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Elektrischer Sturm

Erkennung und Beherrschung

Electrical storm

Recognition and management

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Herzschrittmachertherapie + Elektrophysiologie Aims and scope Submit manuscript

Zusammenfassung

Der elektrische Sturm („electrical storm“, ES) subsummiert in seiner Definition von ≥3 anhaltenden ventrikulären Tachykardien/24 h ein weites klinisches Spektrum an Krankheitsbildern. Im Regelfall sind es jedoch schwer herzkranke Patienten mit erheblicher Komorbidität, weshalb bei ES eine sofortige Verlegung in ein kardiologisches Zentrum mit multidisziplinärer Expertise notwendig ist. Eine initiale psychische und kardiale Abschirmung dieser durch Tachykardien und multiple Kardioversion traumatisierten Patienten mit Anxiolyse und Analgosedierung sowie β‑Blocker-Gabe ist zwingend erforderlich, um den Teufelskreis der sympathikoadrenergen Überaktivierung zu durchbrechen. Multiple ICD-Entladungen als Surrogatparamter für den ES sind in etwa einem Drittel der Fälle inadäquat, was am häufigsten durch pharmakologische oder ablative Therapien von supraventrikulären Tachykardien (SVT) oder Optimierung der Programmierung bei Oversensing behoben werden kann. Doch auch nicht alle adäquaten ICD-Entladungen sind notwendig. Jede Entladung verschlechtert die Prognose des Patienten und sollte, soweit hämodynamisch möglich, vermieden werden. Nach initialer hämodynamischer Stabilisierung des Patienten mit EKG-Schreibung und paralleler Diagnostik reversibler Ursachen des ES erfolgt die erneute Terminierung durch externe oder interne Defibrillation mit spezifischer frühelektiver Therapie. In einigen Fällen ist auch eine sofortige Ablation oder Revaskularisation mit hämodynamischen Unterstützungssystemen oder als weitere Eskalationsstufe eine kardiale sympathische Denervierung durch Ganglion-stellatum-Blockade notwendig. Aufgrund der schlechten Prognose nach ES ist eine weitere dauerhafte engmaschige Überwachung des Patienten vorzugsweise mittels Telemedizin wünschenswert.

Abstract

The electrical storm (ES) defined as ≥3 sustained episodes of ventricular tachycardia within a 24 h period comprises a wide spectrum of clinical entities. Mostly patients suffer from severe heart insufficiency and comorbidities making an immediate transfer into a heart center with multidisciplinary expertise in the treatment of ES mandatory. As these patients are often traumatized by ongoing tachycardia despite multiple cardioversions, early deep sedation and β‑blockade to break the vicious circle of sympathico-adrenergic hyperactivation is very effective. Multiple ICD discharges suggesting the diagnosis of ES are inadequate in one third of cases. Pharmacological suppression, frequency control or ablation of supraventricular tachycardias (SVT) help in most cases. In some cases “oversensing” demands optimization of ICD programming. Even so not all adequate ICD discharges, however, are necessary. Since every ICD discharge worsens the patient’s prognosis, any kind of ICD discharge should be prevented as far as hemodynamically feasible. After clinical stabilization of the patient with simultaneous acquisition of ECG and testing for reversible causes of ES, ES should be terminated by external or internal cardioversion followed by urgent but elective therapy. Some cases of ES, however, may require immediate escalation of therapy with emergency ablation or revascularization sometimes with circulatory support systems. If ES still persists, a further step in escalation may be taken by cardiac sympathetic denervation. Due to the poor prognosis of patients after ES, close monitoring of the patient, preferably with telemedicine, is indicated.

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Literatur

  1. Bedell SE et al (1983) Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 309:569–576

    Article  CAS  Google Scholar 

  2. Gadula-Gacek E et al (2019) Electrical storm—still an extremely poor prognosis. Do the acute state of life threatening arrhythmias require a multidirectional approach from the start. Postepy Kardiol Interwencyjnej 15:1–12

    PubMed  PubMed Central  Google Scholar 

  3. Credner SC et al (1998) Electrical storm in patients with transvenous implantable defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol 32:1909–1915

    Article  CAS  Google Scholar 

  4. Exner DV, AVID INvestigatorsAntiarrhythmic versus implantable defibrillators et al (2001) Electrical storm presages nonsudden death: the antiarrhythmic versus implantable defibrillator (AVID) trial. Circulation 103(16):2066–2071

    Article  CAS  Google Scholar 

  5. Sesselberg HW, Madit II Research Group et al (2007) Ventricular arrhythmia storms in postinfarct patients with implantable defibrillators for primary prevention indications: a MADIT-II substudy. Heart Rhythm 4(11):1395–1402

    Article  Google Scholar 

  6. Guerra JM, Italian Association of Arrhythmology and cardiac pacing (AIAC) et al (2018) Cardiac resynchronization therapy and electrical storm: results of the observational registry on long term outcome of ICD patients (Observo-ICD). Europace 20:979–985

    Article  Google Scholar 

  7. Kowey PR (1996) An overview of antiarrhythmic drug management of electrical storm. Can J Cardiol 12:3B–8B

    PubMed  Google Scholar 

  8. Priori SG et al (2015) 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 36:2793–2867

    Article  Google Scholar 

  9. Al-Khatib SM et al (2018) 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation 138:e272–e391

    PubMed  Google Scholar 

  10. Cronin EM et al (2019) 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm. https://doi.org/10.1016/j.hrthm.2019.03014

    Article  PubMed  Google Scholar 

  11. Israel CW, Barold SS (2007) Electrical storm in patients with an implanted defibrillator: a matter of definition. Ann Noninvasive Electrocardiol 12:375–382

    Article  Google Scholar 

  12. Lampert R (2010) Anger and ventricular arrhythmias. Curr Opin Cardiol 25:46–52

    Article  Google Scholar 

  13. Whang W et al (2004) Heart failure and the risk of shocks in patients with implantable cardioverter defibrillators: results from the triggers of ventricular arrhythmias (TOVA) study. Circulation 109:1386–1391

    Article  Google Scholar 

  14. Greene M et al (2000) Is electrical storm in ICD patients the sign of a dying heart? Outcome of patients with clusters of ventricular tachyarrhytmias. Europace 2:263–269

    Article  CAS  Google Scholar 

  15. Verma A et al (2004) Prevalence, predictors, and mortality significance of the causative arrhythmia in patients with electrical storm. J Cardiovasc Electrophysiol 15:1265–1267

    Article  Google Scholar 

  16. Kutyifa V et al (2013) Dyssynchrony and the risk of ventricular arrhythmias. JACC Cardiovasc Imaging 6:432–444

    Article  Google Scholar 

  17. Guerra F et al (2014) Role of electrical storm as a mortality and morbidity risk factor and its clinical predictors: a meta-analysis. Europace 16:347–353

    Article  Google Scholar 

  18. Mandel JE et al (2011) Remifentanilmidazolam sedation provides hemodynamic stability and comfort during epicardial ablation of ventricular tachycardia. J Cardiovasc Electrophysiol 22:464–466

    Article  Google Scholar 

  19. Newton GE et al (1997) Cardiac sympathetic response to acute vasodilatation. Normal ventricular function versus congestive heart failure. Circulation 94:3161–3167

    Article  Google Scholar 

  20. Billmann GE et al (1997) Beta 2‑adrenergic receptor antagonists protect against ventricular fibrillation: in vivo and in vitro evidence for enhanced sensitivity to beta2-adrenergic stimulation in animals susceptible to sudden cardiac death. Circulation 96:1914–1922

    Article  Google Scholar 

  21. Chatzidou S et al (2018) Propranolol versus metoprolol for treatment of electrical storm in patients with implantable cardioverter-defibrillator. J Am Coll Cardiol 71:1897

    Article  CAS  Google Scholar 

  22. Li L et al (2016) Successful treatment of cardiac electrical storm in dilated cardiomyopathy using esmolol: a case report. Exp Ther Med 12:107–110

    Article  CAS  Google Scholar 

  23. Kitajima R et al (2017) Landiolol suppression of electrical storm of torsades de pointes in patients with congenital long-QT syndrome type 2 and myocardial ischemia. J Arrhythm 33:501–504

    Article  Google Scholar 

  24. Miwa Y et al (2010) Effects of Landiolol, an ultra-short-acting beta1-selective blocker, on electrical storm refractory to class III antiarrhythmic drugs. Circ J 74:856–863

    Article  CAS  Google Scholar 

  25. Sousa-Uva M et al (2019) 2018 ESC/EACTS guidelines on myocardial revascularization. Eur J Cardiothorac Surg 55:4–90

    Article  Google Scholar 

  26. Huikuri HV et al (2001) Sudden death due to cardiac arrhythmias. N Engl J Med 345:1473–1482

    Article  CAS  Google Scholar 

  27. Lewalter T et al (2007) The emergency management of cardiac arrhythmia. Dtsch Arztebl 104(17):A 1172–80

    Google Scholar 

  28. Turagam MK et al (2017) Hemodynamic support in ventricular tachycardia ablation: an international VT ablation center collaborative group study. JACC Clin Electrophysiol 3:1534–1543

    Article  Google Scholar 

  29. Santangeli P et al (2015) Acute hemodynamic decompensation during catheter ablation of scar-related ventricular tachycardia. Incidence, predictors and impact on mortality. Circ Arrhythm Electrophysiol 8:68–75

    Article  Google Scholar 

  30. Vaseghi M et al (2017) Cardiac sympathetic denervation for refractory ventricular arrhythmias. J Am Coll Cardiol 69:3070–3080

    Article  Google Scholar 

  31. Wathen MS et al (2004) Prospective randomized multicenter trial of empirical antitachycardia pacing versus shocks for spontaneous rapid ventricular tachycardia in patients with implantable cardioverter-defibrillators (pacing fast ventricular tachycardia reduces shock therapies (painFREE Rx II) trial results). Circulation 110:2591–2596

    Article  Google Scholar 

  32. Poole JE et al (2008) Sudden cardiac death in heart failure trial. N Engl J Med 359:1009–1017

    Article  CAS  Google Scholar 

  33. Kloppe A et al (2014) Effect of long detection interval versus standard detection for Implantable cardioverter-defibrillator on antitachycardia pacing and shock delivery. The advance III randomized clinical trial. Circulation 130:308–314

    Article  CAS  Google Scholar 

  34. Vollmann D et al (2002) Inhibition of bradycardia pacing and detection of ventricular fibrillation due to far-field atrial sensing in a triple chamber implantable cardioverter defibrillator. Pacing Clin Electrophysiol 25:1513–1516

    Article  Google Scholar 

  35. Schulte B et al (2001) Inappropriate arrhythmia detection in implantable defibrillator therapy due to oversensing of diaphragmatic myopotentials. J Interv Card Electrophysiol 5:487–493

    Article  Google Scholar 

  36. Sears SF et al (2000) Assessing the psychosocial impact of the ICD: a national survey of implantable cardioverter defibrillator health care providers. Pacing Clin Electrophysiol 23(6):939–945

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Klinikum Lüdenscheid, Klinik für Kardiologie, Elektrophysiologie und Angiologie, Märkische Kliniken GmbH, Paulmannshöherstraße 10–14, 58515, Lüdenscheid, Deutschland

    Markus Zarse, Fuad Hasan, Atisha Khan, Zana Karosiene, Bernd Lemke & Harilaos Bogossian

  2. Universität Witten Herdecke, Alfred-Herrhausen-Straße 50, 58455, Witten, Deutschland

    Markus Zarse & Harilaos Bogossian

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  1. Markus Zarse
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  2. Fuad Hasan
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  3. Atisha Khan
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  4. Zana Karosiene
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  5. Bernd Lemke
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  6. Harilaos Bogossian
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Correspondence to Markus Zarse.

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Interessenkonflikt

M. Zarse, F. Hasan, A. Khan, Z. Karosiene, B. Lemke und H. Bogossian geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Zarse, M., Hasan, F., Khan, A. et al. Elektrischer Sturm. Herzschr Elektrophys 31, 55–63 (2020). https://doi.org/10.1007/s00399-020-00672-0

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