ΗΛΕΚΤΡΙΚΗ ΘΥΕΛΛΑ

ΓΕΩΡΓΙΟΣ ΣΤΑΥΡΟΠΟΥΛΟΣΒΚΚ ΓΝ ΙΠΠΟΚΡΑΤΕΙΟ

Period of severe cardiac electrical instability manifested by recurrent ventricular arrhythmias.

Defined as the occurrence of three or more distinct episodes of ventricular tachycardia (VT) and/or ventricularfibrillation (VF) within a 24 h period, leading to appropriate ICD therapies

extensive range of clinical situations and tachyarrhythmia events

❖Dramatic Clinical presentation

❖worsens electrical and hemodynamic decompensation.Arrhythmic emergency!

❖Structural arrhythmogenic cardiomyopathies :ischemic and non-ischemic in terms of arrhythmogenic substrate, represent the gradual evolution of the underlying structural heart Disease❖inherited arrhythmic syndrome:Brugada Syndrome, CPVT early repolarisation and premature ventricular contraction-induced ventricular fibrillation❖ES is also associated with psychological morbidity from multiple implanted cardioverter defibrillator (ICD) shocks and exponential health resource utilisation

ELECTRICAL STORM

ELECTRICAL STORM

❖Distinctive arrhythmia syndrome with its specific management issues andprognostic consequences that differ from ventricular tachycardia andventricular fibrillation episodes unrelated to storm

❖Monomorphic VT due to wavefront reentry is the most comon and doesnot require active ischemia as a trigger, and it is uncommon in patients whoare having an acute MI

Affects patient prognosis:• progressive deterioration of cardiac function from prolonged low-output states

•direct cell injury caused by frequent shocks• and/or an adverse haemodynamical effect of antiarrhythmic medication

Electrocardiographic Morphology

• Monomorphic VT due to wavefront reentry-storm related to anidentifiable electrophysiological substrate, is the most comon and doesnot require active ischemia as a trigger, uncommon in patients who arehaving an acute MI

• Polymorphic ventricular tachycardia and ventricular fibrillation storm aremost often related to acute myocardial ischaemia, ion channelopathies oridiopathic VF, in patients with structurally normal hearts

INCIDENCE

10-30% of ICD recipients for secondary prevention

4-7% for primary prevention may experience storm

Storm recurs in a high proportion of patients after an initial episode, and multiple storm clusters may occur in follow-up

CLINICAL IMPLICATION

AVID trial for secondary prevention: 34 of 90 (38%) electrical storm patients died during follow-

up compared to 15% of those without electrical storm.

Patients with secondary prevention ICDs, had a 5.6-fold increase in mortality in the first 12 weeksafter ES

Electrical storm was a significant independent risk factor for subsequent death, independent ofejection fraction and other prognostic variables

MADIT II18-fold increase risk of death in the first 3months

17 of 32 patients (53%) with ICD for secondary prophylaxis

died during 3 years of follow-up, vs 19 of the 137 (14% ),

ICD patients without electrical storm.

Gatzoulis et al

E.STORM-MORTALITY

T. Noda et al. / International Journal of Cardiology 255 (2018) 85–91

Specific precipitants❑ acute ischemia

❑ worsening heart failure

❑ hypokalemia- hypomagnesemia

❑ proarrhythmic drug therapy

❑ hyperthyroidism

❑ infection or fever

Triggers can be identified onlyin a minority of patients

“28 of the 32 patients with ESpresented with seriouselectrical instability in theabsence of any detectablehaemodynamic, metabolic, orelectrolytic abnormality.”

K.A. Gatzoulis et al

Risk factors• Older age

• Male gender

• lower ejection fraction,

• More advanced heart failure

• higher prevalence of cardiovascular comorbidities

• More inducible VTs

Am J Cardiol 2006;97:389 – 392

TREATMENT

➢ICD reprogramming

➢ sympathetic blockade

(sedation, intubation, ventilation, beta blockers)

➢ anti-arrhythmic drugs

➢intervention techniques

• Catheter ablation

• neuraxial modulation (e.g., thoracic epidural anaesthesia, stellate ganglion block)

ANTI-ARRHYTHMIC DRUGS

• Beta-blockers (Propranolol)Add beta-blockers IV in electrical storm patients already on oral beta-blocker therapy

• AmiodaroneIncidence of IV-amiodarone-refractory electrical storm ≈ 30%. • I B Antiarryhtmics

AADs carry the risk of decreasing the cycle length of re-entryVAs and make VT more stable, which may precipitate toincessant VT. Drug combinations are sometimes necessary toalter electrical instability

Circulation. 2018;138:551–553.

TREATMENT

TREATMENT

TREATMENT

RF ABLATION

ACUTE MANAGEMENT

• Carbucicchio C, Santamaria M, Trevisi N, Maccabelli G,Giraldi F, Fassini G, et al

Outcomes of catheter ablation of ES are excellent with resolution of storm in over 90%ofpatients at1year with a low complication rate( 2%).

PROPHYLACTIC TREATMENT:EARLY vs LATE

Journal of Cardiovascular Electrophysiology Vol. 22, No. 10, October 2011

NEW ABLATION TECHNIQUES

CATHETER ABLATIONOUR EXPERIENCE

Clinical arrhythmia was successfully ablated in 14 out of 19 (73.7%) cases after a singleCA procedure. A completely successful CA outcome was associated with significantly increasedES-free survival compared with a partially successful or failed procedure (Log rank PZ0.039).

S. Paraskevaidis et al.Hellenic Society of Cardiology (2017) 58, 51e56

REAL LIFE

Real life

Conclusions

➢ES is expected to occur in almost one of five patients treated with an ICD for thesecondary prevention of SCD .

➢ES is most likely to occur in older ICD patients with advanced left ventriculardysfunction and CHF.

➢long-term outcome is limited by an increased cardiac mortality

➢Optimal medical therapy with blockers and angiotensin-converting enzyme inhibitors+newer therapies could reduce the incidence of this devastating complication

➢Powerful association between improved survival and freedom from inducible VT and recurrentVT after ablation(outcomes for scar-related VT are actually superior to those achieved with pulmonary veinisolation with regard to arrhythmia recurrence)

➢VT ablation is the first ablation therapy to demonstrate a consistent mortality benefit

➢VT ablation reduces shocks ,recurrences and improves mortality on E. Storm patients(50% to75% freedom from VT

➢Existing data suggest that early ablation is better regarding arrhythmia recurrences ICD shocksand mortality

➢No data from R. Trials regarding the optimal point for Catheter ablation after ICD implant areavailable

Conclusions