Tachycardia As Therapy: Control of an Electrical Storm Through Mechanism-Directed Treatment After Refractory...

Electrical storm (ES) is a life-threatening clinical syndrome defined by recurrent episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) within a short time frame. Although contemporary management relies on guideline-directed therapies, including antiarrhythmic drugs, deep sedation, sympathetic modulation, and catheter ablation in selected refractory cases, some patients remain unstable and require individualized treatment guided by the suspected electrophysiological substrate. We report the case of a 44-year-old previously healthy woman who presented with out-of-hospital cardiac arrest due to VF. Following successful resuscitation, she developed recurrent polymorphic VT apparently initiated by short-coupled premature ventricular complexes (PVCs). Despite implementation of several conventional and guideline-supported strategies for ES, ventricular arrhythmias continued to recur. The clinical pattern and electrocardiographic/telemetry recordings were considered compatible with a short-coupled ectopy-triggered mechanism, raising suspicion for a Purkinje-mediated substrate. Based on this hypothesis, a therapeutic strategy aimed at increasing the basal heart rate was adopted using continuous isoproterenol infusion. Following isoproterenol titration to achieve sinus tachycardia of approximately 120 beats per minute, no further VT was documented. Quinidine therapy was subsequently introduced, allowing withdrawal of isoproterenol with sustained arrhythmia suppression. This case illustrates how careful interpretation of arrhythmia patterns may guide therapeutic decisions in refractory ES and highlights the potential role of heart rate acceleration in selected patients with suspected short-coupled PVC-triggered ventricular arrhythmias.