The Perfect Storm: Ventricular Tachycardia in a Scarred Heart

Introduction: Ventricular tachycardia (VT) storm is a life-threatening cardiac emergency characterized by multiple episodes of sustained VT within 24 hours. Prompt recognition and urgent interventions are critical. We present a case of an 85-year-old male with VT storm, underscoring the challenges of management in the context of advanced age and multiple comorbidities.


Description: An 85-year-old male with a past medical history of coronary artery disease, heart failure with reduced ejection fraction, and atrial fibrillation presented to the hospital after a syncopal episode and firing of his defibrillator. Cardiac monitoring demonstrated ventricular tachycardia (VT), and amiodarone and lidocaine infusions were initiated. Shortly after, he became hemodynamically unstable, required three rounds of synchronized cardioversion, and underwent rapid sequence intubation with sedation. Interrogation of his implanted defibrillator revealed 74 episodes of VT in the 24 hours prior to admission. Electrophysiology was consulted, and the patient underwent an emergent ventricular ablation. His device was reconfigured to have a lower heart rate zone of anti-tachycardia pacing. A left heart catheterization was performed, demonstrating a chronic occlusion of the first marginal branch, and medical management was recommended. The patient transitioned to oral mexiletine and amiodarone. He was discharged home with consideration for repeat VT ablation in the future.


Discussion: Ventricular tachycardia (VT) storm, a severe form of arrhythmic instability often seen in patients with implantable cardioverter-defibrillators (ICDs), is typically triggered by factors like myocardial infarction, heart failure, electrolyte imbalances, or infections. It involves heightened sympathetic activity and reduced vagal tone, often worsened by repeated ICD shocks, creating a vicious cycle of arrhythmia. Management focuses on breaking this cycle through sedation, correcting reversible factors, optimizing ICD settings, and using antiarrhythmic drugs. In refractory cases, catheter ablation or stellate ganglion blocks may be necessary. This case underscores the complexity of managing VT storm in elderly patients with structural heart disease, highlighting the need for individualized, multidisciplinary care.