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Muser D, Santangeli P, Liang JJ. Mechanisms of Ventricular Arrhythmias and Implications for Catheter Ablation. Card Electrophysiol Clin 2022; 14:547-558. [PMID: 36396177 DOI: 10.1016/j.ccep.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Ventricular arrhythmias present with a wide spectrum of clinical manifestations, from mildly symptomatic frequent premature ventricular contractions to life-threatening events. Pathophysiologically, idiopathic ventricular arrhythmias occur in the absence of structural heart disease or ion channelopathies. Ventricular arrhythmias in the context of structural heart disease are usually determined by scar-related reentry and are associated with increased mortality. Catheter ablation is safe and highly effective in treating ventricular arrhythmias. The proper characterization of the arrhythmogenic substrate is essential for accurate procedural planning. We provide an overview on the main mechanisms of ventricular arrhythmias and their implications for catheter ablation.
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Affiliation(s)
- Daniele Muser
- Cardiothoracic Department, Udine University Hospital, Udine 33100, Italy; Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jackson J Liang
- Electrophysiology Section, Division of Cardiology, University of Michigan, Frankel Cardiovascular Center, 1425 E. Ann Street, Ann Arbor, MI 48109, USA.
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Abstract
PURPOSE OF REVIEW Review the current state of the art of arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis and risk stratification in the pediatric population. RECENT FINDINGS ARVC is an inherited cardiomyopathy characterized by progressive myocyte loss and fibrofatty replacement of predominantly the right ventricle and high risk of ventricular arrhythmias and sudden cardiac death (SCD). ARVC is one of the leading causes of arrhythmic cardiac arrest in young people. Early diagnosis and accurate risk assessment are challenging, especially in children who often exhibit little to no phenotype, even if genotype positive. Multimodal imaging provides more detailed assessment of the right ventricle and has been shown in pediatric patients to identify earlier preclinical disease expression. Identification of patients with ARVC allows the clinician to intervene early with appropriate exercise restrictions, even if genotype positive only without phenotypic expression. Emphasis should be placed on stratifying the patient's risk of ventricular arrhythmias and SCD. SUMMARY ARVC is a challenging diagnosis to make in adolescents who often do not exhibit clinical symptoms. Newer multimodal imaging techniques and improvements in genetic testing and biomarkers should help improve early diagnosis. Exercise restriction for children with ARVC has been shown to reduce disease advancement and decreases the risk of a life-threatening event.
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Guarracini F, Casella M, Muser D, Barbato G, Notarstefano P, Sgarito G, Marini M, Grandinetti G, Mariani MV, Boriani G, Ricci RP, De Ponti R, Lavalle C. Clinical management of electrical storm: a current overview. J Cardiovasc Med (Hagerstown) 2021; 22:669-679. [PMID: 32925390 DOI: 10.2459/jcm.0000000000001107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The number of patients affected by electrical storm has been continuously increasing in emergency departments. Patients are often affected by multiple comorbidities requiring multidisciplinary interventions to achieve a clinical stability. Careful reprogramming of cardiac devices, correction of electrolyte imbalance, knowledge of underlying heart disease and antiarrhythmic drugs in the acute phase play a crucial role. The aim of this review is to provide a comprehensive overview of pharmacological treatment, latest transcatheter ablation techniques and advanced management of patients with electrical storm.
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Affiliation(s)
| | - Michela Casella
- Heart Rhythm Center, Centro Cardiologico Monzino, Milan.,Department of Clinical, Special and Dental Sciences, Cardiology and Arrhythmology Clinic, University Hospital 'UmbertoI-Lancisi-Salesi', Marche Polytechnic University, Ancona
| | - Daniele Muser
- Cardiothoracic Department, University Hospital of Udine, Udine
| | | | | | - Giuseppe Sgarito
- Cardiology Division, ARNAS Ospedale Civico e Benfratelli, Palermo
| | | | | | - Marco V Mariani
- Department of Cardiology, Policlinico Universitario Umberto I, Roma
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
| | | | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo & Macchi Foundation, University of Insubria, Varese, Italy
| | - Carlo Lavalle
- Department of Cardiology, Policlinico Universitario Umberto I, Roma
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4
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Kunkel M, Rothstein P, Sauer P, Zipse MM, Sandhu A, Tumolo AZ, Borne RT, Aleong RG, Cleveland JC, Fullerton D, Pal JD, Davies AS, Lane C, Nguyen DT, Sauer WH, Tzou WS. Open surgical ablation of ventricular tachycardia: Utility and feasibility of contemporary mapping and ablation tools. Heart Rhythm O2 2021; 2:271-279. [PMID: 34337578 PMCID: PMC8322924 DOI: 10.1016/j.hroo.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Ventricular tachycardia (VT) catheter ablation success may be limited when transcutaneous epicardial access is contraindicated. Surgical ablation (SurgAbl) is an option, but ablation guidance is limited without simultaneously acquired electrophysiological data. Objective We describe our SurgAbl experience utilizing contemporary electroanatomic mapping (EAM) among patients with refractory VT storm. Methods Consecutive patients with recurrent VT despite antiarrhythmic drugs (AADs) and prior ablation, for whom percutaneous epicardial access was contraindicated, underwent open SurgAbl using intraoperative EAM guidance. Results Eight patients were included, among whom mean age was 63 ± 5 years, all were male, mean left ventricular ejection fraction was 39% ± 12%, and 2 (25%) had ischemic cardiomyopathy. Reasons for surgical epicardial access included dense adhesions owing to prior cardiac surgery, hemopericardium, or pericarditis (n = 6); or planned left ventricular assist device (LVAD) implantation at time of SurgAbl (n = 2). Cryoablation guided by real-time EAM was performed in all. Goals of clinical VT noninducibility or core isolation were achieved in 100%. VT burden was significantly reduced, from median 15 to 0 events in the month pre- and post-SurgAbl (P = .01). One patient underwent orthotopic heart transplantation for recurrent VT storm 2 weeks post-SurgAbl. Over mean follow-up of 3.4 ± 1.7 years, VT storm–free survival was achieved in 6 (75%); all continued AADs, although at lower dose. Conclusion Surgical mapping and ablation of refractory VT with use of contemporary EAM is feasible and effective, particularly among patients with contraindication to percutaneous epicardial access or with another indication for cardiac surgery.
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Affiliation(s)
- Megan Kunkel
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Peter Rothstein
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
| | - Peter Sauer
- Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts
| | - Matthew M. Zipse
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Amneet Sandhu
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
- VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Alexis Z. Tumolo
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Ryan T. Borne
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Ryan G. Aleong
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Joseph C. Cleveland
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - David Fullerton
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Jay D. Pal
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | | | | | - Duy T. Nguyen
- Stanford University, Section of Electrophysiology, Division of Cardiology, Palo Alto, California
| | - William H. Sauer
- Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts
| | - Wendy S. Tzou
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
- Address reprint requests and correspondence: Dr Wendy S. Tzou, University of Colorado School of Medicine Anschutz Medical Campus, Division of Cardiology, Cardiac Electrophysiology Section, 12401 E 17th Ave, MS B-136, Aurora, CO 80045.
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Muser D, Santangeli P. Epicardial Ablation of Idiopathic Ventricular Tachycardia. Card Electrophysiol Clin 2020; 12:295-312. [PMID: 32771184 DOI: 10.1016/j.ccep.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ventricular arrhythmias (VAs) occurring in the absence of structural heart disease or ion channelopathies are referred to as idiopathic. They can clinically present with frequent monomorphic premature ventricular contractions, nonsustained ventricular tachycardia (VT), or sustained VT, and generally share a benign prognosis. Approximately 4% to 10% of idiopathic VAs have an epicardial site of origin, represented in most cases by the left ventricular summit and, less frequently, by the cardiac crux. Epicardial foci can be addressed by catheter ablation via the coronary venous system tributaries. In rarer instances, a direct epicardial access from a subxiphoid approach is needed.
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Affiliation(s)
- Daniele Muser
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Kanagasundram A, John RM, Stevenson WG. Sustained Monomorphic Ventricular Tachycardia in Nonischemic Heart Disease. Circ Arrhythm Electrophysiol 2019; 12:e007312. [DOI: 10.1161/circep.119.007312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
As the population of patients with implanted defibrillators has grown, an increasing number of patients nonischemic cardiomyopathies are requiring therapy to reduce ventricular arrhythmias. Most of these arrhythmias are related to areas of ventricular scar. Although the pathophysiology of scar development is not well understood in these diseases, advances in cardiac imaging and mapping are better characterizing the scar locations that give rise to the arrhythmias. Here, we review the pathophysiologic and electrocardiographic correlations that inform ablation strategies for ventricular tachycardia in these diseases.
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Affiliation(s)
- Arvindh Kanagasundram
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Roy M. John
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - William G. Stevenson
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Geraghty L, Santangeli P, Tedrow UB, Shivkumar K, Kumar S. Contemporary Management of Electrical Storm. Heart Lung Circ 2019; 28:123-133. [DOI: 10.1016/j.hlc.2018.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 01/10/2023]
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Zeppenfeld K. Ventricular Tachycardia Ablation in Nonischemic Cardiomyopathy. JACC Clin Electrophysiol 2018; 4:1123-1140. [PMID: 30236385 DOI: 10.1016/j.jacep.2018.06.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 01/06/2023]
Abstract
Catheter ablation is being increasingly performed as adjunctive treatment to prevent recurrent implantable cardioverter-defibrillator therapies in patients with nonischemic cardiomyopathy and ventricular tachycardia (VT). In the context of VT ablation, nonischemic cardiomyopathy usually refers to dilated cardiomyopathy (DCM) as one morphological phenotype. Over the past decades, progress has been made to better characterize distinct subtypes and to differentiate between causes of DCM, which has important practical and prognostic implications. The goal of this review is to summarize available data on VT ablation in patients with DCM and, more specifically, review procedural and outcome data in specific etiologies and substrate location. It will focus on our current understanding of nonischemic scars, as well as the value of multimodal imaging, image integration, and electroanatomic mapping for substrate identification, procedural planning, and ablation. In addition, recent findings from whole human heart histology of patients with DCM and VT and their potential implications for imaging and mapping will be discussed.
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Affiliation(s)
- Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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Spartalis M, Spartalis E, Tzatzaki E, Tsilimigras DI, Moris D, Kontogiannis C, Livanis E, Iliopoulos DC, Voudris V, Theodorakis GN. Novel approaches for the treatment of ventricular tachycardia. World J Cardiol 2018; 10:52-59. [PMID: 30079151 PMCID: PMC6068734 DOI: 10.4330/wjc.v10.i7.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/24/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
Ventricular tachycardia (VT) is a crucial cause of sudden cardiac death (SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to life-threatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of research. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.
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Affiliation(s)
- Michael Spartalis
- ESC Working Group on Cardiac Cellular Electrophysiology, Sophia Antipolis Cedex 06903, France
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Diamantis I Tsilimigras
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Demetrios Moris
- Department of Surgery, Duke University, Durham, NC 27710, United States
| | - Christos Kontogiannis
- Department of Clinical Therapeutics, “Alexandra” Hospital, University of Athens, Athens 11528, Greece
| | - Efthimios Livanis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Vassilis Voudris
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
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Kawamura I, Fukamizu S, Miyazawa S, Hojo R, Ito F, Watanabe M, Nishizaki M, Sakurada H, Hiraoka M. Ventricular tachycardia storm originating from interventricular septum successfully treated with surgical cryoablation with electroanatomic and electrophysiological mapping before dual valve replacement. J Arrhythm 2018; 34:71-73. [PMID: 29721116 PMCID: PMC5828278 DOI: 10.1002/joa3.12020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/08/2017] [Indexed: 11/21/2022] Open
Abstract
A 58‐year‐old man with dilated cardiomyopathy was admitted with heart failure. He had a history of two catheter ablation procedures for ventricular tachycardia (VT) originating from the intraventricular septum (IVS). Before dual valve replacement (DVR), he suffered a VT storm. An electrophysiological study revealed an extended low‐voltage area at the IVS with the exit of the induced VT at the anterior side. Radiofrequency application was performed at the VT exit as a landmark for surgical cryoablation (SA). During the DVR, SA was performed at the IVS using this landmark. After SA, the patient had no ventricular tachyarrhythmia.
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Affiliation(s)
- Iwanari Kawamura
- Department of Cardiology Tokyo Metropolitan Hiroo Hospital Tokyo Japan
| | - Seiji Fukamizu
- Department of Cardiology Tokyo Metropolitan Hiroo Hospital Tokyo Japan
| | - Satoshi Miyazawa
- Department of Cardiology Tokyo Metropolitan Hiroo Hospital Tokyo Japan
| | - Rintaro Hojo
- Department of Cardiology Tokyo Metropolitan Hiroo Hospital Tokyo Japan
| | - Fusahiko Ito
- Department of Cardiovascular Surgery Tokyo Metropolitan Hiroo Hospital Tokyo Japan
| | - Masazumi Watanabe
- Department of Cardiovascular Surgery Tokyo Metropolitan Hiroo Hospital Tokyo Japan
| | | | - Harumizu Sakurada
- Tokyo Metropolitan Health and Medical Treatment Corporation Ohkubo Hospital Tokyo Japan
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Muser D, Liang JJ, Santangeli P. Electrical Storm in Patients with Implantable Cardioverter-defibrillators: A Practical Overview. J Innov Card Rhythm Manag 2017; 8:2853-2861. [PMID: 32477756 PMCID: PMC7252660 DOI: 10.19102/icrm.2017.081002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/30/2017] [Indexed: 12/17/2022] Open
Abstract
Electrical storm (ES) is an increasingly common medical emergency characterized by clustered episodes of sustained ventricular arrhythmias (VAs) that lead to repeated appropriate implantable cardioverter-defibrillator (ICD) therapies. A diagnosis of ES can be made with the occurrence of three or more sustained episodes of VAs, or of three or more appropriate ICD therapies within 24 hours in patients with implanted devices. ES is associated with poor outcomes in patients with structural heart disease, particularly those with severe left ventricular dysfunction. In large clinical trials involving patients with ICDs for primary and secondary prevention, ES appears to be a predictor of cardiac death, with notably higher rates of mortality soon after the event. ES management is challenging and requires special medical attention with accurate patient risk stratification and a multidisciplinary approach that includes the use of pharmacologic therapies such as antiarrhythmic drugs (AADs) and interventional approaches like catheter ablation, surgical ablation, or sympathetic neuromodulation. Initial management involves determining and addressing the underlying ischemia, any electrolyte imbalances, and/or other causative factors. Hemodynamic support needs to be considered in high-risk patients with unstable VAs or those with severe comorbidities such as low left ventricular ejection fraction, advanced New York Heart Association class, and/or chronic pulmonary disease. Following the acute phase of ES, treatment should shift towards maximizing therapeutic efforts to address heart failure, performing revascularization, and preventing subsequent VAs. In the present manuscript, we offer an overview of the most relevant clinical aspects of ES with regard to novel therapeutic strategies.
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Affiliation(s)
- Daniele Muser
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA
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Muser D, Santangeli P, Liang JJ. Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol 2017; 9:521-530. [PMID: 28706587 PMCID: PMC5491469 DOI: 10.4330/wjc.v9.i6.521] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/24/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
Electrical storm (ES) is a medical emergency characterized by repetitive episodes of sustained ventricular arrhythmias (VAs) in a limited amount of time (at least 3 within a 24-h period) leading to repeated appropriate implantable cardioverter defibrillator therapies. The occurrence of ES represents a major turning point in the natural history of patients with structural heart disease being associated with poor short- and long-term survival particularly in those with compromised left ventricular ejection fraction (LVEF) that can develop hemodynamic decompensation and multi-organ failure. Management of ES is challenging with limited available evidence coming from small retrospective series and a substantial lack of randomized-controlled trials. In general, a multidisciplinary approach including medical therapies such as anti-arrhythmic drugs, sedation, as well as interventional approaches like catheter ablation, may be required. Accurate patient risk stratification at admission for ES is pivotal and should take into account hemodynamic tolerability of VAs as well as comorbidities like low LVEF, advanced NYHA class and chronic pulmonary disease. In high risk patients, prophylactic mechanical circulatory support with left ventricular assistance devices or extracorporeal membrane oxygenation should be considered as bridge to ablation and recovery. In the present manuscript we review the available strategies for management of ES and the evidence supporting them.
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