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Management of a Patient With Electrical Storm: Role of Epicardial Catheter Ablation

Clinical Case: A 53-year-old male patient was referred to our center for the management of severe electrical storm (ES). The patient experienced 76 appropriate shocks within 30 minutes delivered from his implantable cardioverter-defibrillator as a result of recurrent ventricular tachycardia (VT) occurring just after retiring to his hotel room at the end of an uneventful business meeting. The implantable cardioverter-defibrillator was implanted 16 years ago when the patient presented with syncope and had inducible VT at an electrophysiological study. Coronary artery disease was ruled out at that time with coronary angiography. However, the systolic function of the left ventricle was moderately impaired, with an ejection fraction of 38% measured by echocardiography, which also revealed regional wall motion abnormalities. This nonischemic cardiomyopathy was attributed to remote myocarditis.

When presenting with ES, the patient was admitted at first to the intensive care unit of the local university hospital. A 12-lead ECG showed monomorphic VT of 188 bpm (Figure 1A). Ventricular tachyarrhythmia was stabilized acutely by sequential drug application of β-blockers, amiodarone, and lidocaine as well as sedation followed by endotracheal intubation under general anesthesia. After the initial cooling-down phase, the patient was transferred to our center for further management. To prevent more episodes of ES and to avoid long-term use of amiodarone with the risk of potentially severe adverse effects, catheter ablation was performed.



Figure 1. 
A , Twelve-lead ECG showing a monomorphic ventricular tachycardia (VT) with inferior axis, Q wave present in lead I and absent in lead aVF, right bundle-branch block pattern with positive QRS complex in V1 through V3 and negative in V4 through V6, and with a pseudo δ-wave and late intrinsicoid deflection, suggesting a left lateral midventricular epicardial origin. B , Stepwise management of electrical storm. Application of different steps should be individualized for …