Title
Refractory Electrical Storm Managed with VA-ECMO as a Bridge to Durable LVAD
Introduction
Electrical storm can be a symptom of progressive cardiomyopathy. In the setting of electrical storm, MCS can serve as a bridge to catheter ablation, durable LVAD, or heart transplantation. Multidisciplinary team-based approaches are needed to identify the MCS best suited for a specific patient.
Clinical Case
A 62-year-old man with a history of non-ischemic cardiomyopathy presumed to be secondary to cardiac sarcoidosis (not biopsy proven) complicated by VT/VF, with CRT-D, and permanent atrial fibrillation presented from an outside hospital due to recurrent VT. He had a longstanding history of interventions for VT including stellate ganglion block four years ago, right sympathectomy one year ago, PVC ablation one month prior, and was now on quinidine, sotalol, and metoprolol. His current presentation was prompted after receiving two ICD shocks at home while having intercourse. On admission, he was started on amiodarone and lidocaine infusions. No obvious reversible triggers were identified. TTE demonstrated an EF of 45% with diffuse hypokinesis. He continued to have frequent episodes of monomorphic VT and underwent placement of bilateral intercostal nerve blocks with little improvement. EP attempted endocardial and epicardial VT ablation which was unsuccessful. After the attempted ablation, he returned to the CICU intubated, sedated, and in shock requiring pressors. Post-procedure, he developed unstable VT requiring emergent defibrillation. The shock team was activated with an initial plan for Impella placement; however, this was deferred due to concern for myocardial irritability with catheter manipulation in the EP lab. Other options discussed included VA-ECMO, right-sided Protek Duo and left-sided Impella 5.5, or bilateral surgical CentriMags. Ultimately, the decision was made to proceed with right-sided Protek Duo and left-sided Impella 5.5. However, pre-operative CT scan demonstrated incidental acute bilateral pulmonary emboli. Repeat TTE demonstrated worsened biventricular function with no clot-in-transit. Subsequently, the patient developed worsening oxygenation and was taken for catheter-directed thrombectomy. Extensive thrombus was removed from the right pulmonary artery using a FlowTriever, and the patient was cannulated onto ECMO. On day four after ECMO initiation, he underwent Impella 5.5 placement for LV venting. Ultimately, his hemodynamics improved, and he was decannulated from ECMO on day seven and subsequently underwent placement of HeartMate3 LVAD. After a complicated hospital course, he was discharged to rehab and underwent a heart transplantation five months after this admission.
Discussion
Managing cardiogenic shock in the setting of ventricular arrhythmias is particularly challenging. Temporary MCS should be considered in refractory electrical storm resulting in hemodynamic instability. Each MCS modality has its unique advantages and disadvantages with little available evidence to guide the timing and type of MCS device in VT storm, thereby raising the importance of a multidisciplinary shock-team approach. In this case, the patient’s shock was likely due to a combination of hypotension from refractory VT, cardiac stunning related to repeated shocks, requirement of deep sedation for VT storm, and perhaps some component of hemodynamic effect from the acute PE. The timely use of VA-ECMO was able to restore his hemodynamics and prevent end-organ damage.