Patients with Electrical Storm - Clinical Management - D. Bänsch University Clinic Rostock
Disclosures Speakers Bureau: Biotronik, Medtronic, SCM, Boston, Bioscence Trials Biotronik, Medtronic, SCM, Boston, Bioscence Grants: Biotronik Shares: none 2
Electrical Storm Definition VT-/VF-Cluster VT/VF- Storm ( 2-3 Episodes/24h) Incessant VT Present during 50% of time 3
90 80 70 60 50 40 30 20 10 0 294 VT-Cluster in 123 pts 2 3 to 5 6 to 10 11 to 14 >15 VTs/Cluster 4 Brigadeau, F et al. European Heart Journal 2006: 700-707.
Brigadeau, F et al. European Heart Journal 2006: 700-707. VT-Storm Management Hypertyreosis VT-Ablation 2% 6% PCI 2% Heart failure 12% AA 38% ICD-programming 18% none 22%
VT Storm The more dramatic the clinical situation, the more anecdotical the data. 6
VT Storm Publications last 5 Years Veröffentlichungen 25 20 15 10 5 21 21 5 0 Trial (N>5) Case-Report Review 7
Incidence in Secondary Prevention 3 VTs/ 24hours 10% no ES 77% 23% 5% 1 ES 2 ES > 2 ES 8% Mittel :5,6 8 Hohnloser SH et al. European Heart Journal 2006.
VT-Sturm Causes Heart failure 19% none 57% CS 14% Electrolyte 10% 9 Brigadeau, F et al. European Heart Journal 2006: 700-707.
Therapy Options Sedation Antiarrhythmic drugs Sympathetic blockade Stimulation Coronary intervention Hemodynamic Support 10
Therapy Options Sedation Antiarrhythmic drugs Sympathetic blockade Stimulation Coronary intervention Hemodynamic Support 11
Classification > 2 episodes of VT; VF, or ICD shocks Sedation ACLS 12 Eifling M et al. The Evaluation and Mangement of Electrical Storm. Tex Heart Inst J 2011.
Sedation Electrical Storm after ICD-implantation n=9 AA 3,8/Patient Stabilisiert n=2 VT-Storm n=7 ATP Successful n=3 Unsuccessful n=4 Sedation successful n=4 13 Dijkman B. Pace 1995: 148-151.
VT-Sturm Sedation Sympathetic Tone Automaticity DAD EAD Repol. Reentry Anesthesia? Barbiturates - - - - Propofol - - - - Morphin - - - - Benzodiazepine - - - - Gallagher JD. J of Cardiothoracic and Vascular Anesthesia 1997. 14
Therapy Options Sedation is reasonable to decrease symathetic tone, data is rare Antiarrhythmic drugs Sympathetic blockade Stimulation Coronary intervention Hemodynamic Support 15
Classification > 2 episodes of VT; VF, or ICD shocks Sedation ACLS monomorphic VT p VT VF 16 Eifling M et al. The Evaluation and Mangement of Electrical Storm. Tex Heart Inst J 2011.
Classification > 2 episodes of VT; VF, or ICD shocks Sedation ACLS monomorphic VT p VT VF 17 Eifling M et al. The Evaluation and Mangement of Electrical Storm. Tex Heart Inst J 2011.
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Therapy Options Sedation is reasonable to decrease symathetic tone, data is rare Antiarrhythmic drugs Sympathetic blockade Stimulation Coronary intervention Hemodynamic Support 21
Classification > 2 episodes of VT; VF, or ICD shocks Sedation ACLS monomorphic VT polymorphic VT VF normal QT prolonged QT Ischemia PVC-initiated Brugada - secondary - primary 22 Eifling M et al. The Evaluation and Mangement of Electrical Storm. Tex Heart Inst J 2011.
Long QT Prompt a search for acquired causes Increase heart rate Pacing Isoproterenol Magnesium Potassium until 4.5 mmol/l Congenital long QT Cluster is rare Betablocker Increase heart rate 23
Brugada-Syndrome 69 patients with Brugada syndrome VF-Storm n=7 Singular VT/VF n=39 asymptomatic n=21 Isoproterenol 0.003ug/kg/min 24 +/13 days n=5 Denopamine (30mg/day) Quinidine (300mg/day) n=2 acute Denopamine Quinidine Cilostazol Bepridil long term 24 Ohgo T et al. Heart Rhythm 2007;4:695-700.
Brugada-Syndrome Actionpotential 0 mv Na+ Na+ K+ K+ - 90 mv 25 Yan Circulation 1999
Brugada-Syndrome Special considerations are necessary Reverse the imbalance between Na and K current Blocking I to with Quinidine Increase I ca-l with sympathomimetic therapy 26 Ohgo T et al. Heart Rhythm 2007;4:695-700.
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Antiarrhythmic drugs Sympathetic blockade Stimulation Coronary intervention Hemodynamic Support 27
Amiodarone Response 28 Levine JH et al. (J Am Coil Cardiol 1996;27:67-75)
and Amiodarone 29 Levine JH et al. (J Am Coil Cardiol 1996;27:67-75)
and Amiodarone 30 Levine JH et al. (J Am Coil Cardiol 1996;27:67-75)
AA + Risk of VT Below the Detection Rate in ICD Patients.4 Risk of a a Vt below the detection rate.3.2.1 0.0 0 Amiodarone N=41 p<0.001 12 class I AA N=17 n.s. 24 36 sotalole N=46 p=0.004 no AA N=419 ß-blocker N=136 n.s. Months Bänsch D. J Am Coll Cardiol 2000 Aug ;36 (2 ):557-6536:557-65. 48 60 31
VT-Sturm Amiodarone Amiodarone resolves 50% of VT storms Disadvantage 20% of patients die of incessant VT Takes time for action Slows VTs 32
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Antiarrhythmic drugs Sympathetic blockade Stimulation Coronary intervention Hemodynamic Support 33
VF-Storm Sympathetic Blockade vs. Antiarrhythmic Drug Therapy Electriacal Storm n=49 MI between 72 hours to 3 months 20 ³ VT/day or ³ 4/hour 27 Sympathetic blockade 6 Left stellate gangionic blockade 7 Propranolol, 14 Esmolol 20 Amiodarone 22 Advanced Cardiac Life Support 22 Lidocaine, 16 Procainamide, 18 Bretylium 5 Amiodarone 6 died 3 refractory VF 21 survival 78% 1 week 1 year 18 died of refractory VF 4 survival 18% Nademanee et al, Circulation 2000;102:742 744. 34
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Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Stimulation Coronary intervention Hemodynamic Support 37
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Stimulation Coronary intervention Hemodynamic Support 38
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Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Overdrive is fesible in triggered activity, automaticity Coronary intervention Hemodynamic Support 41
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Overdrive is fesible in triggered activity Coronary intervention Hemodynamic Support 42
Management 6% 2% 2% 12% 18% 38% AA keine ICD-programming Heart f ailure VT-Ablation Hy perty reose PTCA 22% Brigadeau, F et al. European Heart Journal 2006: 700-707.
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Overdrive is fesible in triggered activity Coronary intervention only in pvt or VF Hemodynamic Support 44
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Coronary Artery Spasm Therapy N= 127 Nitrat Betablocker pvt 30% Nifedipin 60-120 mg /24h 63% comple Suppression of symtoms 87% reduction of angina and Vt by 50% Antmann E et al. Nifidipine Therapy for coronary artery spasm. Experience in 127 patients. NEJM 1980. 47
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Overdrive is fesible in triggered activity Coronary intervention only in pvt or VF Hemodynamic Support 48
VT-Cluster und IABP 49 Fotopoulos GD et al. Heart. 1999 Jul;82(1):96-100.
and IABP Time until Stabilisation N=21 Storm N=11 Incessant VT N=10 Stabilisation N=8 Stabilisation All patients 30-85 min. Fotopoulos GD et al. Heart. 1999 Jul;82(1):96-100. 50
* * * * * * * * Fotopoulos GD et al. Heart. 1999 Jul;82(1):96-100. 51
Therapy Options in Structural Heart Disease Sedation is reasonable to decrease symathetic tone, data is rare Amiodarone + sympathetic blockade is the best therapy available for structural heart disease Overdrive is fesible in triggered activity Coronary intervention only in pvt or VF Hemodynamic support seems to be helpful Prognosis is impaired in these patients 52
Conclusion Ablation AA+Sympaticolyse IABP 70 78 90 AA 50 0 20 40 60 80 100 53
Conclusion > 2 episodes of VT; VF, or ICD shocks Sedation ACLS monomorphic VT polymorphic VT VF Amiodarone -Blockers Sedation IABP normal QT prolonged QT Ischemia PVC-initiated Brugada Amiodarone -Blockers Sedation IABP - secondary - primary Amiodarone -Blockers (Lidocain) Sedation IABP Amiodarone -Blockers Sedation IABP Isoproterenol Quinidine Isoproterenol Magnesium Potassium Pacing 54 Eifling M et al. The Evaluation and Mangement of Electrical Storm. Tex Heart Inst J 2011.
Conclusion Get into contact with your regional interventional electrophysiologist as early as possible 55
Thank you for your attention D. Bänsch Universitätsklinikum Rostock