Electrical storm and incessant ventricular tachycardia
- Rod Passman, MD, MSCE
Rod Passman, MD, MSCE
- Professor of Medicine
- Northwestern University Feinberg School of Medicine
Electrical storm, also referred to as arrhythmic storm, refers to multiple recurrences of ventricular arrhythmias over a short period of time. In most instances, the arrhythmia is ventricular tachycardia (VT), but polymorphic VT and ventricular fibrillation (VF) can also result in electrical storm. The arrhythmias can be self-terminating but frequently are terminated using antiarrhythmic drugs or device-related therapies (defibrillation or anti-tachycardia pacing).
In contrast to repetitive ventricular arrhythmias occurring in electrical storm, incessant VT is defined as hemodynamically stable VT which persists for longer than one hour.
This topic will discuss the incidence, triggers, clinical significance and treatment of electric storm and incessant VT. The general approach to the diagnosis and management of VT, as well as the use of implantable cardioverter-defibrillators, are discussed separately in various topics. (See "Sustained monomorphic ventricular tachycardia: Clinical manifestations, diagnosis, and evaluation" and "Sustained monomorphic ventricular tachycardia in patients with a prior myocardial infarction: Treatment and prognosis" and "Primary prevention of sudden cardiac death in heart failure and cardiomyopathy" and "Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy".)
Electrical storm refers to a state of cardiac electrical instability characterized by multiple episodes of ventricular tachycardia (VT storm) or ventricular fibrillation (VF storm) within a relatively short period of time, typically 24 hours . The clinical definition of electrical storm is varied, somewhat arbitrary, and is a source of ongoing debate .
●In patients without an implantable cardioverter-defibrillator (ICD), electrical storm has been variously defined as [1,3-5]:
- Kowey PR. An overview of antiarrhythmic drug management of electrical storm. Can J Cardiol 1996; 12 Suppl B:3B.
- Israel CW, Barold SS. Electrical storm in patients with an implanted defibrillator: a matter of definition. Ann Noninvasive Electrocardiol 2007; 12:375.
- Kowey PR, Levine JH, Herre JM, et al. Randomized, double-blind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent, hemodynamically destabilizing ventricular tachycardia or fibrillation. The Intravenous Amiodarone Multicenter Investigators Group. Circulation 1995; 92:3255.
- Hariman RJ, Hu DY, Gallastegui JL, et al. Long-term follow-up in patients with incessant ventricular tachycardia. Am J Cardiol 1990; 66:831.
- Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385.
- Credner SC, Klingenheben T, Mauss O, et al. Electrical storm in patients with transvenous implantable cardioverter-defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol 1998; 32:1909.
- Exner DV, Pinski SL, Wyse DG, et al. Electrical storm presages nonsudden death: the antiarrhythmics versus implantable defibrillators (AVID) trial. Circulation 2001; 103:2066.
- Sesselberg HW, Moss AJ, McNitt S, et al. Ventricular arrhythmia storms in postinfarction patients with implantable defibrillators for primary prevention indications: a MADIT-II substudy. Heart Rhythm 2007; 4:1395.
- Gatzoulis KA, Andrikopoulos GK, Apostolopoulos T, et al. Electrical storm is an independent predictor of adverse long-term outcome in the era of implantable defibrillator therapy. Europace 2005; 7:184.
- Bänsch D, Böcker D, Brunn J, et al. Clusters of ventricular tachycardias signify impaired survival in patients with idiopathic dilated cardiomyopathy and implantable cardioverter defibrillators. J Am Coll Cardiol 2000; 36:566.
- Stuber T, Eigenmann C, Delacrétaz E. Characteristics and relevance of clustering ventricular arrhythmias in defibrillator recipients. Pacing Clin Electrophysiol 2005; 28:702.
- Hohnloser SH, Al-Khalidi HR, Pratt CM, et al. Electrical storm in patients with an implantable defibrillator: incidence, features, and preventive therapy: insights from a randomized trial. Eur Heart J 2006; 27:3027.
- Arya A, Haghjoo M, Dehghani MR, et al. Prevalence and predictors of electrical storm in patients with implantable cardioverter-defibrillator. Am J Cardiol 2006; 97:389.
- Verma A, Kilicaslan F, Marrouche NF, et al. Prevalence, predictors, and mortality significance of the causative arrhythmia in patients with electrical storm. J Cardiovasc Electrophysiol 2004; 15:1265.
- Brigadeau F, Kouakam C, Klug D, et al. Clinical predictors and prognostic significance of electrical storm in patients with implantable cardioverter defibrillators. Eur Heart J 2006; 27:700.
- Streitner F, Kuschyk J, Veltmann C, et al. Predictors of electrical storm recurrences in patients with implantable cardioverter-defibrillators. Europace 2011; 13:668.
- Nedios S, Darma A, Stevanello C, et al. Electrical storm in patients with implantable cardioverter-defibrillator in the era of catheter ablation: Implications for better rhythm control. Heart Rhythm 2015; 12:2419.
- Greene M, Newman D, Geist M, et al. Is electrical storm in ICD patients the sign of a dying heart? Outcome of patients with clusters of ventricular tachyarrhythmias. Europace 2000; 2:263.
- Fries R, Heisel A, Huwer H, et al. Incidence and clinical significance of short-term recurrent ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillator. Int J Cardiol 1997; 59:281.
- Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729.
- Gorenek B, Blomström Lundqvist C, Brugada Terradellas J, et al. Cardiac arrhythmias in acute coronary syndromes: position paper from the joint EHRA, ACCA, and EAPCI task force. Europace 2014; 16:1655.
- Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 1999; 341:871.
- Scheinman MM, Levine JH, Cannom DS, et al. Dose-ranging study of intravenous amiodarone in patients with life-threatening ventricular tachyarrhythmias. The Intravenous Amiodarone Multicenter Investigators Group. Circulation 1995; 92:3264.
- Levine JH, Massumi A, Scheinman MM, et al. Intravenous amiodarone for recurrent sustained hypotensive ventricular tachyarrhythmias. Intravenous Amiodarone Multicenter Trial Group. J Am Coll Cardiol 1996; 27:67.
- Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J 2011; 38:111.
- Murata H, Miyauchi Y, Hayashi M, et al. Clinical and Electrocardiographic Characteristics of Electrical Storms Due to Monomorphic Ventricular Tachycardia Refractory to Intravenous Amiodarone. Circ J 2015; 79:2130.
- Nademanee K, Taylor R, Bailey WE, et al. Treating electrical storm : sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation 2000; 102:742.
- Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
- Carbucicchio C, Santamaria M, Trevisi N, et al. Catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short- and long-term outcomes in a prospective single-center study. Circulation 2008; 117:462.
- Deneke T, Shin DI, Lawo T, et al. Catheter ablation of electrical storm in a collaborative hospital network. Am J Cardiol 2011; 108:233.
- Tan VH, Yap J, Hsu LF, Liew R. Catheter ablation of ventricular fibrillation triggers and electrical storm. Europace 2012; 14:1687.
- Nayyar S, Ganesan AN, Brooks AG, et al. Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis. Eur Heart J 2013; 34:560.
- Izquierdo M, Ruiz-Granell R, Ferrero A, et al. Ablation or conservative management of electrical storm due to monomorphic ventricular tachycardia: differences in outcome. Europace 2012; 14:1734.
- Schwartz PJ, Priori SG, Cerrone M, et al. Left cardiac sympathetic denervation in the management of high-risk patients affected by the long-QT syndrome. Circulation 2004; 109:1826.
- Bourke T, Vaseghi M, Michowitz Y, et al. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation 2010; 121:2255.
- Ajijola OA, Lellouche N, Bourke T, et al. Bilateral cardiac sympathetic denervation for the management of electrical storm. J Am Coll Cardiol 2012; 59:91.
- Burjorjee JE, Milne B. Propofol for electrical storm; a case report of cardioversion and suppression of ventricular tachycardia by propofol. Can J Anaesth 2002; 49:973.
- Vaseghi M, Gima J, Kanaan C, et al. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm 2014; 11:360.
- Remo BF, Preminger M, Bradfield J, et al. Safety and efficacy of renal denervation as a novel treatment of ventricular tachycardia storm in patients with cardiomyopathy. Heart Rhythm 2014; 11:541.
- Zaugg CE, Wu ST, Barbosa V, et al. Ventricular fibrillation-induced intracellular Ca2+ overload causes failed electrical defibrillation and post-shock reinitiation of fibrillation. J Mol Cell Cardiol 1998; 30:2183.
- Swynghedauw B. Molecular mechanisms of myocardial remodeling. Physiol Rev 1999; 79:215.
- Epstein AE, Kay GN, Plumb VJ, et al. Gross and microscopic pathological changes associated with nonthoracotomy implantable defibrillator leads. Circulation 1998; 98:1517.
- Hurst TM, Hinrichs M, Breidenbach C, et al. Detection of myocardial injury during transvenous implantation of automatic cardioverter-defibrillators. J Am Coll Cardiol 1999; 34:402.
- Joglar JA, Kessler DJ, Welch PJ, et al. Effects of repeated electrical defibrillations on cardiac troponin I levels. Am J Cardiol 1999; 83:270.
- Poelaert J, Jordaens L, Visser CA, et al. Transoesophageal echocardiographic evaluation of ventricular function during transvenous defibrillator implantation. Acta Anaesthesiol Scand 1996; 40:913.
- Runsiö M, Bergfeldt L, Brodin LA, et al. Left ventricular function after repeated episodes of ventricular fibrillation and defibrillation assessed by transoesophageal echocardiography. Eur Heart J 1997; 18:124.
- Sears SE Jr, Conti JB. Understanding implantable cardioverter defibrillator shocks and storms: medical and psychosocial considerations for research and clinical care. Clin Cardiol 2003; 26:107.
- TRIGGERS OF ELECTRICAL STORM
- CLINICAL PRESENTATION
- Electrocardiographic monitoring
- Type of ventricular arrhythmia
- DIFFERENTIAL DIAGNOSIS
- Initial management
- - ACLS and defibrillation
- - Amiodarone and beta blockers
- - Coronary revascularization
- Subsequent management
- - Catheter ablation
- - Maintenance antiarrhythmic therapy
- - Other general therapies
- - Condition-specific therapies
- - Management of refractory cases
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS