Multidisciplinary Critical Care Management of Electrical Storm

Electrical storm (ES) is a life-threatening state of electrical instability characterized by 3 or more episodes of sustained ventricular arrhythmia (VA) within 24 hours. Most cases of ES arise in the setting of underlying structural heart disease which provides an arrhythmogenic substrate, often provoked by excessive sympathetic activation or other aggravating factors. Identification of the underlying cardiac substrate and reversible triggers is needed, in addition to diligent interrogation and programming of the implantable cardioverter-defibrillator that is often present. Medical management includes membrane-active anti-arrhythmic drugs, beta-adrenergic blockade, sedation, and often hemodynamic support for hypotension from cardiac decompensation. The intensity of these interventions should be matched to the severity of the ES syndrome and risk of recurrent VA and adverse outcomes. A stepped-care algorithm can be used, involving escalating treatments for higher-risk presentations or recurrent VA. Many patients with ES are considered for catheter ablation and are at elevated risk of hemodynamic compromise, which may justify the use of temporary mechanical circulatory support in selected patients. A multidisciplinary collaborative approach to the management of ES is essential. Outcomes after ES are poor, including frequent recurrences of VA and deaths due to progressive heart failure and other cardiac causes. Evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode. In this State-of-the-Art review, all aspects of the evaluation and management of ES are described to enable providers to provide comprehensive care for these patients with critical illness caused by recurrent VA.