Electrical storm of monomorphic ventricular tachycardia after a cardiac-resynchronization-therapy-defibrillator upgrade

Kantharia, Bharat K.; Patel, Jigar A.; Nagra, Bipinpreet; Ledley, Gary S.

doi:10.1093/europace/eul049

Cited by 42 publications

(31 citation statements)

References 11 publications

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“…Some authors have suggested that prolongation of the transmural dispersion of repolarization, by reversal of the activation sequence caused by LV epicardial pacing, can promote polymorphic VT 9,10 while others have indicated re-entry as the likely mechanism. 4,8 We report our experience in managing CRT-induced proarrhythmia with catheter ablation and postulate that pacing from the epicardium using an LV lead positioned on scar could influence critical components of a re-entrant circuit and induce re-entrant VT. For that purpose, the relationship between CRT-induced proarrhythmia and LV lead tip location within scar was investigated.…”

Section: Editorial See P 1000 Clinical Perspective On P 1069mentioning

confidence: 99%

“…3 Despite this, CRT-induced proarrhythmia has been reported as a clinically serious, rare, and unpredictable phenomenon. [4][5][6][7] Patients usually present with recurrent sustained ventricular tachycardia (VT)/electrical storm (ES), refractory to antiarrhythmic drugs, often accompanied with HF deterioration and cardiogenic shock. 7 Although suppression of recurrent VT with catheter ablation has been reported, 7,8 treatment most often required inactivation of LV pacing, depriving these patients of the beneficial effects of resynchronization.…”

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confidence: 99%

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Electrical Storm Induced by Cardiac Resynchronization Therapy Is Determined by Pacing on Epicardial Scar and Can be Successfully Managed by Catheter Ablation

Roque

Trevisi

Silberbauer

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-The mechanism of cardiac resynchronization therapy (CRT)-induced proarrhythmia remains unknown. We postulated that pacing from a left ventricular (LV) lead positioned on epicardial scar can facilitate re-entrant ventricular tachycardia. The aim of this study was to investigate the relationship between CRT-induced proarrhythmia and LV lead location within scar. Methods and Results-Twenty-eight epicardial and 63 endocardial maps, obtained from 64 CRT patients undergoing ventricular tachycardia ablation, were analyzed. A positive LV lead/scar relationship, defined as a lead tip positioned on scar/border zone, was determined by overlaying fluoroscopic projections with LV electroanatomical maps. CRTinduced proarrhythmia occurred in 8 patients (12.5%). They all presented early with electrical storm (100% versus 39% of patients with no proarrhythmia; P<0.01), requiring temporary biventricular pacing discontinuation in half of cases. They more frequently presented with heart failure/cardiogenic shock (50% versus 7%; P<0.01), requiring intensive care management. Ventricular tachycardia was re-entrant in all. The LV lead location within epicardial scar was significantly more frequent in the proarrhythmia group (60% versus 9% P=0.03 on epicardial bipolar scar, 80% versus 17% P=0.02 on epicardial unipolar scar, and 80% versus 17% P=0.02 on any-epicardial scar). Ablation was performed within epicardial scar, close to the LV lead, and allowed CRT reactivation in all patients. Conclusions-CRT-induced proarrhythmia presented early with electrical storm and was associated with an LV lead positioning within epicardial scar. Catheter ablation allowed for resumption of biventricular stimulation in all patients. (Circ Arrhythm Electrophysiol. 2014;7:1064-1069.)

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Section: Editorial See P 1000 Clinical Perspective On P 1069mentioning

confidence: 99%

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confidence: 99%

Electrical Storm Induced by Cardiac Resynchronization Therapy Is Determined by Pacing on Epicardial Scar and Can be Successfully Managed by Catheter Ablation

Roque

Trevisi

Silberbauer

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…31 Cases have been reported of CRT inducing ventricular arrhythmias, but several trials report a reduction in these events. [32][33][34][35][36] A review of the 2 largest CRT trials did not show significant increases or decreases in ventricular arrhythmia. 37 …”

Section: Patient Selection and Therapeutic Resultsmentioning

confidence: 99%

Interventional Electrophysiology and Cardiac Resynchronization Therapy

Burkhardt

Wilkoff

2007

Circulation

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Abstract-Implantable devices have become a readily available option for patients with heart failure. Not only do these patients develop bradycardia and ventricular tachycardia, but their ventricular dysfunction can often improve with cardiac resynchronization therapy. However, this is a complex and rapidly developing clinical science for which the physician chooses techniques and selects patients on the basis of the results of clinical trials, clinical experience, and rapidly evolving tools. The results depend on the interplay of these complex variables. Placement of the left ventricular lead has forced the device physician to develop new skills and/or interdisciplinary relationships with physicians with vascular intervention, imaging, and surgical skills. Familiarity with the cardiac venous anatomy, occlusive venography, venoplasty, guide wire tools, guiding catheters, stenting, and new intracardiac visualization and magnetic intracardiac lead positioning tools are examples of just a few of the novel skills that are useful in the delivery of cardiac resynchronization therapy. Beyond implantation, these patients and devices require specialized follow-up with continued medical therapy and echo-guided adjustments of device programming. Finally, there are ongoing controversies and many as yet unanswered questions that are the subject of ongoing and planned clinical trials. (Circulation. 2007;115:2208-2220.)Key Words: electrical stimulation Ⅲ heart failure Ⅲ pacemakers Ⅲ defibrillators, implantable P atients with advanced congestive heart failure (CHF) on maximal medical therapy have had very limited options until recently. The advent of cardiac resynchronization therapy (CRT) has revolutionized the treatment of these patients. Many patients with advanced CHF demonstrate dyssynchrony by evidence of a widened QRS complex on the EKG. Most frequently this takes the form of a left bundle-branch block morphology, but right bundle-branch block morphology and intraventricular conduction delay are also less frequently present. 1,2 Electrical dyssynchrony usually implies that different portions of the ventricle contract at different times, unlike that of a normal heart in which contraction of all segments is nearly simultaneous. The presence of a widened QRS itself in the presence of CHF symptoms is associated with increased mortality. 3,4 Dyssynchrony on EKG, particularly of the left bundle-branch type, is associated with delayed activation of the left lateral wall, mitral regurgitation, impaired left ventricular filling, and reduced measures of cardiac contractility. 5-8 CRT operates on the premise that attempts to normalize the timing of activation of the left and right ventricle or lateral wall and septum may improve the consequences of this impaired activation. 9 Multiple trials have shown that CRT improves heart failure symptoms in the majority of recipients. 10 -14 These trials include the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) trial, which studied 453 patients. All patients had a CRT device impla...

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“…The aetiology of electric storm is not clearly understood. The factors contributing to storm onset are: worsening of cardiac function, electrolyte disturbance, autonomic imbalance, drug proarrhythmia, a context with other illness, psychological stress, excess ethanol consumption and cardiac resynchronization therapy (Kantharia et al, 2006). In 35% of the patients storms represent their first event.…”

Section: Icd-specific Complicationsmentioning

confidence: 99%