Scientific Letter
Ventricular electrical storm after acute myocardial infarction successfully treated with temporary atrial overdrive pacing
Tormenta eléctrica ventricular tras infarto agudo de miocardio tratado con éxito mediante sobreestimulación auricular temporal
S. Aguiar Rosa
, M. Oliveira, B. Valente, P. Silva Cunha, L. Almeida Morais, R. Cruz Ferreira
Corresponding author
Cardiology Department, Santa Marta Hospital, Lisbon, Portugal
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Aguiar Rosa, M. Oliveira, B. Valente, P. Silva Cunha, L. Almeida Morais, R. Cruz Ferreira" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Aguiar Rosa" "email" => array:1 [ 0 => "silviaguiarosa@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Oliveira" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "Valente" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Silva Cunha" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Almeida Morais" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Cruz Ferreira" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Santa Marta Hospital, Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tormenta eléctrica ventricular tras infarto agudo de miocardio tratado con éxito mediante sobreestimulación auricular temporal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3473 "Ancho" => 3315 "Tamanyo" => 1060231 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) R on T phenome; (B) R on T phenome, followed by ventricular ectopies; (C) ventricular tachycardia; (D) ventricular tachycardia degenerating into ventricular fibrillation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 53-year-old-caucasian man, ex-smoker, with past medical history of dyslipidaemia had an out-of-hospital successful cardiopulmonary resuscitation after cardiac arrest in ventricular fibrillation (VF) due to an anterior ST-elevation myocardial infarction (STEMI). A primary percutaneous coronary intervention (PCI) was performed with revascularization of the left anterior descending artery (LAD) using a drug eluting stent. The pre-discharge echocardiogram showed a left ventricular ejection fraction (LEVF) of 40%. The patient was discharged at 6th day.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Five days later the patient was resuscitated after another cardiac arrest with documented VF. A repeated coronary angiography revealed acute LAD stent thrombosis. A “stent in stent” PCI of LAD was successfully performed. In the following hours the patient evolved into cardiogenic shock with a LVEF of 20%. Aminergic and inotropic support was started with norepinephrine, dopamine and dobutamine, as well as intra-aortic balloon pump and invasive mechanical ventilation. On the second day of hospitalization the patient presented several episodes of polymorphic ventricular tachycardia (VT), triggered by premature ventricular complexes (VPC), that rapidly degenerated into VF (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). PR, QRS and QT intervals were normal. Intravenous amiodarone, esmolol, lidocaine, magnesium and midazolam were administered. Despite maintaining of combined antiarrhythmic drugs (AAD) ventricular tachyarrythmias persisted, exhibiting the same pattern for VT/VF initiation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In order to suppress premature ectopic beats, it was decided to perform atrial overdrive pacing. This was accomplished by using a temporary pacemaker, programmed at 85<span class="elsevierStyleHsp" style=""></span>bpm (heart rate before pacing was 60 beats per minute), with an active fixation catheter (Biotronik TC-116-Screw) placed in the right atrial appendage, by femoral approach (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After starting atrial pacing there was a complete suppression of VPC and no more VT episodes were observed. AAD were progressively weaned off while maintaining atrial pacing at the same rate and, although lidocaine was discontinued and amiodarone switched to an oral regimen, neither VPC nor VT/VF recurred. The electrocatheter was removed on the 8th day after implantation (four days after suspension of lidocaine and switching of amiodarone to oral regimen). Before discharge, the patient underwent a dual-chamber ICD implantation with the pacing rate programmed at 80<span class="elsevierStyleHsp" style=""></span>bpm, and two zones of tachycardia detection and corresponding therapies (VT zone: at 170<span class="elsevierStyleHsp" style=""></span>bpm; VF zone: at 210<span class="elsevierStyleHsp" style=""></span>bpm).</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The incidence of sustained ventricular arrhythmias (VA) in acute coronary syndromes (ACS) is 5–10%.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> In the context of ischaemia, VPC, VT and VF can be secondary to an automatic or reentrant mechanism.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> Myocardial ischaemia leads to changes in the ionic imbalance of cardiomyocytes, resulting in shorter duration of the action potential and less negative resting membrane potential.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> In this condition early and delayed triggers after depolarization may occur, inducing VPC and arrhythmogenic currents, especially from the ischaemic/reperfused to the non-ischaemic areas.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patient the VPC provoked “R-on-T” phenomenon, resulting in recurrent episodes of VT and VF (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Amiodarone blocks the depolarizing sodium currents and potassium channels responsible for conduction of repolarizing currents inhibiting ventricular arrhythmias (VA) by influencing automaticity and re-entry,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> and esmolol blocks sympathetic mediated triggering mechanisms underlying VA.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,5</span></a> Despite the combined AAD therapy, the patient maintained recurrent episodes of VT/VF and perfusion of lidocaine was started without obtaining electrical stability.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,3,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Temporary overdrive pacing has been pointed as an option for drug resistant ventricular arrythmias.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a> In recent European Society of Cardiology's Guidelines for the management of ventricular arrhythmias, transvenous catheter overdrive stimulation received a class IIa of recommendations, level of evidence <span class="elsevierStyleSmallCaps">C</span>, in cases of recurrent VA despite the use of anti-arrhythmic drugs.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Lower heart rate results in increased ventricular repolarization heterogeneity and increases the possibility of an ectopic ventricular complex reaching reentrant tissue after refractory period. The heart rate increases with temporary pacing, shortens the interval between beats and decreases the likelihood of appearance of premature ventricular complexes and increases the likelihood of these reaching pro-arrhythmic tissue in refractory period.</p><p id="par0050" class="elsevierStylePara elsevierViewall">As right ventricular pacing can be deleterious for ventricular systolic function, and this patient presented a severe impairment in LVEF without evidence of atrio-ventricular conduction disturbances, electrical stimulation was performed in an uncommon way, using an active fixation temporary pacing catheter placed in the right atrium. The aim was to obtain intrinsic atrioventricular conduction with a narrow QRS and avoid the deleterious effect of ventricular pacing in a patient with cardiogenic shock.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Temporary pacing with an active fixation catheter is designed to allow ventricular septal pacing, but alternative pacing points can also be obtained with this type of catheter. Attention should be given while placing this lead in locations other than ventricular septum. Positioning in the atrial septum could be safer and avoid potential complications in patients where any perforation can be a severe complication. The femoral approach may facilitate positioning of the lead in an atrial positioning but, due to longer intravenous trajectory and the exposed fixation helix, the right jugular approach may be preferred.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The use of non-active fixation temporary pacing leads for atrial pacing might be also considered but the risk of dislodgement is high.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, temporary atrial overdrive pacing is an effective and safe treatment for resistant electrical storm in patients with severe impairment of left ventricular systolic function.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no disclosures.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3473 "Ancho" => 3315 "Tamanyo" => 1060231 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) R on T phenome; (B) R on T phenome, followed by ventricular ectopies; (C) ventricular tachycardia; (D) ventricular tachycardia degenerating into ventricular fibrillation.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1315 "Ancho" => 3000 "Tamanyo" => 208439 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Chest radiography showing active fixation catheter, placed in the right atrial appendage by femoral approach (arrow). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 6 | 11 |
| 2024 October | 76 | 43 | 119 |
| 2024 September | 82 | 38 | 120 |
| 2024 August | 68 | 35 | 103 |
| 2024 July | 55 | 41 | 96 |
| 2024 June | 56 | 47 | 103 |
| 2024 May | 57 | 35 | 92 |
| 2024 April | 55 | 35 | 90 |
| 2024 March | 61 | 22 | 83 |
| 2024 February | 35 | 37 | 72 |
| 2024 January | 61 | 40 | 101 |
| 2023 December | 46 | 43 | 89 |
| 2023 November | 63 | 39 | 102 |
| 2023 October | 97 | 41 | 138 |
| 2023 September | 60 | 41 | 101 |
| 2023 August | 56 | 14 | 70 |
| 2023 July | 83 | 25 | 108 |
| 2023 June | 63 | 15 | 78 |
| 2023 May | 75 | 29 | 104 |
| 2023 April | 60 | 22 | 82 |
| 2023 March | 84 | 40 | 124 |
| 2023 February | 81 | 33 | 114 |
| 2023 January | 81 | 28 | 109 |
| 2022 December | 75 | 29 | 104 |
| 2022 November | 82 | 40 | 122 |
| 2022 October | 77 | 51 | 128 |
| 2022 September | 50 | 38 | 88 |
| 2022 August | 59 | 40 | 99 |
| 2022 July | 56 | 50 | 106 |
| 2022 June | 42 | 40 | 82 |
| 2022 May | 60 | 41 | 101 |
| 2022 April | 62 | 51 | 113 |
| 2022 March | 95 | 67 | 162 |
| 2022 February | 63 | 34 | 97 |
| 2022 January | 91 | 48 | 139 |
| 2021 December | 67 | 57 | 124 |
| 2021 November | 68 | 59 | 127 |
| 2021 October | 111 | 83 | 194 |
| 2021 September | 60 | 38 | 98 |
| 2021 August | 100 | 48 | 148 |
| 2021 July | 70 | 54 | 124 |
| 2021 June | 62 | 25 | 87 |
| 2021 May | 96 | 55 | 151 |
| 2021 April | 160 | 80 | 240 |
| 2021 March | 124 | 35 | 159 |
| 2021 February | 101 | 28 | 129 |
| 2021 January | 106 | 14 | 120 |
| 2020 December | 75 | 17 | 92 |
| 2020 November | 83 | 26 | 109 |
| 2020 October | 78 | 38 | 116 |
| 2020 September | 60 | 34 | 94 |
| 2020 August | 42 | 23 | 65 |
| 2020 July | 80 | 27 | 107 |
| 2020 June | 73 | 21 | 94 |
| 2020 May | 80 | 18 | 98 |
| 2020 April | 84 | 31 | 115 |
| 2020 March | 24 | 13 | 37 |
| 2020 February | 77 | 49 | 126 |
| 2020 January | 48 | 36 | 84 |
| 2019 December | 45 | 36 | 81 |
| 2019 November | 41 | 31 | 72 |
| 2019 October | 51 | 38 | 89 |
| 2019 September | 39 | 45 | 84 |
| 2019 August | 45 | 25 | 70 |
| 2019 July | 50 | 29 | 79 |
| 2019 June | 41 | 27 | 68 |
| 2019 May | 73 | 64 | 137 |
| 2019 April | 37 | 25 | 62 |
| 2019 March | 20 | 28 | 48 |
| 2019 February | 29 | 29 | 58 |
| 2019 January | 31 | 30 | 61 |
| 2018 December | 61 | 50 | 111 |
| 2018 November | 82 | 52 | 134 |
| 2018 October | 36 | 24 | 60 |
| 2018 September | 29 | 9 | 38 |
| 2018 August | 28 | 7 | 35 |
| 2018 July | 23 | 9 | 32 |
| 2018 June | 35 | 13 | 48 |
| 2018 May | 14 | 3 | 17 |
| 2018 April | 27 | 10 | 37 |
| 2018 March | 36 | 4 | 40 |
| 2018 February | 20 | 4 | 24 |
| 2018 January | 43 | 14 | 57 |
| 2017 December | 23 | 7 | 30 |
| 2017 November | 33 | 13 | 46 |
| 2017 October | 25 | 15 | 40 |
| 2017 September | 28 | 5 | 33 |
| 2017 August | 2 | 0 | 2 |
| 2017 May | 2 | 1 | 3 |
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