Clinician-to-Clinician Update Clinician-to-Clinician Update

Targeted Radiofrequency Ablation to Manage Electrical Storm

October 2014

Electrical storm is a complex, life- threatening syndrome that involves recurrent episodes of ventricular arrhythmias. It is defined as three or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) shocks during a 24-hour period.1 The condition can manifest itself during the acute phase of a myocardial infarction (MI) and in the presence of structural heart disease, an ICD, or an inherited arrhythmic syndrome.

The major symptoms are palpitations, dizziness, and often syncope. The clinical presentation can involve cardiac arrest or multiple episodes of potentially fatal arrhythmias. Electrical storm increases the risk of cardiac death, with one recent meta-analysis reporting over a three-fold higher risk of death in patients with a history of electrical storm than in those without.2 Here we describe a patient with a complex cardiac history and VT electrical storm that was successfully managed using highly targeted radiofrequency ablation.

Patient

A male patient in his mid-60s was transferred to University of Minnesota Medical Center due to acute heart failure following myocardial infarction. The patient improved steadily after intra-aortic balloon pump placement. After approximately two weeks, the patient suddenly experienced an intractable VT storm requiring about 20 defibrillations over the course of about two hours.

Treatment

Medical management failed to halt the VT storm. The patient was considered a candidate for radiofrequency ablation. During the procedure, we were able to isolate three infarcted areas that were producing premature ventricular contractions, triggering the VT storm (Figure 1 and 2). Very targeted radiofrequency ablation was performed to these three areas, stopping the abnormal rhythm and terminating the storm (Figure 3). The patient reacted and responded after being awoken, and continues to make a good recovery.

RF-Ablation-Figure1-CV-UMMC-0914
— Figure 1
RF-Ablation-Figure2-CV-UMMC-0914
— Figure 2
RF-Ablation-Figure3-CV-UMMC-0914
— Figure 3

Discussion

This is an example of a complex cardiac arrhythmia that was successfully treated with radiofrequency ablation. Studies confirm the usefulness of this approach. In one series of 95 patients, emergency radiofrequency ablation completely suppressed drug-refractory electrical storm in 100% of patients, and long-term suppression of electrical storm was achieved in 92%. About two-thirds were free of VT at 22-month follow-up examination.3 It has been suggested that majority of patients presenting with VT storm should undergo ablation as part of their overall management.4 Nonetheless, judicious targeting of radiofrequency ablation is key, as large ablations have an increased risk of stroke and decompensated heart failure.

Case study presented by: Henri Roukoz, MD
University of Minnesota Heart Care
University of Minnesota Medical Center

References

1. 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 Se 5;114(10):e385-484.

2. Guerra F, Shkoza M, Scappini L, et al. Role of electrical storm as a mortality and morbidity risk factor and its clinical predictors: a meta- analysis. Europace. 2014;16(3):347-53.

3. 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 Jan 29;117(4):462-9.

4. Nayyar S, Ganesan AN, Brooks AG, Sullivan T, Roberts-Thomson KC, Sanders P. Venturing into ventricular arrhythmia storm: a systematic review and meta-analysis. Eur Heart J. 2013 Feb;34(8):560-71. 

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