Atrial overdrive pacing in drug-refractory postinfarction electrical storm case report

Area of Science:

• Cardiology
• Electrophysiology
• Critical Care Medicine

Background:

• Drug-refractory electrical storm (ES) post-acute myocardial infarction (AMI) presents a significant clinical challenge.
• Atrial overdrive pacing (AOP) offers a method for physiological rhythm control, suppressing ventricular ectopy via synchronized atrioventricular activation.
• AOP circumvents the hemodynamic compromise often associated with ventricular pacing.

Purpose of the Study:

• To evaluate the efficacy of atrial overdrive pacing (AOP) in a patient with drug-refractory electrical storm (ES) following acute myocardial infarction (AMI).
• To assess the impact of AOP on arrhythmia recurrence, cardiac function, and natriuretic peptide levels.

Main Methods:

• A 62-year-old female patient with AMI and recurrent polymorphic ventricular tachycardia/ventricular fibrillation refractory to standard treatments was selected.
• X-ray-guided temporary AOP (95 bpm) was initiated via subclavian access, alongside optimized medical therapy (beta-blocker, sacubitril-valsartan) and electrolyte correction.
• Antiarrhythmic medications were discontinued after AOP implementation.

Main Results:

• Sustained suppression of electrical storm was achieved, with zero recurrences over a 9-month follow-up period.
• Left ventricular ejection fraction improved from 40% to 46%.
• N-terminal B-type natriuretic peptide precursor levels decreased by 70.7% (33,593 to 9839 pg/mL).

Conclusions:

• Atrial overdrive pacing (AOP) demonstrated dual efficacy in managing refractory post-AMI ES by restoring physiological conduction and suppressing ectopic triggers.
• AOP successfully avoided ventricular pacing-induced dyssynchrony, positioning it as a hemodynamically favorable intervention.
• Fluoroscopic guidance ensured optimal lead stability during AOP, contributing to its successful clinical application.