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Weathering the Storm

Open AccessPublished:January 25, 2023DOI:https://doi.org/10.1016/j.hrcr.2023.01.008
      Drs Cooper and Sodhi have no conflicts of interest directly related to this editorial content. Dr Cooper takes part in advisory board/consulting activities for Medtronic and Boston Scientific. Dr Cooper gives lectures at fellow teaching conferences sponsored by Abbott and Boston Scientific. Dr Sodhi reports no conflicts of interest.
      The management of recalcitrant polymorphic ventricular arrhythmias following acute myocardial infarction (MI) can represent one of the most challenging clinical scenarios faced in critical care. Post-MI electrical storm often requires a multi-tiered, multidisciplinary approach to manage the complex interplay of arrhythmic triggers, ischemic substrate and the hyperadrenergic state. It requires a combination of antiarrhythmic drug therapy, sympathetic nervous system modulation and other case-specific interventions to obtain stability (see Table 1). The prompt and decisive initiation of these interventions can be the difference between life and death.
      Table 1Points of Emphasis for post MI Electrical Storm
      Obtain HD StabilityTerminate Arrhythmia: ACLS/Cardioversion/Defibrillation
      Initiate Medical TherapyAmiodarone + Beta Blocker (if tolerated) +/- Lidocaine
      Case-Specific Interventions•Assess need for LHC/revascularization if recurrent, active myocardial ischemia suspected as possible trigger

      •Correct any metabolic or electrolyte abnormalities

      •Consider increasing HR with pacing (existing CIED or TVP), especially if brady/pause dependent initiation

      •Optimize ICD programming/ATP to minimize ICD shocks
      If refractory, additional options•Consider catheter ablation

      oTargets: PVC Triggers +/- Scar Substrate

      •Measures to address hyper-adrenergic state

      oBeta Blockers

      oGeneral Anesthesia

      oThoracic Epidural Anesthesia

      oStellate Ganglion Blockage/Denervation

      •Temporary HD support

      oIntra-Aortic Balloon Pump

      oPercutaneous Ventricular Assist Device (Impella)

      oExtracorporeal Membrane Oxygenation (ECMO)

      •Advanced Heart Failures Therapies

      oSurgical Left Ventricular Assist Device

      oOrthotopic Heart Transplantation
      In this issue of the journal, Chartan et al

      Charton J, Tixier R, Sacher F, et al. Stepwise Ablation Strategy for Post-myocardial infarction ventricular fibrillation: from arrhythmia suppression to Ablation. Heart Rhythm Case Reports 2023.

      present a case report illustrating the management of VF storm in a patient shortly after myocardial infraction where the conventional measures of antiarrhythmic drug therapy and autonomic modulation were insufficient to obtain hemodynamic stability and arrhythmia suppression. Rapid atrial pacing and subsequent catheter ablation targeting the initiating PVC was required to stabilize the patient. The most compelling aspect of this case is the strategic, controlled way the authors approached the catheter ablation. The ventricular arrhythmia would rapidly return with intermittent loss of ventricular capture or cessation of pacing despite first line therapy. Faced with this challenge, they managed to minimize defibrillation by using a stepwise approach involving substrate mapping during rapid pacing with minimal interruption to obtain PVC template, followed by pace mapping to home in on the origin with brief multielectrode catheter mapping to identify the Purkinje pre-potentials, and successful ablation at site of earliest potential in the scar border zone.
      Catheter ablation of refractory VF following recent myocardial infarction represents a uniquely challenging clinical scenario in that it differs significantly in terms of risks, periprocedural arrhythmia characteristics, and outcomes compared to ablation targeting scar-based monomorphic VT in mature infarct.
      • Kowlgi G.N.
      • Cha Y.M.
      Management of ventricular electrical storm: a contemporary appraisal.
      Given limited options and lethality of the condition when refractory, current guidelines support the use of ablation in these scenarios.
      • Al-Khatib S.M.
      • Stevenson W.G.
      • Ackerman M.J.
      • et al.
      AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.

      Cronin EM, Bogun FM, Maury P, et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2020 Jan;17(1):e2-e154

      This is based on relatively limited data consisting largely of single center experiences that emphasize the role of targeting the Purkinje potentials that proceed the PMVT/VF initiating PVC. One of the largest, multicenter experiences published in 2019
      • Komatsu Y.
      • Hocini M.
      • Nogami A.
      • et al.
      Catheter Ablation of Refractory Ventricular Fibrillation Storm After Myocardial Infarction.
      was notable for cessation of VF storm in 84% of ablated patients with ablation associated with both short and long-term freedom from recurrent storm. However, they also reported a 27% rate of in-hospital death reflecting the significant morbidity and mortality associated with this clinical situation.
      The patient described in this case report is similar to the majority of the patients included in these prior experiences with recurrent VF in the acute to subacute phases of MI. In most scenarios, the arrhythmias originating from this complex, evolving substrate will calm with time, drugs, and autonomic modulation. However, when it doesn’t calm, catheter ablation can be life-saving and should be pursued. Fortunately, these refractory cases are relatively rare but, for those that find themselves in the predicament of managing post MI electrical storm that requires the full extent of the management armamentarium, this case provides a useful example to emulate.

      References:

      1. Charton J, Tixier R, Sacher F, et al. Stepwise Ablation Strategy for Post-myocardial infarction ventricular fibrillation: from arrhythmia suppression to Ablation. Heart Rhythm Case Reports 2023.

        • Kowlgi G.N.
        • Cha Y.M.
        Management of ventricular electrical storm: a contemporary appraisal.
        Europace. 2020; 22: 1768-1780
        • Al-Khatib S.M.
        • Stevenson W.G.
        • Ackerman M.J.
        • et al.
        AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.
        Heart Rhythm. 2018; 15: 190-252
      2. Cronin EM, Bogun FM, Maury P, et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2020 Jan;17(1):e2-e154

        • Komatsu Y.
        • Hocini M.
        • Nogami A.
        • et al.
        Catheter Ablation of Refractory Ventricular Fibrillation Storm After Myocardial Infarction.
        Circulation. 2019; 139: 2315-2325

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