Deep sedation as temporary bridge to definitive treatment of ventricular arrhythmia storm

Abstract

Background: Electrical storm and incessant ventricular tachycardia (VT) are characterized by the clustering of episodes of VT or ventricular fibrillation (VF) and are associated with a poor prognosis. Autonomic nervous system activity influences VT threshold, and deep sedation may be useful for the treatment of VT emergencies. Methods: We reviewed data from conscious patients admitted to our intensive care unit (ICU) due to monomorphic VT, polymorphic VT or VF at our tertiary center between 2010 and 2018. Results: A total of 46 conscious patients with recurrent ventricular arrhythmia, refractory to initial treatment, were referred to the ICU. The majority ( n = 31) were stabilized on usual care. The remaining treatment-refractory 15 patients (57 years (range 9–74), 80% males, seven with implantable cardioverter-defibrillators) with VT/VF storm ( n = 11) or incessant VT ( n = 4) due to ischemic heart disease ( n = 10), cardiomyopathy ( n = 2), primary arrhythmia ( n = 2) and one patient post valve surgery, were deeply sedated and intubated. A complete resolution of VT/VF within minutes to hours was achieved in 12 patients (80%), partial resolution in two (13%) and one (7%) patient died due to ventricular free-wall rupture. One patient with recurrent VT episodes needing repeated deep sedation developed necrotic caecum. No other major complications were seen. Thirteen (87%) patients were alive after a mean follow-up of 3.7 years. Conclusion: Deep sedation was effective and safe for the temporary management of malignant VT/VF refractory to usual treatment. In emergencies, deep sedation may be widely accessible at both secondary and tertiary centers and a clinically useful bridge to definitive treatment of VT.

Combination of Multidisciplinary Therapies Successfully Treated Refractory Ventricular Arrhythmia in a STEMI Patient: Case Report and Literature Review

“…The recommendations in the guidelines are unreferenced. A small study by Bundgarrd et al suggested that deep sedation and intubation reduced or terminated VT in patients with refractory to guideline-recommended usual clinical care in the acute setting [ 9 ]. It can be used as a bridge to definitive treatment in patients with different underlying cardiac disorders.…”

“…Its side effects include bradycardia, hypotension, respiratory depression, hypertriglyceridemia, and propofol infusion syndrome. Still, no RCTs have been found [ 2 , 9 , 16 ].…”

Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC—endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society

“…Deep sedation and mechanical ventilation have successfully controlled drug-refractory ES. 140 , 141 An acute response, defined as the termination of ES within 15 min without recurrent episodes over the following 24 h, occurred in 47% of a mixed cohort of 116 ES patients who were refractory to AADs. Response to deep sedation was an independent predictor of in-hospital survival.…”

Electrical storm management in structural heart disease

“…catheter ablation, coronary revascularization, therapeutic optimization) or resolution of possible reversible causes. 11 …”