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Introduction: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in patients of younger age without typical atherosclerotic risk factors and can present with ventricular arrhythmia such as ventricular tachycardia (VT) or ventricular fibrillation (VF). Electrical storm (ES) is defined as greater than or equal to 3 episodes of VT or VF occurring within 24 hours.Case Report: A healthy 38-year-old-male developed chest pain while exercising at the gym and presented to the emergency department unresponsive in a ventricular arrhythmia defined as ES. The patient’s cardiac arrest was initially refractory to standard defibrillation and Advanced Cardiac Life Support medications. He was ultimately diagnosed with SCAD of the left anterior descending artery, which was stented. The patient survived neurologically intact after a 13-day hospital stay.Conclusion: Spontaneous coronary artery dissection is a significant cause of acute coronary syndrome and occurs in healthier patients without cardiac risk factors. Electrical storm represents a unique manifestation of SCAD. Emergency physicians should maintain a heightened suspicion for SCAD for accurate diagnosis and treatment.

Audience: This simulation case was created for emergency medicine (EM) residents at all levels of training.Background: Cardiac electrical storm (ES) is commonly defined as three or more episodes of sustainedventricular tachycardia, ventricular fibrillation, or three shocks from an implantable defibrillator within a 24hour period.1 This can occur in up to 30-40% of patients with implantable defibrillators; however, it may alsopresent in a wide variety of patients, including those with structural heart disease, myocardial infarction,electrolyte disturbances, and channelopathies.2,3 With each subsequent episode of ventricular arrhythmia,the arrhythmogenic potential of the heart may increase secondary to increased intracellular calciumdysregulation, myocardial injury, and increased endogenous release of catecholamines. The increased painand catecholamine release from cardioversion/defibrillation and exogenous epinephrine during cardiacarrest further exacerbates ES.2 This carries a significant mortality risk of up to 12% in the first 48 hours.3This case involves a basic knowledge of the Advanced Cardiac Life Support (ACLS) for ventricular tachycardia,both with and without a pulse, and the application of Sgarbossa criteria in a patient with an ST elevationmyocardial infarction (STEMI) which makes it ideal for the PGY-1. However, the case quickly becomesrefractory to the basic management prescribed in ACLS, requiring trouble shooting and quick thinking aboutdeeper pathophysiology, a skill that is crucial for all emergency medicine physicians. There are multiple waysto troubleshoot this case, making for a good variety of discussion and recent literature review on thecomplexities of a relatively common arrhythmia, ventricular tachycardia.Educational Objectives: By the end of this simulation, learners should be able to: 1) recognize unstableventricular tachycardia and initiate ACLS protocol, 2) practice dynamic decision making by switching betweenvarious ACLS algorithms, 3) create a thoughtful approach for further management of refractory ventriculartachycardia, 4) interpret electrocardiogram (ECG) with ST-segment elevation (STE) and left bundle branchblock (LBBB), 5) appropriately disposition the patient and provide care after return of spontaneous circulation(ROSC), 6) navigate a difficult conversation with the patient’s husband when she reveals that the patient’swishes were to not be resuscitated.Educational Methods: This simulation was performed using high-fidelity simulation followed by animmediate debriefing with nine learners who directly participated in the SIM and twenty-three residents,who were online observers via Zoom. This case was done during our conference day, and there were a totalof approximately forty total learners comprised of medical students, PGY-1, PGY-2 and PGY-3 residents. Therewere several medical students who also observed via Zoom but were not surveyed, and the survey was sentto 32 learners. The case was run three separate times with each session consisting of three-four learners atthe same level of training, with other learners in the same level of training observing via Zoomä videoplatform. Since we can only have a team of three-four learners participate per group during simulation, therest of the learners were observing the case and the debrief. There was one simulation instructor and one technician.Research Methods: We sent an online survey to all the participants and the observers after the debrief viasurveymonkey.com. The survey collected responses to the following statements: (1) the case was believable,(2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patientcare, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session aftersimulation helped improve my knowledge. Likert scale was used to collect the responses.Results: A total of thirteen participants responded to the survey. One hundred percent of them eitherstrongly agreed or agreed that the case was believable and that it helped in improving medical knowledgeand patient care. Fifty-four percent strongly agreed, 38 percent agreed, and eight percent were neutral aboutthe case having the right amount of complexity. Thirty one percent strongly agreed, 61 percent agreed, andeight percent were neutral about the case giving them real-life experience. All of them agreed that thedebriefing session helped them improve their knowledge.Discussion: The high-fidelity simulation case was helpful with educating learners with ventricular tachycardiaand fibrillation. Learners learned how to switch between various ACLS algorithms and how to manage apatient with refractory ventricular fibrillation. Learners enforced their knowledge in how to communicatewith patient’s family members when the patient does not want resuscitation.

Background: Conus artery occlusion is a rare life-threatening event, typically secondary to iatrogenic etiology, and is treated mainly with conservative therapy and/or balloon angioplasty without stenting. However, treatment remains challenging. Case presentation: We report the case of a 60-year-old man with a known history of coronary artery disease presenting with multiple internal defibrillator cardioversions due to an electrical storm (recurrent ventricular fibrillation). The coronary angiography showed an acute occlusion of the conus artery arising from the proximal segment of the right coronary artery, treated by percutaneous transluminal coronary angioplasty with stenting (drug-eluting stent) without any serious complications. Conclusions: To our knowledge, this is the first case in the literature where a non-iatrogenic occlusion of the conus artery causing a ST-segment elevation myocardial infarction and electrical storm was treated with percutaneous coronary intervention with drug-eluting stenting. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation (CA) is a well-established treatment in patients with ventricular tachycardia and appropriate implantable cardioverter defibrillator (ICD) therapies. Methods: We enrolled 57 consecutive carriers of ICD undergoing CA for electrical storm (ES). Our aim was to investigate differences in clinical, device-related, and electroanatomic features among patients who had history of appropriate ICD interventions before the ES compared to those who had not. The primary endpoint was a composite of death from any cause and recurrences of sustained VT, ventricular fibrillation, appropriate ICD therapy, or ES. Results: During a median follow up of 39 months, 28 patients (49%) met the primary endpoint. Those with previous ICD interventions had a higher prevalence of late potentials and a greater unipolar low-voltage area at electroanatomic mapping. Patients who met the primary endpoint had a higher prevalence of ATP/shock episodes preceding the ES event. At Cox regression analysis, non-ischemic dilated cardiomyopathy (NIDCM), QRS duration, and previous ATP and/or shock before the ES were associated with arrhythmic recurrences and/or death. At multivariate analysis, NIDCM and previous shock were associated with arrhythmic recurrences and/or death. Conclusions: A history of recurrent ICD therapies predicts worse outcomes when CA is needed because of ES. Although more studies are needed to definitively address this question, our data speak in support of an early referral for CA of ES. [ABSTRACT FROM AUTHOR]

Aims: Drug‐refractory electrical storm (ES) is a life‐threatening medical emergency. We describe the use of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) in drug‐refractory ES without a reversible trigger, for which specific guideline recommendations are still lacking. Methods and results: Retrospective observational study in four Iberian centres on the indications, treatment, complications, and outcome of drug‐refractory ES not associated with acute coronary syndromes, decompensated heart failure, drug toxicity, electrolyte disturbances, endocrine emergencies, concomitant acute illness with fever, or poor compliance with anti‐arrhythmic drugs, requiring VA‐ECMO for circulatory support. Thirty‐four (6%) out of 552 patients with VA‐ECMO for cardiogenic shock were included [71% men; 57 (44–62) years], 65% underwent cardiopulmonary resuscitation before VA‐ECMO implantation, and 26% during cannulation. Left ventricular unloading during VA‐ECMO was used in 8 (24%) patients: 3 (9%) with intraaortic balloon pump, 3 (9%) with LV vent, and 2 (6%) with Impella. Thirty (88%) had structural heart disease and 8 (24%) had an implantable cardioverter‐defibrillator. The drug‐refractory ES was mostly due to monomorphic ventricular tachycardia (VT) and ventricular fibrillation (VF) (59%), isolated monomorphic VT (26%), polymorphic VT (9%), or VF (6%). Thirty‐one (91%) required deep sedation, 44% overdrive pacing, 36% catheter ablation, and 26% acute autonomic modulation. The main complications were nosocomial infection (47%), bleeding (24%), and limb ischaemia (21%). Eighteen (53%) were weaned from VA‐ECMO, and 29% had heart transplantation. Twenty‐seven (79%) survived to hospital discharge (48 (33–82) days). Non‐survivors were older [62 (58–67) vs. 54 (43–58); P < 0.01] and had a higher first rhythm disorder‐to‐ECMO interval [0 (0–2) vs. 2 (1‐11) days; P = 0.02]. Seven (20%) had rehospitalization during follow‐up [29 (12–48) months], with ES recurrence in 6%. Conclusions: VA‐ECMO bridged drug‐refractory ES without a reversible trigger with a high success rate. This required prolonged hospital stays and coordination between the ECMO centre, the electrophysiology laboratory, and the heart transplant programme. [ABSTRACT FROM AUTHOR]

Abstract Background Conus artery occlusion is a rare life-threatening event, typically secondary to iatrogenic etiology, and is treated mainly with conservative therapy and/or balloon angioplasty without stenting. However, treatment remains challenging. Case presentation We report the case of a 60-year-old man with a known history of coronary artery disease presenting with multiple internal defibrillator cardioversions due to an electrical storm (recurrent ventricular fibrillation). The coronary angiography showed an acute occlusion of the conus artery arising from the proximal segment of the right coronary artery, treated by percutaneous transluminal coronary angioplasty with stenting (drug-eluting stent) without any serious complications. Conclusions To our knowledge, this is the first case in the literature where a non-iatrogenic occlusion of the conus artery causing a ST-segment elevation myocardial infarction and electrical storm was treated with percutaneous coronary intervention with drug-eluting stenting. Graphical abstract

Abstract Aims Drug‐refractory electrical storm (ES) is a life‐threatening medical emergency. We describe the use of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) in drug‐refractory ES without a reversible trigger, for which specific guideline recommendations are still lacking. Methods and results Retrospective observational study in four Iberian centres on the indications, treatment, complications, and outcome of drug‐refractory ES not associated with acute coronary syndromes, decompensated heart failure, drug toxicity, electrolyte disturbances, endocrine emergencies, concomitant acute illness with fever, or poor compliance with anti‐arrhythmic drugs, requiring VA‐ECMO for circulatory support. Thirty‐four (6%) out of 552 patients with VA‐ECMO for cardiogenic shock were included [71% men; 57 (44–62) years], 65% underwent cardiopulmonary resuscitation before VA‐ECMO implantation, and 26% during cannulation. Left ventricular unloading during VA‐ECMO was used in 8 (24%) patients: 3 (9%) with intraaortic balloon pump, 3 (9%) with LV vent, and 2 (6%) with Impella. Thirty (88%) had structural heart disease and 8 (24%) had an implantable cardioverter‐defibrillator. The drug‐refractory ES was mostly due to monomorphic ventricular tachycardia (VT) and ventricular fibrillation (VF) (59%), isolated monomorphic VT (26%), polymorphic VT (9%), or VF (6%). Thirty‐one (91%) required deep sedation, 44% overdrive pacing, 36% catheter ablation, and 26% acute autonomic modulation. The main complications were nosocomial infection (47%), bleeding (24%), and limb ischaemia (21%). Eighteen (53%) were weaned from VA‐ECMO, and 29% had heart transplantation. Twenty‐seven (79%) survived to hospital discharge (48 (33–82) days). Non‐survivors were older [62 (58–67) vs. 54 (43–58); P

Electrical storm (ES) is among the most fearsome events in patients in waiting list for heart transplantation (HT) and catheter ablation (CA) demonstrated to be effective in reduce the arrhythmic burden. However, selection criteria for CA suitability in this specific population have never been addressed before. We retrospectively enrolled 36 patients (mean age 51 ± 8 years; 83% men) waiting HT referred to our department for ES resistant to antiarrhythmic drugs and percutaneous stellate ganglion blockade. Twenty patients were judged suitable for VT ablation according to specific criteria including absence of increased arrhythmic burden secondary to volume overload and hemodynamic decompensation; expected CA outcome favorable due to etiology of the cardiomyopathy, no need for coronary revascularization and technical feasibility of the procedure. The pre‐emptive use of mechanical circulatory supports (MCS) were discussed integrating the PAINESD score with additional clinical and hemodynamic parameters. Acute procedural success was accounted in 85% of cases with only two major complications. The CA group reported lower length of in‐hospital stay after CA suitability evaluation (56 ± 17 vs. 131 ± 64 days, p = .004). Furthermore, at a mean follow‐up of 703 ± 145 days, this group showed reduction of ventricular arrhythmia (VA) recurrence leading to implantable cardioverter defibrillator shock (4 vs. 8, p = .051) and underwent HT with a lower level of urgency (0 vs. 6 patients needed for UNOS1 status upgrade). Respectively, one patient of the CA group and two patients of the conservative group died (p = .839). At the end of follow‐up, eight patients underwent heart transplantation (p = .964) while four patients underwent Left Ventricular Assist device (LVAD) implantation (p = .440). This pilot study should be a proof for further studies exploring CA of VAs as a possible bridge therapy to HT. [ABSTRACT FROM AUTHOR]

Background Left ventricular (LV) summit arrhythmias account for up to 14% of LV arrhythmias. The ablation of LV summit arrhythmias is challenging, as testified by the fact that radiofrequency (RF) catheter ablation failure is frequent. Retrograde coronary venous ethanol infusion has been proposed as an alternative approach for the ablation of LV summit arrhythmias. Case summary A 47-year-old man with Lamin A/C cardiomyopathy was referred for the ablation of a pleiomorphic ventricular tachycardia (VT) storm, with dominant morphology compatible with LV summit origin. He first received a combined endo- and epicardial RF ablation with the elimination of three clinically relevant VTs. However, the dominant VT could not be ablated due to the proximity of the coronary vasculature and phrenic nerve and remained inducible. Accordingly, an urgent rescue redo procedure consisting of retrograde coronary venous ethanol ablation was performed. Based on the best pace-match and precocity, the first septal, retro-pulmonary branch and the first diagonal branch were infused with ethanol with immediate cessation of the tachycardia and non-inducibility. Anti-arrhythmic drugs were withdrawn, while guideline-directed medical therapy for heart failure was continued. No complications occurred. After 3 months, the patient remained free from any arrhythmias. Discussion Ablation of LV summit arrhythmias is challenging, especially in the context of an electrical storm or in patients with structural heart disease. In such a situation, rescue ablation with retrograde coronary venous ethanol infusion represents an attractive alternative ablation modality. [ABSTRACT FROM AUTHOR]

We present a case of a 45-year-old female with advanced heart failure due to nonischemic cardiomyopathy, an ejection fraction of 15% complicated by ventricular arrhythmias degenerating into an electrical storm. The treatment approach involved antiarrhythmic medications, inotrope support, diuretics, and the placement of an Impella 5.5 device for mechanical circulatory support. Due to persistent polymorphic ventricular tachycardia, a bilateral stellate ganglion blockade was performed along with intensified antiarrhythmic therapy and deep sedation. This case highlights the role of axillary mechanical circulatory support with the Impella 5.5 in providing unfettered hemodynamic stability and the potential added benefit of stellate ganglion blockade in managing malignant ventricular arrhythmias.

Abstract Background Electrical storm (ES) is a clinical emergency characterized by multiple malignant ventricular arrhythmias or ICD discharges within 24 h, requiring early rational management. Case presentation We report a 55-year-old man who underwent aortic valve replacement experienced recurrent ventricular tachycardia/ventricular fibrillation. A temporary permanent pacemaker with the EnSite system was implanted, and significant inhibition of the electrical storm, attributed to the atrial overdrive pacing, ensued. Conclusions In emergency regarding an electrical storm, the bedside temporary permanent pacemaker implantation with the EnSite system is concluded to be feasible and safe.

Aims Percutaneous stellate ganglion block (PSGB) through single-bolus injection and thoracic epidural anaesthesia (TEA) have been proposed for the acute management of refractory ventricular arrhythmias (VAs). However, data on continuous PSGB (C-PSGB) are scant. The aim of this study is to report our dual-centre experience with C-PSGB and to perform a systematic review on C-PSGB and TEA. Methods and results Consecutive patients receiving C-PSGB at two centres were enrolled. The systematic literature review follows the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Our case series (26 patients, 88% male, 60 ± 16 years, all with advanced structural heart disease, left ventricular ejection fraction 23 ± 11%, 32 C-PSGBs performed, with a median duration of 3 days) shows that C-PSGB is feasible and safe and leads to complete VAs suppression in 59% and to overall clinical benefit in 94% of cases. Overall, 61 patients received 68 C-PSGBs and 22 TEA, with complete VA suppression in 63% of C-PSGBs (61% of patients). Most TEA procedures (55%) were performed on intubated patients, as opposed to 28% of C-PSGBs (P = 0.02); 63% of cases were on full anticoagulation at C-PSGB, none at TEA (P < 0.001). Ropivacaine and lidocaine were the most used drugs for C-PSGB, and the available data support a starting dose of 12 and 100 mg/h, respectively. No major complications occurred, yet TEA discontinuation rate due to side effects was higher than C-PSGB (18 vs. 1%, P = 0.01). Conclusion Continuous PSGB seems feasible, safe, and effective for the acute management of refractory VAs. The antiarrhythmic effect may be accomplished with less concerns for concomitant anticoagulation compared with TEA and with a lower side-effect related discontinuation rate. [ABSTRACT FROM AUTHOR]

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA. [ABSTRACT FROM AUTHOR]

Background and Aims An electrical storm (ES) is a clinical emergency with a paucity of established treatment options. Despite initial encouraging reports about the safety and effectiveness of percutaneous stellate ganglion block (PSGB), many questions remained unsettled and evidence from a prospective multicentre study was still lacking. For these purposes, the STAR study was designed. Methods This is a multicentre observational study enrolling patients suffering from an ES refractory to standard treatment from 1 July 2017 to 30 June 2023. The primary outcome was the reduction of treated arrhythmic events by at least 50% comparing the 12 h following PSGB with the 12 h before the procedure. STAR operators were specifically trained to both the anterior anatomical and the lateral ultrasound-guided approach. Results A total of 131 patients from 19 centres were enrolled and underwent 184 PSGBs. Patients were mainly male (83.2%) with a median age of 68 (63.8–69.2) years and a depressed left ventricular ejection fraction (25.0 ± 12.3%). The primary outcome was reached in 92% of patients, and the median reduction of arrhythmic episodes between 12 h before and after PSGB was 100% (interquartile range −100% to −92.3%). Arrhythmic episodes requiring treatment were significantly reduced comparing 12 h before the first PSGB with 12 h after the last procedure [six (3–15.8) vs. 0 (0–1), P <.0001] and comparing 1 h before with 1 h after each procedure [2 (0–6) vs. 0 (0–0), P <.001]. One major complication occurred (0.5%). Conclusions The findings of this large, prospective, multicentre study provide evidence in favour of the effectiveness and safety of PSGB for the treatment of refractory ES. [ABSTRACT FROM AUTHOR]

BACKGROUND: A structural heart disease or functional electrical abnormalities can cause an electrical storm. Case presentation: We present a young boy with an electrical storm who had no cardiac risk factors and a positive family history of sudden cardiac death. The stepwise diagnostic approach was ineffective in determining previously known causes as the origin of the electrical storm. However, whole-exome sequencing (with Next Generation Illumina Sequencing) revealed a mutation in the GJB2 (NM_004004:exon2:c.G71A:p.W24X) gene. CONCLUSION: A mutation in the GJB2 gene, which forms the connexin 26 protein, a crucial component of the myocytes’ intercalated disc of gap junction complex between the myocytes, results in an abnormal electrical cell-by-cell conductance, and, eventually, ventricular storm. General anesthesia was used to control the storm, and intracardiac pacing was fruitful in ceasing the subsequent VT storms. [ABSTRACT FROM AUTHOR]

An electrical storm (ES) is defined as the presence of at least three episodes of sustained ventricular tachycardia or ventricular fibrillation within 24 h. This patient had a previously known arterial hypertension, type II diabetes mellitus, and chronic kidney disease and has presented to the Emergency Department (ED) with symptoms of retrosternal chest pain lasting for several hours prior. The initial 12-lead electrocardiogram revealed ST segment elevation in the anterior leads (V1–V6). Emergent coronary angiography revealed an acute occlusion of the proximal left anterior descending artery (pLAD) and percutaneous coronary intervention was performed with successful implantation of one drug-eluting stent in the pLAD. On day 8 of hospitalization, the patient developed a refractory ES for which he received 50 DC shocks and did not respond to multiple lines of antiarrhythmic medications. Due to a failure of medical therapy, we decided to implant a temporary pacemaker and initiate ventricular overdrive pacing (VOP) that was successful in terminating ES. Following electrical stabilization, the patient underwent a successful ICD implantation. This case demonstrates that VOP can contribute to hemodynamic and electrical stabilization of a patient that suffers from refractory ES and this treatment modality might serve as a temporary bridge to ICD implantation. [ABSTRACT FROM AUTHOR]

Background The use of percutaneous stellate ganglion block (SGB) in the management of drug-refractory electrical storm (ES) has been increasingly reported in the last years. Few data are available on the safety, duration, and dosage of local anaesthetic used. Case summary A 66-year-old male patient with a history of ischaemic cardiomyopathy and an implantable cardioverter–defibrillator (ICD) presented to the emergency room complaining several ventricular arrhythmias and ICD shocks received in the last 24 h. He was treated with many lines of anti-arrhythmic drugs but his condition deteriorated with cardiovascular instability and respiratory distress, so he was intubated. The ES still worsened (82 episodes of ventricular arrhythmias), so we performed an ultrasound-guided left SGB, using a modified technique, with success in suppressing the ventricular arrhythmias. The patient was then treated with electrophysiological study and catheter ablation. Discussion The ultrasound approach to SGB is feasible in emergency setting, and it is safe and effective also using a modified and easier technique in patient with difficult sonographic visualization of the neck structures. Moreover, it is possible and safe to use a combination of short-acting rapid-onset local anaesthetic with a long-lasting one with a good outcome. [ABSTRACT FROM AUTHOR]

Introduction: Prognosis after electrical storm (ES) ablation remains severe, especially in patients with recurrent sustained monomorphic ventricular tachycardia (SMVT) or progressive heart failure (HF). However, single-factor-based prediction is suboptimal and may be refined by more complex algorithms. We sought to evaluate if a novel score MSA-VT (M = moderate/severe mitral regurgitation, S = severe HF at admission, A = atrial fibrillation at admission, VT = inducible SMVT after ablation) may improve prediction of death and recurrences compared to single factors and previous scores (PAINESD, RIVA and I-VT). Methods: A total of 101 consecutive ES ablation patients were retrospectively analyzed over a 32.8-month (IQR 10-68) interval. The MSA-VT score was calculated as the sum of the previously mentioned factors' coefficients based on hazard ratio values in Cox regression analysis. The AUC for death prediction by MSA-VT was 0.84 (p < 0.001), superior to PAINESD (AUC 0.63, p = 0.03), RIVA (AUC 0.69, p = 0.02) and I-VT (0.56, p = 0.3). MSA-VT ≥ 3 was associated with significantly higher mortality during follow-up (52.7%, p < 0.001). Conclusions: Prediction by single factors and previously published scores after ES ablation may be improved by the novel MSA-VT score; however, this requires further external validation in larger samples. [ABSTRACT FROM AUTHOR]

Background: Electrical storm (ES) is a clinical emergency characterized by multiple malignant ventricular arrhythmias or ICD discharges within 24 h, requiring early rational management. Case presentation: We report a 55-year-old man who underwent aortic valve replacement experienced recurrent ventricular tachycardia/ventricular fibrillation. A temporary permanent pacemaker with the EnSite system was implanted, and significant inhibition of the electrical storm, attributed to the atrial overdrive pacing, ensued. Conclusions: In emergency regarding an electrical storm, the bedside temporary permanent pacemaker implantation with the EnSite system is concluded to be feasible and safe. [ABSTRACT FROM AUTHOR]

Introduction: Electrical storm (ES) of ventricular tachyarrhythmias (VTAs) is an important cause of sudden death in patients with cardiac sarcoidosis (CS). VTAs in CS are associated with myocardial scarring and inflammation. However, little is known about the risk factors of ES in patients with CS and VTAs. The objective of this study is to clarify the characteristics and risk factors for the development of ES in patients with CS. Methods: The study population included consecutive 52 patients with CS and sustained VTA. Twenty‐five out of 52 patients experienced ES. We evaluated clinical characteristics, imaging modalities, and electrocardiogram (ECG) parameters to determine the risk factors associated with ES. Results: Half of the patients experienced VTAs as the initial symptom of sarcoidosis, and eight patients had ES as the initial VTA episode. There were no differences in cardiac imaging abnormalities between patients with and without ES. Among ECG markers, significant QRS fragmentation (odds ratio [OR]: 7.9, p =.01) and epsilon waves (OR: 12.24, p =.02) were associated with ES. Among the ventricular tachycardia (VT) characteristics, multiple morphologies of monomorphic VTs (OR: 10.9, p <.01), short VT cycle lengths (OR: 12.5, p <.01), and polymorphic VT (OR: 13.5, p <.01) were associated with ES. Bidirectional VTs were detected in 10 patients with ES and one patient without ES. Immunosuppressive therapy relieved ES in some patients. Conclusions: ES was common in patients with CS and VTAs. Significant depolarization abnormalities that appeared as QRS fragmentation, epsilon waves, and specific VT characteristics were associated with ES. [ABSTRACT FROM AUTHOR]

An electrical storm (ES) is defined as the presence of at least three episodes of sustained ventricular tachycardia or ventricular fibrillation within 24 h. This patient had a previously known arterial hypertension, type II diabetes mellitus, and chronic kidney disease and has presented to the Emergency Department (ED) with symptoms of retrosternal chest pain lasting for several hours prior. The initial 12-lead electrocardiogram revealed ST segment elevation in the anterior leads (V1–V6). Emergent coronary angiography revealed an acute occlusion of the proximal left anterior descending artery (pLAD) and percutaneous coronary intervention was performed with successful implantation of one drug-eluting stent in the pLAD. On day 8 of hospitalization, the patient developed a refractory ES for which he received 50 DC shocks and did not respond to multiple lines of antiarrhythmic medications. Due to a failure of medical therapy, we decided to implant a temporary pacemaker and initiate ventricular overdrive pacing (VOP) that was successful in terminating ES. Following electrical stabilization, the patient underwent a successful ICD implantation. This case demonstrates that VOP can contribute to hemodynamic and electrical stabilization of a patient that suffers from refractory ES and this treatment modality might serve as a temporary bridge to ICD implantation.

Background: Catheter ablation (CA) is a well-established treatment in patients with ventricular tachycardia and appropriate implantable cardioverter defibrillator (ICD) therapies. Methods: We enrolled 57 consecutive carriers of ICD undergoing CA for electrical storm (ES). Our aim was to investigate differences in clinical, device-related, and electroanatomic features among patients who had history of appropriate ICD interventions before the ES compared to those who had not. The primary endpoint was a composite of death from any cause and recurrences of sustained VT, ventricular fibrillation, appropriate ICD therapy, or ES. Results: During a median follow up of 39 months, 28 patients (49%) met the primary endpoint. Those with previous ICD interventions had a higher prevalence of late potentials and a greater unipolar low-voltage area at electroanatomic mapping. Patients who met the primary endpoint had a higher prevalence of ATP/shock episodes preceding the ES event. At Cox regression analysis, non-ischemic dilated cardiomyopathy (NIDCM), QRS duration, and previous ATP and/or shock before the ES were associated with arrhythmic recurrences and/or death. At multivariate analysis, NIDCM and previous shock were associated with arrhythmic recurrences and/or death. Conclusions: A history of recurrent ICD therapies predicts worse outcomes when CA is needed because of ES. Although more studies are needed to definitively address this question, our data speak in support of an early referral for CA of ES.

Background: Electroanatomical mapping (EAM)-guided stereotactic arrhythmia radioablation (STAR) is a novel noninvasive therapy option for patients with monomorphic ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or urgent catheter ablation (CA). Data on success rates in an emergency situation such as electrical storm (ES) are rare. We present a case of a patient with an initially very poor life expectancy after extensive myocardial infarction with therapy–resistant ES, not amendable for further antiarrhythmic drug therapy, implantable cardioverter-defibrillator implantation, or repeated CA who was introduced to the radiation oncology department for emergency STAR as a bail-out therapy. Methods: Target volume definition and transfer from EAM to CT were validated and quality assured with a semi-automatic, dedicated visualization tool (CARDIO-RT). Emergency STAR was performed with 25 Gy in the framework of the RAVENTA study. The VT burden gradually decreased after STAR; however, a second VT morphology occurred, which was successfully treated with EAM-guided CA 12 days after STAR. Results: The second EAM-guided CA showed areas of low voltage in the irradiated segments, indicating a precise targeting and early functional response to STAR. The patient remained free of any VT recurrence or any radiation-related toxicities and in good general condition during the recent follow-up of 18 months. Conclusion: The case highlights the possible approach, caveats, difficulties, and prognosis of a patient severely affected by therapy-resistant VT in whom CA could not lead to VT suppression. Further studies of putative mechanisms of STAR in the acute and chronic phase of this novel therapy are warranted. [ABSTRACT FROM AUTHOR]

Torsades de Pointes (TdP) refers to a polymorphic ventricular tachycardia (VT) with undulating QRS axis that occurs in long QT syndrome (LQTS), although the term has been used to describe polymorphic ventricular tachyarrhythmias in which QT intervals are not prolonged, such as short-coupled variant of TdP currently known as short-coupled ventricular fibrillation (VF) and Brugada syndrome. Extensive works on LQTS-related TdP over more than 50 years since it was first recognized by Dessertennes who coined the French term meaning “twisting of the points”, have led to current understanding of the electrophysiological mechanism that TdP is initiated by triggered activity due to early afterdepolarization (EAD) and maintained by reentry within a substrate of inhomogeneous repolarization. While a recently emerging notion that steep voltage gradients rather than EADs are crucial to generate premature ventricular contractions provides additions to the initiation mode, the research to elucidate the maintenance mechanism hasn't made much progress. The reentrant activity that produces the specific form of VT is not well characterized. We have conducted optical mapping in a rabbit model of electrical storm by electrical remodeling (QT prolongation) due to chronic complete atrioventricular block and demonstrated that a tissue-island with prolonged refractoriness due to enhanced late Na+ current (INa−L) contributes to the generation of drifting rotors in a unique manner, which may explain the ECG characteristic of TdP. Moreover, we have proposed that the neural Na+ channel NaV1.8-mediated INa−L may be a new player to form the substrate for TdP. Here we discuss TdP mechanisms by comparing the findings in electrical storm rabbits with recently published studies by others in simulation models and human and animal models of LQTS.

Background: For the treatment of patients with electrical storm (ES), we established a two-step algorithm comprising standard anti-arrhythmic measures and early ultrasound-guided stellate ganglion blockade (SGB). In this single-center study, we evaluated the short-term efficacy of the algorithm and tested the hypothesis that early SGB might prevent the need for intubations. Methods: Overall, we analyzed data for 70 ES events in 59 patients requiring SGB (mean age 67.7 ± 12.4 years, 80% males, left ventricular ejection fraction 30.0% ± 9.1%), all with implantable cardioverter-defibrillators (ICDs). Results: The mean time from ES onset to SGB was 13.2 ± 12.3 hours. Percentage and mean absolute reduction in shocks at 48 hours after SGB reached 86.8% (−6.3 shocks), and anti-tachycardiac pacing (ATP) declined by 65.9% (−51.1 ATPs; all P

Background: An electrical storm due to malignant ventricular tachycardia (VT) is a life-threatening condition that requires catheter ablation (CA). Most VT arrhythmias evolve over time after acute myocardial infarction, coronary artery bypass grafting, or chronic heart failure. Clinically, only radiofrequency ablation can identify and block all arrhythmia origin points. The procedure necessitates continuous VT induction in patients, resulting in hemodynamic instability; therefore, extracorporeal membrane oxygenation (ECMO) support is required. Earlier studies have reported substantial mortality rates; however, our results are significantly more favorable. In this study, we combined the minimally invasive extracorporeal circulation (MiECC) approach with ECMO to preserve an appropriate ECMO flow rate, thus reducing intraoperative left heart afterload. We report 21 cases illustrating the usefulness of modified veno-arterial (VA)-ECMO in this scenario. Methods: Data of 21 patients supported by the modified VA-ECMO system (MiECC approach combined with the ECMO system) during VT CA in the Wuhan Asia Heart Hospital between June 2020 and July 2021 were reviewed retrospectively. Results: Successful ablation was achieved in 20 out of 21 patients (95%). The median time for ECMO implantation was 206 min. Only two patients experienced complications post-treatment. All patients made complete recovery and were discharged. All patients were alive at the 1-year-follow-up. Conclusions: Our modified VA-ECMO system helped restore systemic circulation in patients experiencing an electrical storm, thus achieving greater electrical stability during VT CA. Pre-insertion of VA-ECMO can achieve even better results.

Objective: Electrical storm (ES) carries a high mortality rate even with current advancements in care. There are limited data about clinical characteristics, risk factors and etiologies of ES from India. We aim to report the clinical profile and risk factors related to ES from a tertiary care hospital in southern state of India. Methods: This is a retrospective, single center observational study done in the Department of Cardiology & Electrophysiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research (SJICSR), a tertiary care medical center in Bengaluru, Karnataka. The data collected from medical records of patients presenting with ES from year October 1, 2022-September 1, 2023. Hospital medical chart of all patients who had received ES diagnosis were reviewed for demographic data (age, gender), clinical data (comorbidities, presenting symptoms), lab (complete blood counts and inflammatory markers), Electrocardiogram (ECG), echocardiography data and treatment options (medical and / or surgical). Other parameters assessed included type of procedure patient underwent. Results: A total of 29 ES were identified with mean age of 55.4±14.6 years, predominantly male population. The most common risk factor seen in this patient sample was prior history of MI (58. 6%).Post MI scar VT was the predominant etiology found in 18(72%) patients in our study. MMVT was the predominant form seen in 24 (82.7%) patients with RBBB morphology the dominant pattern on ECG. Cardiac imaging was done in 8 (27.5%) patients. The majority of patients were on amiodarone as the anti-arrhythmic drug of choice, while propranolol and ramipril were the most common beta blockers and RAAS inhibitors prescribed in our study population. In addition to standard care, radiofrequency ablation was performed in 5 patients and cardiac sympathetic denervation (CSD) was done in 2 patients only. Overall 17 (58.6%) patients died. When compared with patients who survived, presence of severe LV systolic dysfunction had trend towards higher mortality. Conclusion: The study population of ES of southern state of Karnataka is characterized by middle age population with hypertension, tobacco consumption and diabetes as the prominent risk factors. ES portends a high mortality in acute settings particularly in patients with severe LVSD. There is a considerable scope of taking initiatives to improve patient outcomes in ES. [ABSTRACT FROM AUTHOR]

Aims Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of therapy-refractory ventricular tachycardia (VT). VT recurrences have been reported after STAR but the mechanisms remain largely unknown. We analysed recurrences in our patients after STAR. Methods and results From 09.2017 to 01.2020, 20 patients (68 ± 8 y, LVEF 37 ± 15%) suffering from refractory VT were enrolled, 16/20 with a history of at least one electrical storm. Before STAR, an invasive electroanatomical mapping (Carto3) of the VT substrate was performed. A mean dose of 23 ± 2 Gy was delivered to the planning target volume (PTV). The median ablation volume was 26 mL (range 14–115) and involved the interventricular septum in 75% of patients. During the first 6 months after STAR, VT burden decreased by 92% (median value, from 108 to 10 VT/semester). After a median follow-up of 25 months, 12/20 (60%) developed a recurrence and underwent a redo ablation. VT recurrence was located in the proximity of the treated substrate in nine cases, remote from the PTV in three cases and involved a larger substrate over ≥3 LV segments in two cases. No recurrences occurred inside the PTV. Voltage measurements showed a significant decrease in both bipolar and unipolar signal amplitude after STAR. Conclusion STAR is a new tool available for the treatment of VT, allowing for a significant reduction of VT burden. VT recurrences are common during follow-up, but no recurrences were observed inside the PTV. Local efficacy was supported by a significant decrease in both bipolar and unipolar signal amplitude. [ABSTRACT FROM AUTHOR]

Aims We report a series of patients with Electrical Storm (ES) who underwent bilateral stellate ganglion ablation by using conventional radio frequency (RFA). Methods and results The procedure was done with fluoroscopic guidance using the COSMAN™ 1A RF Generator and a 22G RF needle (5 cm length and 5 mm active tip). Six patients, four male and two female (mean age 55 ± 7 years and mean LVEF—42 ± 21%) with ES underwent the procedure under fluoroscopic guidance. All patients experienced recurrent ICD shocks or required multiple external defibrillation shocks. There were no procedural complications. All patients survived free of ES at discharge. At a mean follow—up of 22 ± 8months, all were alive free of ES but two patients received appropriate shocks for VT and one patient had VT terminated by ATP. Conclusion This small series of cases is a proof of concept that neuromodulation by conventional RFA targeting bilateral stellate ganglia appears safe, feasible, and effective in treating selected unstable patients with ES. [ABSTRACT FROM AUTHOR]

Heightened sympathetic input to the myocardium potentiates cardiac electrical instability and may herald an electrical storm. An electrical storm is characterized by 3 or more episodes of ventricular tachycardia, ventricular fibrillation, or appropriate internal cardiac defibrillator shocks within 24 hours. Management of electrical storms is resource-intensive and inevitably requires careful coordination between multiple subspecialties. Anesthesiologists have an important role in acute, subacute, and long-term management. Identifying the phase of an electrical storm and understanding the characteristics of each morphology may help the anesthesiologist anticipate the management approach. In the acute phase, management of an electrical storm is aimed at providing advanced cardiac life support and identifying reversible causes. After initial stabilization, subacute management focuses on dampening the sympathetic surge with sedation, thoracic epidural, or stellate ganglion blockade. Definitive long-term management with surgical sympathectomy or catheter ablation also may be warranted. Our objective is to provide an overview of electrical storms and the anesthesiologist's role in management. [ABSTRACT FROM AUTHOR]

Introduction: Prognosis after electrical storm (ES) ablation remains severe, especially in patients with recurrent sustained monomorphic ventricular tachycardia (SMVT) or progressive heart failure (HF). However, single-factor-based prediction is suboptimal and may be refined by more complex algorithms. We sought to evaluate if a novel score MSA-VT (M = moderate/severe mitral regurgitation, S = severe HF at admission, A = atrial fibrillation at admission, VT = inducible SMVT after ablation) may improve prediction of death and recurrences compared to single factors and previous scores (PAINESD, RIVA and I-VT). Methods: A total of 101 consecutive ES ablation patients were retrospectively analyzed over a 32.8-month (IQR 10-68) interval. The MSA-VT score was calculated as the sum of the previously mentioned factors’ coefficients based on hazard ratio values in Cox regression analysis. The AUC for death prediction by MSA-VT was 0.84 (p < 0.001), superior to PAINESD (AUC 0.63, p = 0.03), RIVA (AUC 0.69, p = 0.02) and I-VT (0.56, p = 0.3). MSA-VT ≥ 3 was associated with significantly higher mortality during follow-up (52.7%, p < 0.001). Conclusions: Prediction by single factors and previously published scores after ES ablation may be improved by the novel MSA-VT score; however, this requires further external validation in larger samples.

Background and aimsThere is limited data concerning the effect of non-revascularized chronic total occlusions (NR-CTOs) after VT ablation. This study sought to evaluate the impact of NR-CTOs after ablation for electrical storm (ES).MethodsPost-hoc retrospective analysis of data regarding 64 consecutive post-myocardial infarction patients (out of which 12 patients with NR-CTOs and 52 without NR-CTOs) undergoing substrate ablation for ES with an available median follow-up of 37.53 (7.25–64.65) months. Ablation result was assessed by inducibility of sustained monomorphic VT (SMVT) during final programmed ventricular stimulation (PVS). The primary endpoints were all-cause mortality and VT/VF recurrences after ablation, respectively, stratified by the presence of NR-CTOs. The secondary endpoint was to assess the predictive effect of NR-CTOs on all-cause mortality and VT/VF recurrences in relation to other relevant prognostic factors.ResultsAt baseline, the presence of NR-CTOs was associated with higher bipolar BZ-to-total scar ratio (72.4% ± 17.9% vs. 52% ± 37.7%, p = 0.022) and more failure to eliminate the clinical VT (25% (3) vs. 0% (0), p

Patients who present with electrical storms (ES) due to rapid recurrence of ventricular tachycardia/ventricular fibrillation represent major medical emergencies without easy solutions. Antiarrhythmic drugs have limited value, and ES need to be stopped quickly to prevent irreversible patient deterioration and death. Since the mid-1970s, we have provided the rationale for interrupting cardiac sympathetic nerves and evidence of its antifibrillatory action in different clinical settings. Slowly but progressively, from isolated clinical reports to small case series, increasing evidence has indicated that pharmacologic stellate ganglion block (SGB) is highly effective in interrupting ES. However, medical guidelines have largely ignored SGB, and few centers are prepared to perform SGB in actual emergencies. Our own experience shows that a direct anatomic approach that does not require echocardiographic assistance can be performed rapidly, thus saving time in highly critical patients. In this review, we retrace the evolution in our understanding of the mechanism of action of SGB, discuss the current approaches and their limitations, and review the correct indications that overcome still existing biases. Furthermore, we propose a practical solution to increase the availability of SGB to more patients by extending the number of centers where this approach can be rapidly implemented. [ABSTRACT FROM AUTHOR]

Electrical storm (ES) refers to a life-threatening condition characterised by three or more episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter defibrillator (ICD) shocks in 24 hours. We report a case of a 58-year-old man who suffered recurrent episodes of sustained VT despite appropriate defibrillation and antiarrhythmic drug therapy. On stepwise evaluation, arrhythmogenic right ventricular cardiomyopathy (ARVC) was considered the most likely substrate for his dysrhythmia. He was managed conservatively on antiarrhythmic drugs with no further clinical episodes of VT, and ICD implantation for secondary prophylaxis was recommended. [ABSTRACT FROM AUTHOR]

Refractory ventricular dysrhythmia, or electrical storm, is a cardiac condition consisting of three or more episodes of ventricular dysrhythmia resistant to treatment within a 24-hour period. These dysrhythmias carry high morbidity and mortality if not diagnosed and abated promptly. When traditional resuscitative algorithms fail to return a patient to a perfusing rhythm, providers need to consider other, more novel techniques to terminate these dangerous dysrhythmias. One approach is the use of a stellate ganglion block, which has been documented in the literature only a handful of times for its resuscitative use in cardiac arrest. This case series details two cases from an urban emergency department (ED) in a large metropolitan city, where the use of ultrasound-guided stellate ganglion blocks during cardiac arrest provided successful ablation of the tachydysrhythmia. The first case involves a patient who went into cardiac arrest while in the ED and was found to be in refractory pulseless ventricular tachycardiawhile. The second case describes a patient who went into a witnessed out-of-hospital cardiac arrest while with emergency medical services. The stellate ganglion block is a procedure currently being used as a treatment modality for a variety of neurologic, psychological, and cardiac conditions. This intervention may provide a viable and lifesaving option for emergency physicians to adopt when traditional resuscitative algorithms fail to break resistant ventricular tachydysrhythmias. [ABSTRACT FROM AUTHOR]

A 63-year-old man with hypertrophic cardiomyopathy (HCM), mid-ventricular obstruction, and an apical aneurysm had an episode of cardiac arrest due to sustained ventricular tachycardia (VT). He was resuscitated and an implantable cardioverter-defibrillator (ICD) was implanted. In the following years, several episodes of VT and ventricular fibrillation were successfully terminated by antitachycardia pacing or ICD shocks. Three years after ICD implantation, he was re-admitted because of refractory electrical storm (ES). Since aggressive pharmacological treatments, direct current cardioversions, and deep sedation were not effective, he underwent epicardial catheter ablation which was successful to terminate ES. However, because of the recurrence of refractory ES after one year, he proceeded to surgical left ventricular myectomy with apical aneurysmectomy which provided him a relatively stable clinical course for six years. Although epicardial catheter ablation may be an acceptable option, surgical resection of apical aneurysm seems to be most efficacious for ES in patients with HCM and an apical aneurysm. In patients with hypertrophic cardiomyopathy (HCM), implantable cardioverter-defibrillators (ICDs) are the gold standard of therapy for prophylaxis against sudden death. Electrical storm (ES) caused by recurrent episodes of ventricular tachycardia can cause sudden death even in patients with ICDs. Although epicardial catheter ablation may be an acceptable option, surgical resection of apical aneurysm is most efficacious for ES in patients with HCM, mid-ventricular obstruction, and an apical aneurysm. [ABSTRACT FROM AUTHOR]

Background: Electrical storm (ES) represents a serious heart rhythm disorder. This study investigates the impact of ES on acute ablation success and long-term outcomes after VT ablation compared to non-ES patients. Methods: In this large single-centre study, patients presenting with ES and undergoing VT ablation from June 2018 to April 2021 were compared to patients undergoing VT ablation due to ventricular tachyarrhythmias but without ES. The primary prognostic outcome was VT recurrence, and secondary endpoints were rehospitalization rates and cardiovascular mortality, all after a median follow-up of 22 months. Results: A total of 311 patients underwent a first VT ablation due to ventricular tachyarrhythmias and were included (63 ± 14 years; 86% male). Of these, 108 presented with ES. In the ES cohort, dilated cardiomyopathy as underlying heart disease was significantly higher (p = 0.008). Major complications were equal across both groups (all p > 0.05). Ablation of the clinical VT was achieved in 94% of all patients (p > 0.05). Noninducibility of any VT was achieved in 91% without ES and in 76% with ES (p = 0.001). Patients with ES revealed increased VT recurrence rates during follow-up (65% vs. 40%; log rank p = 0.001; HR 1.841, 95% CI 1.289–2.628; p = 0.001). Furthermore, ES patients suffered from increased rehospitalization rates (73% vs. 48%; log rank p = 0.001; HR 1.948, 95% CI 1.415–2.682; p = 0.001) and cardiovascular mortality (18% vs. 9%; log rank p = 0.045; HR 1.948, 95% CI 1.004–3.780; p = 0.049). After multivariable adjustment, ES was a strong independent predictor of VT recurrence and rehospitalization rates, but not for mortality. In a propensity score-matched cohort, patients with ES still had a higher risk of VT recurrences and rehospitalizations compared to non-ES patients. Conclusions: VT ablation in patients with ES is challenging and these patients reveal the highest risk for recurrent VTs, rehospitalization and cardiovascular mortality. These patients need close follow-ups and optimal guideline-directed therapy. [ABSTRACT FROM AUTHOR]

Electrical storm (ES) is a predictor of mortality, and its treatment is challenging. Moreover, not all potential therapeutic strategies are available in all hospitals, and a standardized approach among European centres is lacking. The aim of this European Heart Rhythm Association (EHRA) survey was to assess the current management of patients with ES both in the acute and post-acute phases in 102 different European centres. A 20-item online questionnaire was sent out to the EHRA Research Network Centres. The median number of patients with ES treated annually per centre is 10 (IQR 5–15). The possibility of using autonomic modulation (e.g. percutaneous stellate ganglion block or thoracic epidural anaesthesia) for the acute ES treatment is available in only 29.3% of the centres. Moreover, although over 80% of centres perform ventricular tachycardia ablation, this procedure is available 24/7 in only 16.5% of the hospitals. There is a significant heterogeneity among centres regarding the availability of AADs and their use before deciding to proceed with a non-AAD strategy; specifically, 4.4% of centres use only one drug, 33.3% use two drugs, and 12.2% >two drugs, while about 50% of the centres decide based on individual patient's characteristics. Regarding the type of AADs used for the acute and post-acute management of ES patients, important variability is reported depending upon the underlying heart disease. Most patients considered for percutaneous ablation have structural heart disease. Only 46% of centres refer patients to psychological counselling after ES. [ABSTRACT FROM AUTHOR]

Electrical storm is a medical emergency characterized by ventricular arrythmia recurrence that can lead to hemodynamic instability. The incidence of this clinical condition is rising, mainly in implantable cardioverter defibrillator patients, and its prognosis is often poor. Early acknowledgment, management and treatment have a key role in reducing mortality in the acute phase and improving the quality of life of these patients. In an emergency setting, several measures can be employed. Anti-arrhythmic drugs, based on the underlying disease, are often the first step to control the arrhythmic burden; besides that, new therapeutic strategies have been developed with high efficacy, such as deep sedation, early catheter ablation, neuraxial modulation and mechanical hemodynamic support. The aim of this review is to provide practical indications for the management of electrical storm in acute settings. [ABSTRACT FROM AUTHOR]

Abstract We described a case of a patient who developed repetitive episodes of polymorphic ventricular tachycardias with a stereotypical pattern of initiation. A short‐long‐short‐short (S‐L‐S‐S) cardiac cycle sequence preceded all episodes and was considered to be the underlying initiative mechanism for these fatal arrhythmic events. In the patient, the paroxysmal atrial fibrillation was responsible for S‐L‐S‐S sequence. It had been suggested that the electrophysiological mechanism by which the S‐L‐S‐S cardiac sequence induces ventricular tachyarrhythmias was reentrant excitation, not early afterdepolarization and triggered activity. Early attempts to restore and maintain sinus rhythm by administration of antiarrhythmic drug with amiodarone, the patient experienced no atrial fibrillation and ventricular tachycardia recurrence.

An electrical storm is a life-threatening emergency characterized by recurrent and sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). The clinical presentation of electrical storms can vary widely, requiring a systematic evaluation and personalized management approach. The management of electrical storms should be individualized based on the specific clinical presentation and underlying heart disease. We present a rare case of an electrical storm triggered by a catecholamine crisis induced by a paraganglioma, highlighting the critical role of early diagnosis and management of paraganglioma-related complications. [ABSTRACT FROM AUTHOR]

Background: Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and non-ischemic cardiomyopathy (NICM) populations. Methods: Multicentric observational registry included 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-day mortality and procedure-related complications. Results: Most of the patients were male (85%), with IHD (67%) and mean age of 63 ± 13 years. During a mean follow-up of 3 ± 2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class III / IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The identified independent predictors of mortality were C-ABL, ES, LVEF, age, and NYHA class III / IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction = 0.04). Mortality at 30 days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P = 0.777), as was complication rate (10.3% vs. 15.1%, respectively, P = 0.336). Conclusion: A combined or sequential endo-epicardial VT ablation strategy was associated with lower VT recurrence and lower all-cause death in IHD and NICM patients undergoing repeated procedures. Both approaches seemed equally safe. [ABSTRACT FROM AUTHOR]

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 revascularization 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 hospitalization, 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. [ABSTRACT FROM AUTHOR]