious acute ischaemia or apparent precipitating factors, presenting as out-of-hospital polymorphic VT with high risk of arrhythmic storms that respond uniquely to quinidine therapy.
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Jiravsky, O., R. Spacek, J. Chovancik, R. Stepanova, M. Hudec, A. Svobodnik, L. Sknouril, and M. Fiala. "Malignant arrythmic storm, stellate ganglion and diabetes mellitus." EP Europace 23, Supplement_3 (May 1, 2021). http://dx.doi.org/10.1093/europace/euab116.347.
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Abstract Funding Acknowledgements Type of funding sources: None. Introduction Malignant arrhythmic storm (MAS) increases mortality more than three-fold according to current data. In the acute setting, besides resolving reversible causes, antiarrhythmics are the mainstay of treatment. The role of suppressing the local sympathetic nervous system activity, using stellate ganglion block (SGB) for example, is still being investigated. Purpose To show short-term efficacy of SGB in suppressing the ventricular arrhythmia recurrence in MAS. To identify subgroups of patients with better clinical response after SGB. Methods All consecutive patients with MAS, with standard treatment failure and ventricular arrhythmia recurrence, treated with ultrasound guided SGB, instilating 7ml of 0,5% Bupivacain. 58 MAS treated with SGB durin 2017 – 2020. There were 49 men (84,5%), average age 68,7 +/- 11,4, with average left ventricular EF 28,9 +/- 8,43%. There were 17 diabetics (29,3%). Results When we compare the numbers of defibrillations for sustained ventricular tachycardia 48 hours before and 48 hours after SGB, being the primary therapeutic endpoint in MAS, we see a 96,7% reduction (p < 0,001). When we evaluate ventricular arrhythmias treated with both antitachycardia pacing and shocks, then we see 90% reduction (p < 0,001). The effect of SGB in ventricular arrhythmia suppression was statistically significant during the entire follow-up of 8 days. When we analyzed the cohort, looking for groups showing better response after SGB in terms of ventricular arrhythmia reduction, the only group showing statistical significance in this regard are patients with diabetes mellitus. Conclusions In our cohort, stellate ganglion block is exceptionally effective in the treatment algorithm of malignant arrhythmic storm. SGB shows significantly higher efficacy in the subgroup of patients with diabetes mellitus. Abstract Figure. VA before and after BSG
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Kiyohara, Takuya, Kenta Sakaguchi, Daichi Maeda, and Masaaki Hoshiga. "Stellate ganglion blockade combined with nifekalant for patients with electrical storm: a case report." European Heart Journal - Case Reports, December 8, 2022. http://dx.doi.org/10.1093/ehjcr/ytac468.
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Abstract Background Although both stellate ganglion blockade and nifekalant are effective treatment options for electrical storm, the clinical effect of their combination is uncertain. Case Summary A 71-year-old male patient was admitted to our hospital with acute myocardial infarction and heart failure. Emergency coronary angiography revealed triple-vessel disease. Although coronary artery bypass grafting was planned, the patient experienced electrical storm before the surgery could be performed. Despite complete revascularisation by percutaneous coronary intervention, mechanical circulatory support and administration of antiarrhythmic agents (amiodarone and lidocaine), electrical storm was not controlled. After stellate ganglion blockade was initiated on the 9th day of hospitalisation, ventricular arrhythmia decreased. However, when stellate ganglion blockade was temporarily discontinued, ventricular arrhythmia increased substantially. Subsequently, combination therapy with stellate ganglion blockade and nifekalant was initiated, after which ventricular arrhythmia disappeared completely. Afterwards, the patient had no further ventricular arrhythmia episodes, and his haemodynamic status gradually improved. The patient was discharged from hospital in an ambulatory condition and did not experience arrhythmia during the follow-up. Discussion This case demonstrates that combination therapy with stellate ganglion blockade and nifekalant can completely suppress ventricular arrhythmia, suggesting that blocking multiple conduction pathways is a key to treating refractory electrical storm.
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Tavazzi, Guido, Valentino Dammassa, Costanza Natalia Julia Colombo, Eloisa Arbustini, Thomas Castelein, Martin Balik, and Christophe Vandenbriele. "Mechanical circulatory support in ventricular arrhythmias." Frontiers in Cardiovascular Medicine 9 (October 11, 2022). http://dx.doi.org/10.3389/fcvm.2022.987008.
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In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
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Lee, Jeongyoon, Kyeongyoon Woo, Haesoo Kim, and Eunju Kim. "ELECTRICAL STORM FOLLOWING CORONARY ARTERY BYPASS GRAFTING IN A PATIENT WITH HYPERTHYROIDISM: A CASE REPORT." GLOBAL JOURNAL FOR RESEARCH ANALYSIS, June 15, 2022, 149–50. http://dx.doi.org/10.36106/gjra/6810051.
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An electrical storm, dened as repeated ventricular arrhythmia has been reported as a relatively rare but challenging event. We report a case of an electrical storm following coronary artery bypass grafting (CABG) surgery in a 49-year-old man with untreated hyperthyroidism. The patient underwent successful CABG surgery after being diagnosed with ST elevation myocardial infarction and three vessel disease of coronary artery. Six days after the operation, ventricular tachy-arrhythmias were continuously observed, and direct current cardioversions were performed more than 30 times over 24 hours. Based on laboratory test results, the patient had persistent hyperthyroidism, and we continued anti- thyroid therapy and anti-arrhythmic medication. Eventually, the patient was successfully treated with a second trial of catheter ablation. In conclusion, physicians must carefully manage thyroid function in patients undergoing cardiac surgery. We also recommend that cardiac surgery teams take a multidisciplinary perioperative approach to critical care for cardiac surgery.
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Grune, Jana, Andrew J. M. Lewis, Masahiro Yamazoe, Maarten Hulsmans, David Rohde, Ling Xiao, Shuang Zhang, et al. "Neutrophils incite and macrophages avert electrical storm after myocardial infarction." Nature Cardiovascular Research, July 11, 2022. http://dx.doi.org/10.1038/s44161-022-00094-w.
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AbstractSudden cardiac death, arising from abnormal electrical conduction, occurs frequently in patients with coronary heart disease. Myocardial ischemia simultaneously induces arrhythmia and massive myocardial leukocyte changes. In this study, we optimized a mouse model in which hypokalemia combined with myocardial infarction triggered spontaneous ventricular tachycardia in ambulatory mice, and we showed that major leukocyte subsets have opposing effects on cardiac conduction. Neutrophils increased ventricular tachycardia via lipocalin-2 in mice, whereas neutrophilia associated with ventricular tachycardia in patients. In contrast, macrophages protected against arrhythmia. Depleting recruited macrophages in Ccr2−/− mice or all macrophage subsets with Csf1 receptor inhibition increased both ventricular tachycardia and fibrillation. Higher arrhythmia burden and mortality in Cd36−/− and Mertk−/− mice, viewed together with reduced mitochondrial integrity and accelerated cardiomyocyte death in the absence of macrophages, indicated that receptor-mediated phagocytosis protects against lethal electrical storm. Thus, modulation of leukocyte function provides a potential therapeutic pathway for reducing the risk of sudden cardiac death.
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Mancini, Nastasia, Pasquale Crea, Giuseppe Dattilo, Francesco Costa, Giampiero Vizzari, Enrico Baldi, Francesco Luzza, Scipione Carerj, Antonio Micari, and Gianluca Di Bella. "892 ELECTRICAL STORM IN ISCHAEMIC HEART DISEASE: A CASE OF LEFT STELLATE GANGLION BLOCK AS BRIDGE TO URGENT PCI RESCUE." European Heart Journal Supplements 24, Supplement_K (December 14, 2022). http://dx.doi.org/10.1093/eurheartjsupp/suac121.054.
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Abstract A 73 year-old man was admitted for syncope and sustained ventricular arrhythmia complicated by cardiogenic shock treated with electrical cardioversion and restoration of sinus rhythm. Former smoker, he suffered by arterial hypertension, hypercholesterolemia and known heart failure with reduced ejection fraction. In the 1995 the patient underwent aortic valve replacement surgery with a mechanical prosthetic valve. The patient underwent coronary angiography that showed multivessel coronary artery disease with functional occlusion of posterior interventricular artery (rehabilitated by hetero-coronary circles) and critical stenosis of the middle left anterior descending artery. In this angiographic framework, the indication was collegial revaluation considering other patient's comorbidities (chronic renal dysfunction, mitral moderate-severe regurgitation). The patient underwent ICD implantation for secondary prevention. Despite maximal medical therapy, the patient experienced new episodes of sustained VT complicated by hemodynamic instability. Hypokalemia, hypomagnesemia and hyperthyroidism were excluded as triggering factors for arrhythmias on laboratory investigations. In the following days due to persistent and symptomatic arrhythmias, configuring electrical storm, we decided to proceed with anatomical stellate ganglion block, guarantying a free interval from ventricular arrhythmia about six hours. The anesthetic has been injected at the C6 or C7 vertebral level with the Chassignac's tubercle, the cricoid cartilage, and the carotid artery serving as the anatomic landmarks to the procedure. An aspiration test must be done to avoid the suction of blood or cerebrospinal fluid, then a local anesthetic is injected, and the diffusion of the injectate is seen in real-time. Local anesthetic (lidocaine mixed with bupivacaine) is injected until the fluid spread along the paravertebral fascia to the stellate ganglion. The period free from VA allowed us to transfer the patient in another center in order to receive myocardial revascularization supported by ECMO. Left ganglion stellate block has a central role in the treatment of the refractory ventricular arrhythmias and may offer effective arrhythmia control giving time to rescue and/or other bridge therapy. In our case, it had a key role to perform an inter-hospital transfer and subsequent “rescue PCI therapy”. Thanks to Stellate ganglion block, the sinus rhythm was retained immediately, there were no ventricular tachycardia episodes for at least six hours allowing to perform myocardial revascularization supported by ECMO. No further ventricular arrhythmias occurred after revascularization, corroborating the ischemic trigger of electrical storm.
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Namita, Soni, Shruti A, Soni Anand, Nikalje A, and Bharadwaj M. "UNEXPLAINED DELIRIUM : THINK OF THYROID STORM." INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH, July 1, 2021, 23–25. http://dx.doi.org/10.36106/ijar/3900897.
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Background: Thyroid storm is a life-threatening Endocrine emergency with an incidence rate of 1% to 2% all over the world. It is a systemic condition leading to increased production of Thyroid Hormone and its release leading to Thermoregulatory, Adrenergic, Neuropsychiatric, Cardiovascular, and Abdominal Manifestations. Thyroid storm with Malignant Arrhythmia and delirium both together is rare entity, but the mortality rate is very high. The presentation of Malignant Arrhythmias and delirium together in the initial phase of the disease is much less common with only a few isolated cases described in the scientic literature. Objective: To present a case in which a patient had two simultaneous complication of thyroid storm i.e. delirium and ventricular tachycardia. Case Study: We report a 65 years-year-old man who came with complaints of Diarrhea, Fever, Breathlessness and psychosis. His serum tsh was <0.015 and anti tpo antibodies was 83. He was diagnosed to be in Thyroid storm and later had complications including Ventricular Tachycardia and delirium in an undiagnosed case of Hyperthyroidism. He was started on anti thyroid medication and slowly as his condition improved he was discharged. Conclusion: Patients with Thyrotoxicosis need to be closely monitored for complications since its early diagnosis and treatment may save lives.
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Jakstaite, Aiste Monika, Peter Luedike, Reza Wakili, Simon Kochhäuser, Arjang Ruhparwar, Tienush Rassaf, and Maria Papathanasiou. "Case report: incessant ventricular fibrillation in a conscious left ventricular assist device patient." European Heart Journal - Case Reports 5, no. 9 (September 1, 2021). http://dx.doi.org/10.1093/ehjcr/ytab337.
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Abstract Background Ventricular arrhythmia in left ventricular assist device (LVAD) recipients represents a challenging clinical scenario and the optimal treatment strategy in this unique patient population still needs to be defined. Case summary We report on a 61-year-old LVAD patient with incessant ventricular fibrillation (VF) despite multiple unsuccessful attempts to restore normal rhythm with external defibrillation and antiarrhythmic medication. He remained initially stable as an outpatient and subsequently developed secondary organ failure. Discussion This case demonstrates that under LVAD support long-term haemodynamic stability is possible even in case of VF, a situation that resembles Fontan circulation. However, ventricular arrhythmias are associated with a high risk of secondary organ damage due to right heart failure if left untreated. In case of refractory ventricular tachycardia or electrical storm listing for heart transplantation with high priority status should be pursued when possible. Alternatively, catheter ablation may be considered in selected cases and be performed in experienced centres in close collaboration with all involved specialists.
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Torselletti, Lorenzo, Stronati Giulia, Alessandro Barbarossa, Giuseppe Ciliberti, Francesca Coretti, Sara Belleggia, Francesca Coraducci, et al. "178 ARRHYTHMIC STORM IN ATTR WILD TYPE AMYLOIDOSIS: AN UNUSUAL COMBINATION." European Heart Journal Supplements 24, Supplement_K (December 14, 2022). http://dx.doi.org/10.1093/eurheartjsupp/suac121.087.
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Abstract Cardiac amyloidosis (CA) is characterized by extracellular protein fibril deposition in the myocardium leading to restrictive heart failure. Both atrial and ventricular arrhythmias are common in CA. Study have shown up to one half of patients with CA die suddenly. However, the most common cause of sudden death has been historically through to be secondary electromechanical dissociation rather than a lethal ventricular arrhythmia. We present the case of a 84 years old man, with a history of hypertension, dyslipidaemia, and prior smoking. In June 2020 the patient was admitted to the emergency room of our hospital due to an episode of hemodynamically unstable sustained ventricular tachycardia (SVT). The patient underwent electrical cardioversion with restoration of sinus rhythm. An echocardiogram that showed a slightly reduced ejection fraction (FE = 45%), severe concentric hypertrophy, grade 3 diastolic dysfunction with high pressures in the left ventricular (LV) cavity, and a reduced GLS (-13.8%) with a typical apical-sparing aspect. A cardiac magnetic resonance (Fig.1). was performed showing a diffuse area of LGE with a subepicardial pattern involving left ventricular and atrial segments, compatible with myocardial storage disease. In order to complete the diagnostic workout, we performed a bone scintigraphy (Fig.2). (Positive for CA, with Perugini score grade 2), a genetic test (negative for hATTR-CA mutations) and free light chain in serum (negative for AL-CA). The patient was discharged at home after ICD implantation in secondary prevention and prescribed appropriate heart failure therapy. In May 2022 the patient was readmitted in emergency room for dyspnea during an arrhythmic storm characterized by several SVTs and ICD interventions, and atrial fibrillation (FA). After stabilization of clinical parameters, the patient was hospitalized in our ward. We optimized medical therapy with metaprololo 100 mg 1 cp BID, cordarone 600 mg ev and mexiletina 200 mg cp BID. During the hospitalization we succeeded in reducing SVT burden. However, ventricular PVCs and slow SVT remained. For this reason, we decided to perform an electrophysiological study (EPS) followed by catheter ablation. The EPS found two low voltage areas (Fig.3). The first were found under the aortic valve; the second was an area of dense scar and fragmented potentials along the basal-posterior wall. After ablation of the first area we succeeded in removing clinical PVCs. During the ablation of the second area the procedure was complicated by ventricular fibrillation that required advanced life support and many electrical shocks. The patient was discharged at home in absence of further episodes of SVTs with optimized therapy At a three moths follow up no arrhythmic events were recorded.
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Gul, Ibrahim, Aamir Hameed Khan, Musa Karim, and Ayemen Shakeel Mirza. "IN HOSPITAL OUTCOME OF VENTRICULAR ARRHYTHMIA STORM AT THE AGA KHAN UNIVERSITY HOSPITAL, KARACHI, PAKISTAN." Pakistan Heart Journal 53, no. 4 (January 19, 2021). http://dx.doi.org/10.47144/phj.v53i4.1970.
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Objective: Our objective was to know the percent mortality of ventricular arrhythmia (VA) storm, its major leading factor and the predictors of in-hospital mortality of VA storm in our population. Methodology: In this retrospective observational study conducted at The Aga Khan University Hospital Karachi, all patients with age ≥16, with VA storm were included. Baseline demographic, clinical characteristics, laboratory parameters and management interventions were recorded in pre prepared questionnaire. The data was analyzed using SPSS version 21. Results: Of the total 74 patients, 86.5% were male, 77% were having monomorphic VT and 60.8% were in pulmonary edema. Hypertension (73%), IHD (63.5%), DM (48.6%) MR (56.8%) TR (50%) and LV dysfunctions were the commonest risk factors of VA storm. The mean hospital stay was 5.64 ± 5.63 and 59.5% patients were discharged home in stable condition. On bivariate analysis female gender, polymorphic VT, pulmonary edema, intubation, baseline hemoglobin levels, and baseline WBC counts were predictors of in-hospital mortality of VA storm with hazard ratios (HR) of 2.22 [0.95-5.18], 2.44 [1.18-5.08], 13.49 [1.82-99.85], 17.54 [2.38-129.44], 1.25 [1.05-1.47], and 1.06 [1.01-1.11] respectively. On multivariate analysis, female gender, intubation, and baseline hemoglobin level were independent predictors of in-hospital mortality of VA storm with adjusted HRs of 3.88 [1.02-14.77], 9.9 [0.95-103.25], and 1.47 [1.2-1.79] respectively. Conclusion: VA storm mortality for conservative management in our region is comparable to the international figures. Also we have similar risk factors for VA storm like low EF, structural heart disease and similar predictors of in-hospital mortality for VA storm.
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Spacek, R., O. Jiravsky, M. Hudec, J. Fismol, and L. Sknouril. "P5698What predicts the inefficiency of stellate ganglion block in the treatment of electrical storm?" European Heart Journal 40, Supplement_1 (October 1, 2019). http://dx.doi.org/10.1093/eurheartj/ehz746.0640.
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Abstract Introduction Electrical storm (ES) is an emergent condition which requires a sofisticated approach. Massive sympathetic surge almost always connected with ES precipitates recurrent ventricular arrhythmias. Performing stellate ganglion block (SGB) to alleviate the sympathetic activity on myocardium is becoming a standard of care in many centers. However, there is no clear data to predict in which patients the SGB will be ineffective. Purpose To identify predictors of SGB failure in patients with ES. Methods We analyzed our case series of SGB – the procedure was performed in 31 patients with ES in our center from March 2017 to December 2018. Results Mean left ventricular ejection fraction was 27% (±9%), 74% of patients had ischaemic cardiomyopathy. The most frequent type of arrhythmia was monomorphic ventricular tachycardia (VT), occurring in 71% of patients, followed by polymorphic VT in 13% of cases. After SGB, the burden of ventricular arrhythmias failed to decrease by at least 50% in 10% of cases - these patients were marked as non-responders. Slow monomorphic VT (under 160/min) was observed in all of these patients. On the other hand, fast monomorphic VT or polymorphic VT seemed to respond very well to SGB. We also observed, that patients with ES after acute coronary syndromes were good responders as well. The effect of SGB was not related to age, gender, EF LK or the etiology of cardiomyopathy. Conclusions According to our experience, the failure of SGB in the treatment of ES is not frequent. It typically occurs in patients with slow monomorphic VT. It is probable that such arrhythmias are sustained primarily due to the extensive myocardial substrate, and not because of the sympathetic surge. The situation is quite the opposite in patients with fast VT and acute ischemia.
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Zafeiropoulos, S., A. Bikou, I. T. Farmakis, I. Doundoulakis, G. Giannakoulas, and S. Zanos. "Stellate ganglion blockade for treatment of ventricular arrhythmia storm: a meta-analysis." European Heart Journal 43, Supplement_2 (October 1, 2022). http://dx.doi.org/10.1093/eurheartj/ehac544.684.
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Abstract Background Autonomic neuromodulation and particularly stellate ganglion blockade (SGB) has been tested in ventricular arrhythmia (VA) storm, but there is so far no robust evidence to inform clinical practice and its use remains limited. Purpose We aimed to summarize the efficacy and safety of SGB in patients with VA storm. Methods We searched PubMed, the Cochrane Library and Scopus from inception to 15th March 2022, for studies performing either pharmacological or electrical SGB in the context of drug-refractory VA storm. Case series with less than 10 patients were excluded. We performed a single-arm random effects meta-analysis of studies to calculate the pooled proportion estimate of freedom from VA recurrence after SBG and the overall mean change of VA burden from baseline. Results Of 409 articles identified and screened, we considered eligible six studies comprising a total of 106 patients. The mean age was 61.6±13.9 years, 79.2% were male, the mean left ventricular ejection fraction was 28.8±12.7%, and 47.1% had underlying ischemic cardiomyopathy. In five trials the patients received pharmacological SGB with bupivacaine, ropivacaine, or/and lidocaine (left-sided or bilateral), while in one study transcutaneous magnetic stimulation of the left stellate ganglion was used. The pooled proportion of patients free of VA recurrences was 65% (95% CI 51–78%, I2=46%) at the first 24 hours post-SGB (Figure 1A), and 54% (95% CI 43–64%, I2=0%) at 72 hours (Figure 1B). The number of VA episodes was significantly reduced from a mean baseline of 7.01±8.34 episodes/24h before SGB to 0.93±1.64 episodes/24h after SGB. The mean absolute reduction of VA episodes was 5.44 (95% CI 2.83–8.05, I2=88%) (Figure 1C) while the mean absolute reduction of external or internal defibrillation events was 3.36 (95% CI 0.62–6.09, I2=84%) (Figure 1D). No serious procedure-related complications were reported. The overall in-hospital mortality was 28.4%. Conclusions SGB appears an effective and safe treatment in patients with VA storm with approximately 1 in 2 patients exhibiting complete suppression of VA for 72 hours and an approximately 80% mean relative reduction in VA burden. Funding Acknowledgement Type of funding sources: None.
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Liang, Ying, Feilong Hei, and Yulong Guan. "Electrical storm after correction of an uncomplicated congenital atrial septal defect in an adult: a case report." BMC Cardiovascular Disorders 21, no. 1 (July 22, 2021). http://dx.doi.org/10.1186/s12872-021-02164-6.
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Abstract Background There is a paucity of published literature describing electrical storm after the correction of uncomplicated atrial septal defect (ASD) in an adult. Case presentation We present a 49-year-old woman with a congenital ASD combined with mild tricuspid regurgitation who denied any history of arrhythmia or other medical history. She suffered from electrical storm (≥ 3 episodes of ventricular tachycardias or ventricular fibrillations) in the early stage after ASD repair with combined tricuspid valvuloplasty. During electrical storm, her electrolytes were within normal ranges and no ischemic electrocardiographic changes were detected, which suggested that retained air embolism or acute coronary thrombosis were unlikely. Additionally, echocardiographic findings and her central venous pressure (5–8 mmHg during the interval between attacks) failed to support the diagnosis of pericardial tamponade. After a thorough discussion, the surgeons conducted an emergent re-exploration and repeated closure of the ASD with combined DeVega's annuloplasty. Eventually, the patient recovered uneventfully, without reoccurring arrhythmias during follow-up. Although we fail to determine the definite cause, we speculate that the causes probably are iatrogenic injury of the conduction system due to a rare anatomic variation, poor intraoperative protection, latent coronary distortion during tricuspid valvuloplasty, or idiopathic or secondary abnormalities of the conduction system. Conclusions For most surgeons, performing re-exploration without a known etiology is a difficult decision to make. This case illustrates that re-exploration could be an option when electrical storm occurs in the early stage postoperatively. Nevertheless, surgeons should assess the benefit-risk ratio when taking this unconventional measure.