Ventricular tachycardia (VT) storm refers to recurrent episodes of VT. Although any individual episode of VT can be broken, the overall process of recurrent arrests (or ICD shocks) creates a vicious cycle. Aggressive management is required including intubation, deep sedation, antiarrhythmics, and sympatholysis. Given the rarity of this condition, it's difficult to obtain high-level evidence or extensive experience. This chapter attempts to create an organized pathway, incorporating some emerging evidence regarding ultrasound-guided stellate ganglion blocks.
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The IBCC chapter is located here.
- The podcast & comments are below.
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Addendum: Electrophysiologist Michael Katz (@MGKatz036) left a series of great comments on twitter. Honestly I haven't covered all of these aspects in the chapter, so to make up for that I've pasted all his comments below:
Have you ever done stellate gangilion block at the bedside? If so, that’s freakin’ awesome. I need to learn how to do this!! Would be amazing arrow in our quiver. Thoracic block has also been shown to be helpful. We need to try this more often.
— Michael Katz (@MGKatz036) April 18, 2019
I haven't done this (refractory VT storm is thankfully a fairly rare phenomenon), but over time I think this will become increasingly common and may be incorporated earlier in the algorithm. Injecting 10 ml of lidocaine into the neck of a patient who is intubated isn't rocket science – this is something which we should be able to do. Furthermore, we've all spent lots of time poking around in the neck while trying to place jugular lines; this seems to be a reasonable forgivable maneuver if done gently.
If VF or VT is polymorphic and pt is in storm, IC should be involved ASAP. It is impossible to fight acute ischemia with medications. Pts need revascularization +/- mechanical support.
— Michael Katz (@MGKatz036) April 18, 2019
Agree, interventional cardiology & electrophysiology should be involved immediately in all of these cases. Also, it's important to maintain clear lines of communication if the patient isn't responding favorably.
If there is BIV, consider arrythmogenticity of ventricular pacing, consider changing to RV only vs LV only vs no ventricular pacing at all.
— Michael Katz (@MGKatz036) April 18, 2019
I'll make sure to point out to the electrophysiologist that *their* BiV pacer might be causing the problem; I'm sure they'll love that 😛
Does pt have ICD/BIV? Other considerations… is VT/VF pause dependent? Consider rapid Atrial, or even ventricular, pacing. Sometimes LRL 90 or 100 is essential. This can even facilitate BB addition.
— Michael Katz (@MGKatz036) April 18, 2019
Is there a section on VT/VF storm in the LVAD pt? If not, it is an important topic…. VT/VF is generally well tolerated for short intervals in these pts. Your most important therapeutic tool? MAGNET!!! Preventing PTSD is most essential goal.
— Michael Katz (@MGKatz036) April 18, 2019
Great point. I didn't cover this, but I expect that we will be seeing this increasingly over time as the population of patients with LVADs increases.
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Great post! I think the straightforward algorithm is a great idea and your diagram is very helpful. I wonder if bilateral sympathetic blockade is a bit premature to recommend at this point, even as a last ditch effort. As you point out, most of the data is for the LSGB specifically – that case series out of Virginia is with 6 patients, most of whom got LSBG before their bilateral blockade. The ACC put out this article (https://www.acc.org/latest-in-cardiology/articles/2017/01/10/12/11/left-stellate-ganglion-block) that cites an old study where right sided sympathetic blockade in dogs actually precipitated arrhythmia and may worsen the disease state. I… Read more »
Fair, the use of right-sided block is pretty new. That said, the use of bilateral surgical sympathetic block for arrhythmia has been around for a while and seems to be potentially beneficial (e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3551540/). So knocking out the right-sided sympathetic outflow isn’t a particularly crazy idea.
Team,
I’ve had three VT storm patients with AICD in the past 15 years. 1 st one did badly.
2nd and 3rd were after I heard Amal Mattu podcast re: procainimide. It works,
My Algorithm:
Amio load with fentanyl for pain. (while getting procain ready/ 1 minute RN education since they only use every 4 years). Then if recurrent VT/shock:
Procainimide load, one gram over 20 min with lower dose dissociative ketamine (1mg/kg)
until bolus is complete.
Never fails
(if it ever does…then I’ll have stellate block to consider)
Should not have this discussion without procainimide. Thanks.
The issue with procainamide is that it’s logistically difficult/impossible to give it as a long-term infusion. So procainamide is great for breaking VT, but it’s hard to use it to prevent VT recurrence. Thus amiodarone or beta-blockade seems to remain front-line therapy for genuine VT storm (multiple VT recurrences). That being said, starting with procainamide for the first episode of VT is well evidence-based and a totally valid approach.
We see a case of VT storm about every week or two here in our CCU as a regional EP center. Most of them have responded quite well to lidocaine drips. We usually reserve amiodarone as a second line drug because our EP docs feel that it interferes with VT induction and mapping during ablation. I haven’t personally seen the stelate ganglion block done for this purpose, but it’s intriguing. It might be worth mentioning in the text two unlikely but very scary complications, namely accidental injection into the vertebral (which may immediately cause a seizure) and accidental injection into… Read more »
Any experience with dexmedetomidine for sedation in these patients given its antiarrhythmic/sympatholyitc properties? There’s some sparse data out there showing decreased rates of ventricular arrhythmias in post-cardiac surgery patients as well as some effectiveness in refractory afib.
I survived a VT storm. Had an episode of VT. Cardiac cath was completely clean, EP study found no ectopic pacemaker so they put in a pacemaker (my resting HR was 35-40) and an ICD. 3 weeks later the ICD went off, next day I was in the CC-ICU, the ICD went off 25 times in ten minutes. Intubated, placed in a coma, when they tried to bring me out I keep going into VT. They had to put in an impellor in my heart. Life flighted to Gainesville, they put in a high block, extubated me and 4 days… Read more »
Last ejection fraction was 65%