1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; 2GZO Spital Wetzikon Klinik für Kardiologie und Angiologie Wetzikon, Schweiz; 3Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; 4Herz- und Diabeteszentrum NRW Klinik für Kardiologie Bad Oeynhausen, Deutschland
Background:
Electrical storm (ES) is a life-threatening situation associated with high mortality, worsening of heart failure and multiple therapy deliveries of implanted cardioverter defibrillators (ICD). Chronic myocardial ischemia may be an important trigger of ES and restitution of coronary perfusion may be crucial. Nevertheless, the role of invasive coronary angiography in the setting of ES remains unclear.
Objective:
The purpose of this single-center study was to analyze incidence and outcome of invasive ischemia testing in patients presenting with ES.
Methods:
All patients who were admitted for treatment of at least one ES in absence of acute coronary syndrome to our VT unit from 2016 to 2021 were retrospectively analyzed. Individual patient characteristics and data on ES management and outcome were collected. The decision to perform invasive ischemia testing in ES patients was at discretion of treating physicians. Follow-up after ES treatment investigated freedom from a combined clinical endpoint consisting of left ventricular assist device implantation, heart transplantation and death as well as ventricular arrhythmia recurrence.
Results:
A total of 155 patients with ES were analyzed. In 150 patients (96.8%) a history of structural heart disease was present: Coronary artery disease (CAD) or ischemic cardiomyopathy (ICM) in 81 patients (54%), dilative cardiomyopathy in 59 patients (39.3%), arrhythmogenic right ventricular cardiomyopathy in 6 patients (4%) and hypertrophic cardiomyopathy in 4 patients (2.7%). In 5 patients (3.2%) no history of structural heart disease was present. Invasive coronary angiography was performed in 65 patients (41.9%) during hospitalization for ES, with 44 patients (67.7%) having a history of CAD (Figure 1 A). A high-degree coronary lesion was found in 9 patients (13.8%, Figure 1 B). All patients in whom high-degree coronary lesions were observed had a history of CAD. Percutaneous coronary intervention (PCI) was performed in 9 cases (4 PCIs of right coronary artery, 3 PCIs of the left anterior descending artery, 1 PCI of the right circumflex artery and 1 PCI of a venous bypass graft to a marginal branch). Freedom from a combined endpoint consisting of left ventricular assist device implantation, heart transplantation and death was similar among patients with and without coronary angiography at admission for ES (log rank P=0.94) (Figure 2). Freedom from ventricular arrhythmia in patients who underwent catheter ablation for ES was not different between patients with and without coronary angiography (log rank P=0.11).
Conclusion:
Invasive coronary angiography performed in patients presenting with ES found high-degree coronary lesions in a relevant number of cases with known ICM/CAD. However, there was no difference of freedom from clinical endpoints in patients with or without coronary angiography during ES. Coronary angiography during the acute treatment may be delayed or omitted in selected patients without previously known CAD, but further studies are needed to improve patient selection for that matter.
Figure 1
Figure 2
LVAD = left ventricular assist device, HTX = heart transplantation