Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review (JACC June 2023-1)-Article: Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review

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

Pdf Summary

Electrical storm (ES) represents a state of critical cardiac electrical instability characterized by recurrent ventricular arrhythmias (VAs) within a 24-hour period. Predominantly emerging from structural heart disease or channelopathies, it threatens high morbidity and mortality. Immediate management prioritizes identifying arrhythmia sources, triggers, and implementing medical interventions. Essential steps include interrogation and programming of implantable cardioverter-defibrillators (ICDs), conventional use of antiarrhythmic drugs (AADs) like amiodarone or lidocaine, beta-blockers, sedatives for psychological stabilization, and hemodynamic support, including temporary mechanical circulatory support if warranted.<br /><br />Patients with ICDs often exhibit a more stable presentation despite recurrent VAs, while those without are critically compromised. Effective ICD programming to prevent unnecessary shocks, ideal for well-tolerated VAs, involves optimal antitachycardia pacing.<br /><br />Catheter ablation becomes crucial in cases refractory to AADs or those with incessant arrhythmias. The procedure entails either activation mapping or substrate modification based on the pinpointed VAs. Preprocedural evaluations ensure hemodynamic stability and resolve potential triggers. Hemodynamic supports, such as intra-aortic balloon pump (IABP) or venoarterial extracorporeal membrane oxygenation (VA-ECMO), might facilitate procedural safety.<br /><br />Advanced heart failure (HF) often accompanies ES, with many survivors requiring either heart transplantation or left ventricular assist device (LVAD). Palliative care integration is vital given the high-risk recurrence of VAs and subsequent progressive HF.<br /><br />Continued vigilance post-recovery involves long-term AADs, propranolol as preferred beta-blockade, and meticulous GDMT optimization to mitigate HF exacerbations. Regular follow-ups are paramount due to heightened recurrence risks. Collaborative clinical trials are necessary to refine treatment protocols comprehensively, considering ES's broad clinical severity spectrum.

Keywords

Electrical storm

ventricular arrhythmias

structural heart disease

channelopathies

implantable cardioverter-defibrillators

antiarrhythmic drugs

catheter ablation

hemodynamic support

heart failure

palliative care