Early catheter ablation versus conservative- only management in patients with electrical storm. Systematic review and...

Electrical storm (ES) is a life- threatening condition. Both recurrence and mortality rates remain unacceptably high. Current guidelines recommend initial conservative approach using anti-arrhythmic drugs (AADs), followed by catheter ablation (CA) for those with refractory ES.

We searched PubMed and Scopus for articles comparing an initial conservative approach - based on AADs/ sedation- with an early referral for CA approach. The primary endpoint was long term mortality, while secondary endpoints included ES recurrence and the incidence of ventricular arrhythmias (VAs)/ defibrillator shocks during the follow- up.

Seven studies, primarily observational cohorts, were analyzed. The pooled population (999 patients) consisted mostly of males with ischemic cardiomyopathy, presenting with ventricular tachycardias (VTs). The mean left ventricular ejection fraction was 35.5 % (9.5 %). 493 patients were treated with CA during the index hospitalization. Early CA was associated with significantly lower long- term mortality (OR: 0.44, 95 %CI: 0.31-0.63). Additionally, it was associated with lower rates of both ES recurrence and VAs/ shocks during the follow- up (OR: 0.27, 95 %CI: 0.15-0.48 and OR: 0.33, 95 %CI: 0.21-0.52, respectively).

Meta- analysis of primarily observational studies revealed that early referral of ES patients for CA may improve their prognosis. The invasive approach was associated with lower mortality and reduced recurrence rates of major arrhythmic events. Although some inherent limitations affect the strength of these findings, they remain promising. They highlight the need for further research on the topic, as their confirmation in randomized trials could lead to a shift in the standard of care of ES patients.