Management of ventricular tachycardia storm in patients with structural heart disease

Table 1 Reversible causes of electrical storm

Acute myocardial ischemia

Electrolyte imbalances

Decompensated heart failure

Hyperthyroidism

Infections, fever

Pro-arrhythmic drug Effects

Early postoperative period

Table 2 Anti-arrhythmic medications for acute and long-term treatment of electrical storm

		Acute management	Long-term treatment	Desired plasma concentration
β-blockers	Propranolol	Bolus: 0.15 mg/kg IV over 10 min	10-40 mg by mouth three-four times a day	NA
	Metoprolol	Bolus: 2-5 mg IV every 5 min up to 3 doses in 15 min	25 mg by mouth twice a day up to 200 mg a day	NA
	Esmolol	Bolus: 300 to 500 mg/kg IV for 1 min	Not recommended	NA
		Infusion: 25-50 mg/kg per minute up to a maximum dose of 250 mg/kg per minute (titration every 5-10 min)
Class III agents	Amiodarone	Bolus: 150 mg IV over 10 min, up to total 2.2 g in 24 h	Oral load: 800 mg by mouth twice a day until 10 g total	1.0-2.5 μg/mL
				No efficacy proven for plasma concentrations < 0.5 μg/mL
		Infusion: 1 mg/min for 6 h, then 0.5 mg/min for 18 h	Maintenance dose: 200-400 mg by mouth daily	Serious toxicity risk for plasma concentrations > 2.5 μg/mL
	Sotalol	Not recommended	80 mg by mouth twice a day, up to 160 mg twice a day (serious side effects > 320 mg/d)	1-3 µg/mL (not of great value, usually monitored by QT prolongation with indication to reduction/discontinuation if prolongation > 15%-20%)
Class I agents	Procainamide	Bolus: 10 mg/kg IV over 20 min	3-6 g by mouth daily fractionated in ≥ 3 administrations	4-12 μg/mL
		Infusion: up to 2-3 g/24 h
	Lidocaine	Bolus: 1.0 to 1.5 mg/kg IV, repeat dose of 0.5-0.75 mg/kg IV up to a total dose of 3 mg/kg	Not recommended	2-6 μg/mL
		Infusion: 20 μcg/kg per minute IV
	Mexiletine	Not recommended	200 mg by mouth three times a day, up to 400 mg by mouth three times a day	0.6-1.7 μg/mL

Table 3 Principal studies analyzing the role of catheter ablation in controlling electrical storm

Ref.	No. of patients	Left ventricular ejection fraction	Epicardial procedures	Acute success	VT recurrence	ES recurrence	Death	Follow-up duration, mo
Sra et al[64]	19	27 ± 8	0%	87%	37%	-	0%	7 ± 2
Silva et al[65]	14	31 ± 13	20%	80%	13%	-	27%	12 ± 17
Carbucicchio et al[56]	95	36 ± 11	11%	89%	34%	8%	16%	Median 22
Arya et al[66]	13	33 ± 9	31%	100%	38%	-	31%	Median 23
Pluta et al[67]	21	-	0%	81%	19%	0%	0%	3
Deneke et al[68]	31	28 ± 15	9%	94%	25%	12%	9%	Median 15
Kozeluhova et al[69]	50	29 ± 11	0%	85%	52%	26%	29%	18 ± 16
Koźluk et al[70]	24	27 ± 7	7%	-	34%	12%	13%	28 ± 16
Di Biase et al[57]	92	27 ± 5	47%	100%	34%	0%	2%	25 ± 10
Izquierdo et al[71]	23	34 ± 10	0%	56%	-	35%	30%	Median 18
Jin et al[72]	40	21 ± 7	0%	80%	53%	-	25%	17 ± 17
Kumar et al[73]	287	27 ± 10 in ICM and 33 ± 16 in NICM	3.8% in ICM and 24% in NICM	60% in ICM and 50% in NICM	49% in ICM and 64% in NICM	17% in ICM and 27% in NICM	25% in ICM and 28% in NICM	Median 42
Muser et al[59]	267	29 ± 13	22%	73%	33%	5%	29%	Median 45

VT: Ventricular tachycardia; ES: Electrical storm.