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Flowchart with the algorithm for the management of ventricular electrical storm. ICCU -Intensive Cardiac Care Unit; HR -heart rate; BP -blood pressure; BPM -breaths per minute; SaO2 -oxygen saturation; ECMO -extracorporeal membrane oxygenation.
Source publication
Patient: Female, 39-year-old
Final Diagnosis: Ventricular electrical storm (VES)
Symptoms: Fainting
Medication: —
Clinical Procedure: Defibrillation • electrophysiological study • endocavitary electrode for temporary cardiac pacing • ICD implantation • radiofrequency ablation • renal replacement therapy • venous-arterial ECMO
Specialty: Cardiology...
Context in source publication
Citations
... 4,5 Interestingly, however, it has been found that a shockable rhythm usually indicates a good prognosis in patients with CA. 6,7 Experience from clinical practice has indicated that patients undergoing VA-ECMO-based treatment, especially in the early stages (usually within 72 h), are likely to have persistent or intermittent episodes of VF/VT; however, only a few studies have been conducted to evaluate the incidence, clinical significance, and therapeutic principles of VF/VT that occurs during VA-ECMO treatment. 8,9 Defibrillation is the preferable method with which to terminate episodes of VF/VT, although intravenous antiarrhythmic drugs, such as amiodarone or beta-blockers, may be also considered. 6,10 There is no consensus, however, as to which method should be used to terminate VF/VT episodes during VA-ECMO treatment and whether defibrillation is necessary and appropriate. ...
Aims
Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is an important technique for the treatment of refractory cardiogenic shock and cardiac arrest; however, the early management of ventricular fibrillation/ventricular tachycardia (VF/VT), within 72 h of VA‐ECMO, and its effects on patient prognosis remain unclear.
Methods and results
We retrospectively analysed patients at the First Affiliated Hospital of Nanjing Medical University who underwent VA‐ECMO between January 2017 and March 2022. The patients were divided into two groups, VF/VT and nVF/VT, based on whether or not VF/VT occurred within 72 h after the initiation of VA‐ECMO. We utilized logistic regression analysis to evaluate the independent risk factors for VF/VT in patients undergoing VA‐ECMO and to ascertain whether the onset of VF/VT affected 28 day survival rate, length of intensive care unit stay, and/or other clinical prognostic factors. Subgroup analysis was performed for the VF/VT group to determine whether defibrillation affected prognosis. In the present study, 126 patients were included, 65.87% of whom were males (83/126), with a mean age of 46.89 ± 16.23, a 28 day survival rate of 57.14% (72/126), an incidence rate of VF/VT within 72 h of VA‐ECMO initiation of 27.78% (35/126), and 80% of whom (28/35) received extracorporeal cardiopulmonary resuscitation. The incidence of VF/VT resulting from cardiac arrest at an early stage was significantly higher than that of refractory cardiogenic shock (80% vs. 20%; P = 0.022). The restricted cubic spline model revealed a U‐shaped relationship between VF/VT incidence and initial heart rate (iHR), and multivariate logistic regression analysis showed that an iHR > 120 b.p.m. [odds ratio (OR) 6.117; 95% confidence interval (CI) 1.672–22.376; P = 0.006] and hyperlactataemia (OR 1.125; 95% CI 1.016–1.246; P = 0.023) within 1 h of VA‐ECMO initiation were independent risk factors for the occurrence of VF/VT. VF/VT was not found to be associated with the 28 day survival of patients undergoing VA‐ECMO support, nor did it affect other secondary endpoints. Defibrillation did not alter the overall prognosis in patients with VF/VT during VA‐ECMO.
Conclusions
An iHR > 120 b.p.m. and hyperlactataemia were independent risk factors for the occurrence of VF/VT within 72 h of VA‐ECMO initiation. The occurrence of VF/VT does not affect, nor does defibrillation in these patients improve the overall patient prognosis.
Trial registration
ChiCTR1900026105.
... ES has been reported in various clinical settings, such as after cardiac surgery and in patients with structural heart disease [12][13][14]. Nevertheless, its occurrence in the context of liver transplantation (LT) has not been well documented, especially in patients without ICDs. ...
Patient: Female, 61-year-old
Final Diagnosis: Electrical storm
Symptoms: Cardiac arrest • ventricular fibrillation
Clinical Procedure: —
Specialty: Cardiology • Critical Care Medicine • Gastroenterology and Hepatology • Transplantology
Objective
Unknown etiology
Background
Electrical storm is a rare but potentially life-threatening syndrome characterized by recurrent ventricular arrhythmias. Liver transplant recipients are at increased risk of developing electrical storms due to conditions that prolong QT intervals, such as cirrhotic cardiomyopathy. However, limited information exists on electrical storms in this specific population. This case report presents a patient who experienced 13 cardiac arrests during ventricular fibrillation following liver transplantation.
Case Report
A 61-year-old woman with a medical history of diabetes, obesity, and cirrhosis due to non-alcoholic fatty liver disease underwent liver transplantation using a deceased donor’s liver. Following the procedure, she developed a deterioration in her respiratory function, necessitating orotracheal intubation. Approximately 21 hours post-surgery, she experienced cardiac arrest during ventricular fibrillation, which was rapidly reversed with electrical defibrillation. However, the patient entered a state of electrical storm. Management involved antiar-rhythmic medications and temporary transvenous cardiac pacing. She remained stable for 40 hours, but a dislodgment of the device triggered another episode of ventricular fibrillation, leading to her death.
Conclusions
This case report highlights the clinical presentation and challenges in managing electrical storms in liver transplant recipients. We hypothesize that cirrhotic cardiomyopathy could be the cause of her recurrent ventricular arrhythmias. Further studies are needed to better understand the underlying mechanisms and risk factors of this life-threatening syndrome in this population, which may enhance risk stratification and enable earlier intervention.
