Advanced management of electrical storm: beyond antiarrhythmics

The acute management of patients presenting with electrical storm secondary to ventricular arrhythmias (VAs) can be quite challenging, even with traditional attempts at rhythm control. Novel approaches are necessary to incorporate contemporary diagnostic investigations and therapeutic interventions to improve outcomes. Endomyocardial biopsy is an important but underutilised diagnostic tool that can rapidly guide the selection of tailored interventions, such as cardiac transplantation and other non-pharmacological interventions, to maximise survival. In our case, a previously healthy woman in her early 50s was hospitalised for symptomatic, pleomorphic ventricular tachycardia. Early rhythm control was achieved, but VAs recurred, consistent with electrical storm. Cardiac MRI demonstrated biventricular patchy fibrosis and late gadolinium enhancement. Endomyocardial biopsy confirmed giant cell myocarditis. She continued to deteriorate, developing cardiogenic shock requiring extracorporeal membrane oxygenation followed by urgent cardiac transplantation, eventually making a full recovery. We propose a contemporary algorithm for the management of electrical storm to maximise survival.