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