Management and outcomes of patients with refractory arrhythmogenic storm: experience of a tertiary hospital and code shock referral center

Abstract Introduction Arrhythmogenic storm (AT) is a life-threatening emergency caused by the relentless onset of ventricular arrhythmias (3 or more in less than 24 hours) that cause hemodynamic instability in the patient. It is accompanied by high mortality in the acute phase, but also a poor prognosis in long-term survivors. Methods A retrospective and descriptive study of our series. Our hospital, as a heart transplant referral center, receives patients with AT refractory to conventional treatment to assess therapeutic options. Our objective is to describe the outcomes of the last 3 years in this specific group of patients. Results In our center, all patients diagnosed with AT (46 cases) were admitted to the Coronary Care Unit. Of these, 17 patients met the criteria for high risk or had AT refractory to initial conventional treatment (sedation and IV antiarrhythmics). Seventy-six percent (13) were men, and the mean age was 61.5 years. The predominant etiologies were ischemic cardiomyopathy (53%) followed by dilated cardiomyopathy (29.4%). The mean LVEF was 27% (range 10-50%) and the predominant type of arrhythmia was monomorphic VT in 76.4%. All our patients were receiving orotracheal intubation, deep sedation, analgesia, and IV antiarrhythmics (Esmolol 88%, procainamide 70%). Mechanical circulatory support was necessary in 76% of cases. With these initial measures, 3 of the 17 patients described (17.6%) responded effectively. Of the remaining 14, heart transplant candidates were assessed. Seven patients were not candidates for transplant, of whom ablation was attempted in three cases, which was successful in one. Furthermore, in the seven patients who were candidates for transplant, ablation was successful in two, and transplantation was not necessary. The remaining five cases required heart transplant support. The mortality rate in the acute phase of refractory AT in our series was 35% (6 cases); however, the mean follow-up survival rate of 1 year was 47%. Conclusions: AT is associated with a poor prognosis in the literature. Although in our series, mortality in refractory AT in the acute phase is somewhat lower than that reported in the literature, the long-term prognosis is just as poor as described. Therefore, early assessment of possible heart transplantation in these patients is essential.