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Arrhythmic Storm
Clinical Case
Saverio Iacopino, MD, FACC, FESC
ü ICD have become the main therapeutic tool for patients with life-threatening VE arrhythmias
ü Some patients receive multiple appropriate shocks during a short period due to arrhythmic storm
ü The arrhythmic episodes was successfully controlled in the majority of patients with antiarrhythmic drug therapy
Background
ü Men, 51 years old with single chamber PM for paroxistical AV block
ü Syncope and sustained VT with RBBB morphology and superior axis deviation at a rate of 150 bpm
Case History
ü Coronary risk factors ü Family history of early CAD ü Hypercholesterolemia ü Continued heavy smoking
ü ECHO: dilated cardiomyopathy (EF=45%)
ü No angiographic coronary artery stenosis
Case History
ü EP study
ü Easily inducible symptomatic sustained monomorphic VT with RBBB, superior axis, CL 350 msec, terminated by overdrive pacing
ü Patient then underwent implantation of an single chamber ICD
Case History
ü Tachycardia zone ü For rates between 150-200 bpm
ü ATP
ü Low energy cardioversion
ICD Therapy
ü VF zone ü For rates exceeding 200 bpm
ü Beta-blockers ü ACE-Inhibitor ü Diuretics ü Amiodarone
Drug Therapy
ü At first month ü 6 episodes of VT were recorded and were ü terminated by ATP schemes
Follow-up
ATP Therapy
ü At six month ü Patient was admitted to our hospital in a state of
panic because of multiple shocks deliveries by the device
Follow-up
ü Myocardial ischemia, electrolyte disturbances or other triggering factors as an etiology of the arrhythmic storm could not be supported
ü Intravenous amiodarone and mexiletine were initiated
ü The arrhythmic storm subsided two days after
Follow-up
ü 58 tachyarrhythmic episodes were recorded in the tachycardia zone
ü 41 were terminated by ATP schemes
ü 3 episodes were accelerated by ATP and entered in VF zone and terminated by low energy shock
ü 10 fast VT episodes were detected in VF zone and terminated by low energy shocks
ü 3 episodes exhibited immediate reinitiation and thus required maximal energy shocks
ICD Therapy
ü The patient reported dizziness but not syncope just before shock delivery
…. and we proposed RFA of the slow VT with the probability of modification or even elimination of the fast VT
Basal EKG
Inducible VT
VT Induced
Conventional LV Mapping
Lateral Postero-Lateral
Posterior Postero-Septal
Lateral
Left Lateral Region Mapping Early Activation During VT
Concealed entrainment from ablation site Inducible VT
Concealed entrainment from ablation site Inducible VT
450 mS
VT termination during RF
RF on
VT termination during RF
stimulation protocol with up to three extra stimuli from the right
ventricle apex
in basal conditions
and after isoprenaline infusion
ü RF current (7 applications) was applied for 60 seconds at maximum power output of 50 W and temperature limit of 50 °C with the 4-mm closed Cooled-tip catheter
ü The targets considered are the following:
ü discontinuation of VT
ü persistency of this result for 30 minutes in basal conditions and with the infusion of the isoprenaline
Methods
Follow-up
ü During a follow-up of 12 months without any antiarrhythmic drug, no VT relapse has been documented
ü Holter ECG executed at one, three and six months later, no NSVT has been documented
Conclusion ü Patients who experience multiple ICD shock
therapies require urgent evaluation and management
ü Antiarrhythmic drugs, alone or in combination, may be effective in decreasing the frequency of recurrences of VE arrhythmias or ICD shocks
ü RFA may be a curative approach