Cardiac electrical storm (ES) is characterised by three or more discrete episodes
of ventricular arrhythmia within 24 hours, or incessant ventricular arrhythmia for more than 12 hours. ES is a distinct medical emergency that portends a significant increase in
mortality risk and often presages progressive heart failure. ES is also associated
with psychological morbidity from multiple implanted cardioverter defibrillator (ICD)
shocks and exponential health resource utilisation. Up to 30% of ICD recipients may
experience storm in follow-up, with the risk higher in patients with a secondary prevention
ICD indication. Storm recurs in a high proportion of patients after an initial episode,
and multiple storm clusters may occur in follow-up. The mechanism of storm remains
elusive but is likely influenced by a complex interplay of inciting triggers (e.g.,
ischaemia, electrolyte disturbances), with autonomic perturbations acting on a vulnerable
structural and electrophysiologic substrate. Triggers can be identified only in a
minority of patients. An emergent treatment approach is warranted, if possible with
emergent transfer to a high-volume centre for ventricular arrhythmia management with
a multi-modality approach including ICD reprogramming, sympathetic blockade (sedation,
intubation, ventilation, beta blockers), and anti-arrhythmic drugs, and adjunctive
intervention techniques, such as catheter ablation and neuraxial modulation (e.g.,
thoracic epidural anaesthesia, stellate ganglion block). Outcomes of catheter ablation
of ES are excellent with resolution of storm in over 90% of patients at 1 year with a low complication rate (∼2%). ES may occur in the absence of structural
heart disease in the context of channelopathies, Brugada syndrome, early repolarisation
and premature ventricular contraction-induced ventricular fibrillation. There are
unique treatment approaches to these conditions that must be recognised. This state-of-the-art
review will summarise the incidence, mechanism, and multi-modality treatment of ES
in the contemporary era.
Keywords
Abbreviations:
AAD (anti-arrhythmic drugs), ATP (anti-tachycardia pacing), CRT (cardiac resynchronisation therapy), CSD (cardiac sympathetic denervation), DCM (dilated cardiomyopathy), ES (electrical storm), ICM (ischaemic cardiomyopathy), ICD (implanted cardioverter defibrillator), IV (amiodarone), LV (left ventricular), SG (stellate ganglion blockade), TEA (thoracic epidural anaesthesia), VF (ventricular fibrillation), VT (ventricular tachycardia)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 13, 2018
Identification
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© 2018 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
