Atrial overdrive pacing in drug-refractory postinfarction electrical storm case report

Rationale: Drug-refractory electrical storm (ES) following acute myocardial infarction (AMI) constitutes a critical therapeutic challenge. Atrial overdrive pacing (AOP) provides physiological rhythm control by suppressing ventricular ectopy through synchronized atrioventricular activation, circumventing ventricular pacing-associated hemodynamic compromise. Patient concerns: A 62-year-old female with AMI developed recurrent polymorphic ventricular tachycardia/ventricular fibrillation refractory to antiarrhythmics (amiodarone/esmolol/lidocaine) and revascularization, fulfilling ES criteria. Diagnoses: The patient was diagnosed with acute anterior wall myocardial infarction, Killip class II–III acute left heart failure, secondary hepatic dysfunction, hypertension, type 2 diabetes mellitus and ES. Interventions: X-ray-guided temporary AOP (95 bpm) via subclavian access was implemented with concurrent β-blocker/sacubitril-valsartan optimization and electrolyte correction. Antiarrhythmics were discontinued post-AOP. Outcomes: Sustained arrhythmia suppression was achieved (0 recurrences/9 months), alongside improved left ventricular ejection fraction (40%→46%) and 70.7% N-terminal B-type natriuretic peptide precursor reduction (33,593→9839 pg/mL). Implantable cardioverter-defibrillator was declined without clinical sequelae. Lessons: AOP demonstrates dual therapeutic efficacy in refractory post-AMI ES: (1) physiological conduction restoration suppressing ectopic triggers and (2) avoidance of ventricular pacing-induced dyssynchrony. Fluoroscopic guidance ensures lead stability, positioning AOP as a hemodynamically favorable intervention in ES management.