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Refractory electrical storm suppression by bretylium
International Journal of Cardiology 113 (2006) e111 – e112 www.elsevier.com/locate/ijcard
Letter to the editor
Refractory electrical storm suppression by bretylium John R. Kapoor a,⁎, William P. Batsford b , JoAnne M. Foody b a
Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06511, USA b Section of Cardiology, Yale University School of Medicine, New Haven, CT 06511, USA Received 7 February 2006; accepted 2 June 2006 Available online 10 August 2006
Keywords: Electrical storm; Bretylium
Electrical Storm (ES) is a syndrome of recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) occurring three or more times in a 24 h period [1]. Treatment of such patients remains one of the most difficult challenges in medicine. Although adequate management is not well established, it usually relies on the use of anti-arrhythmics, electrical cardioversion, defibrillation and ablation techniques [1,2,3]. Despite aggressive therapy, mortality remains alarmingly high at N 80–90% [4]. We report an idiopathic case of refractory electrical storm in a young patient eventually suppressed by bretylium. 1. Case report A 40-year-old man with a history significant only for obesity was admitted to the hospital in cardiac arrest after multiple episodes of recurrent and refractory polymorphic ventricular fibrillation (Fig. 1). Prior to arrival he received over 100 defibrillations as well as epinephrine, amiodarone and lidocaine boluses. On arrival, he was on amiodarone, lidocaine and magnesium drips. Prior to admission he was on no medications and did not use illicit drugs. His family history was remarkable for a maternal grandfather and great grandmother who died suddenly of cardiac causes at young ages. Physical examination, routine labs, cardiac biomarkers, serum/urine toxicology,
⁎ Corresponding author. Yale University School of Medicine, 333 Cedar Street, Room: 1072 LMP, New Haven, CT 06520-8030, PO BOX 208030, USA. Tel.: +1 203 785 4119; fax: +1 203 785 6954. E-mail address: [email protected] (J.R. Kapoor). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.06.025
stool/viral studies and cultures were unremarkable. Genetic testing for common “channelopathies” was unrevealing. A cardiac catheterization performed during the recurrent episodes did not identify significant plaque burden or a culprit lesion. He had a dominant right coronary artery, normal filling pressures, and an ejection fraction estimated at 40%. Overdrive pacing was unsuccessful and he did not meet body surface area requirements for placement of a biventricular assist device. The ES was resistant to agents commonly used for suppressionamiodarone, lidocaine, magnesium, procainamide, diltiazem and propofol. Isopreterenol was used to maintain hemodynamic stability. After approximately 3 h and delivering over 300 debrillation shocks, a bolus of bretylium was administered, followed by an infusion. The incessant VT/VF almost immediately subsided and he had no recurrent episodes. A dual chamber defibrillator/DDD pacer was placed and all antiarrhythmic agents were discontinued. He was weaned off of bretylium and started on oral metoprolol and loaded on amiodarone. He was extubated on hospital day #4. Over a year later, he has had no recurrent episodes of ES and is maintained on oral amiodarone and metoprolol. To our knowledge, this is the first report of bretylium suppression of ES refractory to the most commonly used antiarrhythmic agents today. In the majority of cases, ES can be attributed to myocardial infarction, electrolyte/metabolic disturbances, or drug overdoses. Although optimal antiarrhythmic management has not been clearly defined, the current literature supports the use of amiodarone and/or a beta-blocker for ES [2,3]. Bretylium is a quaternary ammonium compound which has an unknown mechanism of antiarrhythmic action. The efficacy of bretylium was comparable to that of amiodarone in one study [5], but no
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J.R. Kapoor et al. / International Journal of Cardiology 113 (2006) e111–e112
Fig. 1. Portion of the ECG rhythm strip showing one of the many recurrent episodes of polymorphic ventricular tachycardia experienced by this patient.
other large-scale randomized controlled studies of ES have demonstrated efficacy for bretylium and it is currently not recommended (removed from the guidelines in 2000). Its side effects, especially hypotension, place additional limitations on its use [5]. Finally, there is very limited supply b/c of a shortage of raw material. This case, however, supports the notion that bretylium may be used when all else fails to abort refractory storm. References [1] Credner SC, Klingenheben T, Mauss O, et al. Electrical storm in patients with transvenous implantable cardioverter–defibrillators: incidence,
[2]
[3]
[4] [5]
management and prognostic implications. J Am Coll Cardiol 1999;34:950–1. Scheinman MM, Levine JH, Cannom DS, et al. Dose-ranging study of intravenous amiodarone in patients with life-threatening ventricular tachyarrhythmias. Circulation 1995;92:3264–72. Tavernier R, Derycke E, Jordaens L. An arrhythmia storm dependency on adrenergic drive late after implantation of an internal cardioverter defibrillator. Eur J Card Pacing Electrophysiol 1997;1:33–6. Urberg M, Ways C. Survival after cardiopulmonary resuscitation for an in-hospital cardiac arrest. J Fam Pract 1987;25:41–4. Kowey PR, Levine JH, Herre JM, et al. Randomized, double-blind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent, hemodynamically destabilizing ventricular tachycardia or fibrillation. Circulation 1995;92:3255–63.
Letter to the editor
Refractory electrical storm suppression by bretylium John R. Kapoor a,⁎, William P. Batsford b , JoAnne M. Foody b a
Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06511, USA b Section of Cardiology, Yale University School of Medicine, New Haven, CT 06511, USA Received 7 February 2006; accepted 2 June 2006 Available online 10 August 2006
Keywords: Electrical storm; Bretylium
Electrical Storm (ES) is a syndrome of recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) occurring three or more times in a 24 h period [1]. Treatment of such patients remains one of the most difficult challenges in medicine. Although adequate management is not well established, it usually relies on the use of anti-arrhythmics, electrical cardioversion, defibrillation and ablation techniques [1,2,3]. Despite aggressive therapy, mortality remains alarmingly high at N 80–90% [4]. We report an idiopathic case of refractory electrical storm in a young patient eventually suppressed by bretylium. 1. Case report A 40-year-old man with a history significant only for obesity was admitted to the hospital in cardiac arrest after multiple episodes of recurrent and refractory polymorphic ventricular fibrillation (Fig. 1). Prior to arrival he received over 100 defibrillations as well as epinephrine, amiodarone and lidocaine boluses. On arrival, he was on amiodarone, lidocaine and magnesium drips. Prior to admission he was on no medications and did not use illicit drugs. His family history was remarkable for a maternal grandfather and great grandmother who died suddenly of cardiac causes at young ages. Physical examination, routine labs, cardiac biomarkers, serum/urine toxicology,
⁎ Corresponding author. Yale University School of Medicine, 333 Cedar Street, Room: 1072 LMP, New Haven, CT 06520-8030, PO BOX 208030, USA. Tel.: +1 203 785 4119; fax: +1 203 785 6954. E-mail address: [email protected] (J.R. Kapoor). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.06.025
stool/viral studies and cultures were unremarkable. Genetic testing for common “channelopathies” was unrevealing. A cardiac catheterization performed during the recurrent episodes did not identify significant plaque burden or a culprit lesion. He had a dominant right coronary artery, normal filling pressures, and an ejection fraction estimated at 40%. Overdrive pacing was unsuccessful and he did not meet body surface area requirements for placement of a biventricular assist device. The ES was resistant to agents commonly used for suppressionamiodarone, lidocaine, magnesium, procainamide, diltiazem and propofol. Isopreterenol was used to maintain hemodynamic stability. After approximately 3 h and delivering over 300 debrillation shocks, a bolus of bretylium was administered, followed by an infusion. The incessant VT/VF almost immediately subsided and he had no recurrent episodes. A dual chamber defibrillator/DDD pacer was placed and all antiarrhythmic agents were discontinued. He was weaned off of bretylium and started on oral metoprolol and loaded on amiodarone. He was extubated on hospital day #4. Over a year later, he has had no recurrent episodes of ES and is maintained on oral amiodarone and metoprolol. To our knowledge, this is the first report of bretylium suppression of ES refractory to the most commonly used antiarrhythmic agents today. In the majority of cases, ES can be attributed to myocardial infarction, electrolyte/metabolic disturbances, or drug overdoses. Although optimal antiarrhythmic management has not been clearly defined, the current literature supports the use of amiodarone and/or a beta-blocker for ES [2,3]. Bretylium is a quaternary ammonium compound which has an unknown mechanism of antiarrhythmic action. The efficacy of bretylium was comparable to that of amiodarone in one study [5], but no
e112
J.R. Kapoor et al. / International Journal of Cardiology 113 (2006) e111–e112
Fig. 1. Portion of the ECG rhythm strip showing one of the many recurrent episodes of polymorphic ventricular tachycardia experienced by this patient.
other large-scale randomized controlled studies of ES have demonstrated efficacy for bretylium and it is currently not recommended (removed from the guidelines in 2000). Its side effects, especially hypotension, place additional limitations on its use [5]. Finally, there is very limited supply b/c of a shortage of raw material. This case, however, supports the notion that bretylium may be used when all else fails to abort refractory storm. References [1] Credner SC, Klingenheben T, Mauss O, et al. Electrical storm in patients with transvenous implantable cardioverter–defibrillators: incidence,
[2]
[3]
[4] [5]
management and prognostic implications. J Am Coll Cardiol 1999;34:950–1. Scheinman MM, Levine JH, Cannom DS, et al. Dose-ranging study of intravenous amiodarone in patients with life-threatening ventricular tachyarrhythmias. Circulation 1995;92:3264–72. Tavernier R, Derycke E, Jordaens L. An arrhythmia storm dependency on adrenergic drive late after implantation of an internal cardioverter defibrillator. Eur J Card Pacing Electrophysiol 1997;1:33–6. Urberg M, Ways C. Survival after cardiopulmonary resuscitation for an in-hospital cardiac arrest. J Fam Pract 1987;25:41–4. Kowey PR, Levine JH, Herre JM, et al. Randomized, double-blind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent, hemodynamically destabilizing ventricular tachycardia or fibrillation. Circulation 1995;92:3255–63.