(233) Into the Storm: ECMO to Stop VT Storm

Introduction: Extracorporeal life support (ECLS) is an effective bridging therapy in patients with refractory ventricular tachycardia (VT). Managing refractory VT can be challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. VA ECMO can provide vital organ perfusion and facilitate effective bridging to therapeutic interventions.

Description: 49 y/o male recently diagnosed with Ischemic Cardiomyopathy post-acute coronary syndrome complicated by left ventricular thrombus. He was discharged with a life-vest and started on apixaban. He was subsequently admitted to our hospital and being treated for Bi-ventricular heart failure. The hospital course was complicated by ventricular tachycardia requiring transfer to the ICU. While on amiodarone, the patient developed refractory VT and worsening cardiogenic shock despite intubation, sedation, paralysis, lidocaine boluses and drip, and eight failed cardioversions. With each VT, the arterial waveform would become non pulsatile. The ECMO team was consulted venoarterial ECMO (VA-ECMO) implanted at bedside. There was no further VT post ECMO implantation. The patient was transferred to the destination center and ECMO conversion to RA to Pulmonary artery for RV support and percutaneous transvalvular microaxial flow pump for LV support. After a multidisciplinary discussion, a HeartMate 3 LVAD was implanted with mitral and tricuspid valve repair. He is now being evaluated for a heart transplant.

Discussion: Ventricular storm is defined by 3 or more sustained episodes of ventricular tachycardia, ventricular fibrillation requiring cardioversion within 24 hours. As VT progresses, it may lead to worsening circulatory failure and persistent VT storm despite antiarrhythmic therapy, sedation/paralysis, and electrical therapy. There are no randomized clinical trials that examine the use of VA-ECMO in VT storm. Clinical decisions are made by experienced clinicians in institutions with established ECMO programs. VA-ECMO provides a means to stop VT storm when everything else has failed and there are no other options to prevent death.