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Management of VT/VF Storm in
Advanced Heart Failure: What to Think About,
What Works?
What Doesn’t Work?
Owen Obel, MD
VA North Texas Healthcare System, UT
Southwestern Medical Center
Dallas, Texas
Disclosures
Speaker: Medtronic, Biotronik, Boston Scientific
Advisory: Medtronic, Biotronik
Definition of VT/VF Storm • Diverse arrhythmic
mechanisms, broad
definition
• Frequent episodes of
VT/VF requiring
cardioversion
• Management guidelines
rely on anecdotal evidence
• Most trials define >2
episodes/24h. Episodes
usually more frequent
6 minute recording
SUBSTRATE Scar
Myopathy
Hypertrophy
Valve/congenital
Ischemia
Channelopathy
Monomorphic VT
Polymorphic VT
Ventricular Fibrillation
VT/VF Storm Mechanisms
TRIGGER Unknown / 1st shock
Sympathetic hyperactivation
HF decompensation
Ischemia/infarction
Electrolyte (K+ and Mg++)
Ectopy
Special situations
VS
ACLS
Guidelines
Group 2 Group 1
OR
VT/VF Storm in Advanced Heart Failure Beta-Blockade
12 patients received all 3
Lidocaine (22)
Procainamide (16)
Bretylium (18)
1 week mortality: 22% group 1 vs. 82% group 2
1 year mortality: 33% group 1 vs. 95% group 2 Nadamanee Circulation 2000
IV beta-
blockers
(21)
Left stellate
ganglion
block (6)
• 342 patients with recurrent
VT/VF (BP<80, shock)
• Refractory to/intolerant of:
lidocaine/procainamide/bretylium
• IV Amiodarone:
125mg/24 hr
500mg/24 hr
1000mg/24 hr
• Supplemental infusions for
breakthrough VT
IV Amio Multicenter Trial Group Circulation 1995
VT/VF Storm in Advanced Heart Failure Amiodarone
P=0.067
Amiodarone and beta-blockade
are synergistic
Beta-blockers should always be
co-administered at maximum
tolerated doses
Beta-blockade
Amiodarone
Dofetilide
Lidocaine/Mexilitene
✔ Procainamide
Sotalol
Dronedarone
Flecainide
Propafenone
Verapamil/Diltiazem
✗
VT/VF Storm in Advanced
Heart Failure
• IV Sedation is used very early in treatment path
• General anesthesia is a highly effective measure
• Propofol reduces sympathetic tone by inhibiting
central sympathetic discharge
• Patients may require >48 hours of full anesthesia
Sedation / General Anesthesia
VT/VF Storm in Advanced Heart Failure When AADs Fail
LV Assist Devices
Cardiac Sympathetic Denervation
VT/VF Storm in Advanced Heart Failure LV Assist Devices
IV inotropes for hemodynamic support
are proarrhythmic
LVADs should be used instead
LVADs have a powerful independent
anti-arrhythmic effect (even in DCM)
VT/VF Storm in Advanced Heart Failure Cardiac Sympathetic Denervation
Thoracic epidural
anesthesia
Stellate ganglion block/
ganglionectomy
• Both TEA and CSD have been used with success in
VT/VF storm
• Patients with advanced heart failure have been included
in case series
• TEA has more of an immediate effect
• Neither procedure is reported to cause hemodynamic
compromise Vashegi HRJ 2014
VT/VF Storm in Advanced Heart Failure CRT-induced Proarrhythmia
Conclusions • VT/VF storm is not uncommon in patients with advanced
heart failure, precipitant often not known
• Beta-blockade and amiodarone are the cornerstone AADs
• Sedation (often) or general anesthesia (sometimes)
required
• IV inotropes exacerbate ventricular arrhythmias
• LV assist devices can be of great benefit
• Cardiac sympathetic denervation has been successfully
used