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An Electrical Storm 9 th May 2014 U Buckley, D Eaton, J Galvin, T Keelan Mater Misericordiae Hospital, Dublin. 55 year old female Atrial septal defect & mitral valve repair in 1990’s Out of hospital cardiac arrest 2011 on clarithromycin AED torsade de pointe LV dysfunction – 40% - PowerPoint PPT Presentation
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An Electrical Storm9th May 2014
U Buckley, D Eaton, J Galvin, T KeelanMater Misericordiae Hospital, Dublin
• 55 year old female
• Atrial septal defect & mitral valve repair in 1990’s
• Out of hospital cardiac arrest 2011 on clarithromycin• AED torsade de pointe
• LV dysfunction – 40%
• Long QT on ECG at 490ms
• Fhx sudden cardiac death – 2 first degree relatives
• ICD – single chamber device implanted
• Left sided invasive ductal carcinoma requiring radiotherapy • Post operatively cardiac arrest requiring 6 shocks to defibrillate (ICD off for surgery)• Device repositioned & tunnelled lead to right
• Inappropriate therapy from the device Nov 2013• Reprogrammed• Increased meds• Rising threshold and drop in R wave
• Beta-blockade
• Appropriate therapy from the device Jan 2014
•Further 5 shocks from device
• First looked inappropriate• 4 others were appropriate
•Check Coronary Angiogram
•Medications optimized• Switched to propranolol• Mexilitene after loading with intravenous lignocaine
•Further fine ventricular fibrillation undetected by the device
•Atrial lead inserted & new RV lead
•Further Appropriate therapies
Video Assisted Transaxillary Transthoracic Left Cervical
Sympathectomy
• LCSD • lengthening repolarization• Prolong refractory periods• Increase VF threshold
• Defibrillation threshold testing was performed
• Genetic testing sent
• No Horner's Syndrome
• 8 weeks on and no further ventricular arrhythmias
• Natural history of electrical storm or success?
Management of Ventricular Arrhythmic Storms
1. Beta blockers2. Antiarrhythmics3. Reprogramme Device4. Manage reversible proarrhythmic causes5. Ablation6. Deep sedation/skeletal muscle relaxants7. Stellate ganglion blocking8. Cervical Sympathectomy
Neuromodulation
Presynaptic
Postsynaptic
Central inhibition
Sympathetic Activation
Previous Surgical Options
• Supraclavicular
• Open thoracotomy
• Posterior approach
• Chemical ablation
• Resection
How much of the chain is enough?
• T1-4
• C8
• Can the nerves grow back?
• Lessons from orthotopic heart transplantation
• Left versus bilateral sympathectomy
Surgical Failure
• Multiple shocks prior to surgery
• Decompensated end stage intractable heart failure
• Lack of sympathetic triggers
• Circulating catecholamines
• Failure to dissect the nerve of Kuntz