When the Storm Strikes Hard: Incessant VT/VF Complicated by Cardiogenic Shock
A 30-year-old female patient with past medical history of alcohol abuse presented to a community hospital after she had collapsed at home. Initial rhythm upon emergency medical service arrival was noted to be ventricular fibrillation (VF) (Figure 1). Cardiopulmonary resuscitation was initiated, and the patient was shocked twice with success, intubated, and transported to the hospital. Upon arrival to the hospital, the patient again developed VF, which was cardioverted successfully, and was started on amiodarone drip. In the interim, the patient also developed hypotension requiring norepinephrine drip vasopressors. The initial laboratory work revealed cardiac troponin I level of 2.7 ng/ml and no electrolyte abnormalities. Baseline electrocardiogram (ECG) showed sinus tachycardia, premature ventricular contractions, and a QTc interval of 420 ms (Figure 2). Also noted in the ECG was the terminal slurring of the QRS in the inferolateral leads, suggestive of a J-wave/early repolarization pattern. The patient continued to have multiple runs of ventricular tachycardia (VT) and VF, requiring electrical shocks and further addition of lidocaine drip (Figure 3). Due to ongoing hemodynamic decompensation, the patient was transferred to the tertiary care center for further management. Of note, the patient's family reported that the patient had had multiple emergency department visits in the past month for difficulty breathing, skipped heart beats, and decreased exercise tolerance prior to this episode. The family also reported that the patient had contact with a sick child a few days' prior, upper respiratory symptoms 6-7 weeks before this presentation, and a recent episode of self-resolved diarrhea. On arrival to the tertiary center, an emergent bedside echocardiogram was performed, which showed ejection fraction (EF) of 6-10% with global cardiomyopathy (Video 1). The patient was taken for emergent coronary angiogram for suspected acute coronary syndrome, which showed normal coronaries (Figure 4) and severely depressed EF (Video 2). While in the cardiac catheterization laboratory, the patient again had multiple runs of VT/VF, requiring 15 shocks.
Figure 4: Coronary Angiogram
What is the best next step in the management of incessant electrical storm in this patient?