Jonathon Davis, DO
Resident Physician
Legacy Health System, United States
Disclosure information not submitted.
Alexandra Ross, DO
Resident Physician
Legacy Health System, United States
Disclosure information not submitted.
Ajay Tripuraneni, MD
Cardiac Electrophysiologist
Legacy Health System, United States
Disclosure information not submitted.
Title: Refractory Slow Ventricular Tachycardia with Cardiogenic Shock Requiring Impella-Assisted Ablation
Introduction: Electrical storm (ES) is a life-threatening condition that occurs in approximately 2% of patients with an implantable cardioverter-defibrillator (ICD) per year. Patients rarely present with slow ventricular tachycardia (VT), leading to underdiagnosis. Catheter ablation (CA) has a pivotal role in managing recurrent VT. About 11% of patients undergoing CA will experience peri-procedural acute hemodynamic decompensation (AHD) linked with a 6-fold increase in death. The PAINESD score (0-31) was created to predict AHD during CA and identify high-risk patients who may benefit from prophylactic mechanical circulatory support (PMCS) which has shown reduced risk of AHD and death. We describe a case using the PAINESD score to screen for potential mortality benefit of PMCS in a critically ill patient with refractory slow VT.
Description: A 76-year-old male with history of coronary artery disease, systolic heart failure, and paroxysmal VT with ICD presented for multiple ICD discharges. The patient was refractory to antiarrhythmic infusions, antitachycardia pacing, and defibrillation. He developed sustained slow VT with subthreshold heart rates in the 80s, deteriorating into cardiogenic shock requiring vasopressor support. He had a PAINESD score of 31. Urgent multidisciplinary discussion held with electrophysiology, cardiothoracic surgery, and interventional cardiology to proceed with CA and PMCS with an Impella CP via right axillary approach. He had an uneventful Impella-assisted CA with successful removal on postoperative day 3.
Discussion: Patients with ES have poor outcomes and we assert that pre-procedural optimization with multidisciplinary collaboration and an assessment of candidacy for PMCS is necessary to reduce AHD and death. We recommend that PMCS be considered in all patients with cardiogenic shock, irrespective of their PAINESD score. We suggest utilization of an axillary approach for PMCS in patients with profound shock to provide higher cardiac output and potentially further decrease the risks associated with CA. We recommend further studies into the benefits of axillary versus femoral approach and that this option be integrated into multidisciplinary discussions. We assert that there may be benefit in adding hemodynamic values to the PAINESD score to guide the decision-making on vascular approach.