An Electrical Storm
9th May 2014
U Buckley, D Eaton, J Galvin, T Keelan
Mater Misericordiae Hospital, Dublin
• 55 year old female
• Atrial septal defect & mitral valve repair in 1990’s
• Out of hospital cardiac arrest 2011 on clarithromycin
• AED torsade de pointe
• LV dysfunction – 40%
• Long QT on ECG at 490ms
• Fhx sudden cardiac death – 2 first degree relatives
• ICD – single chamber device implanted
• Left sided invasive ductal carcinoma requiring radiotherapy
• Post operatively cardiac arrest requiring 6 shocks to defibrillate (ICD off for surgery)
• Device repositioned & tunnelled lead to right
• Inappropriate therapy from the device Nov 2013
• Reprogrammed
• Increased meds
• Rising threshold and drop in R wave
• Beta-blockade
• Appropriate therapy from the device Jan 2014
• Further 5 shocks from device
• First looked inappropriate
• 4 others were appropriate
• Check Coronary Angiogram
• Medications optimized
• Switched to propranolol
• Mexilitene after loading with intravenous lignocaine
• Further fine ventricular fibrillation undetected
by the device
• Atrial lead inserted & new RV lead
• Further Appropriate therapies
Video Assisted Transaxillary Transthoracic Left
Cervical Sympathectomy
• LCSD
• lengthening repolarization
• Prolong refractory periods
• Increase VF threshold
• Defibrillation threshold testing was
performed
• Genetic testing sent
• No Horner's Syndrome
• 8 weeks on and no further ventricular
arrhythmias
• Natural history of electrical storm or
success?
Management of Ventricular Arrhythmic
Storms
1. Beta blockers
2. Antiarrhythmics
3. Reprogramme Device
4. Manage reversible proarrhythmic causes
5. Ablation
6. Deep sedation/skeletal muscle relaxants
7. Stellate ganglion blocking
8. Cervical Sympathectomy
Neuromodulation
Presynaptic
Postsynaptic
Central inhibition
Sympathetic Activation
Previous Surgical Options
• Supraclavicular
• Open thoracotomy
• Posterior approach
• Chemical ablation
• Resection
How much of the chain is enough?
• T1-4
• C8
• Can the nerves grow back?
• Lessons from orthotopic heart
transplantation
• Left versus bilateral sympathectomy
Surgical Failure
• Multiple shocks prior to surgery
• Decompensated end stage intractable heart failure
• Lack of sympathetic triggers
• Circulating catecholamines
• Failure to dissect the nerve of Kuntz