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Antiarrhythmic Drugs Are not the Only Option in Electrical Storm: Extracorporeal Membrane
Oxygenation as a Life-saving Alternative
Raphaël P Martins, Erwan Flecher, Solène Le Pennec-Prigent, Vincent Galand
To cite this version:
Raphaël P Martins, Erwan Flecher, Solène Le Pennec-Prigent, Vincent Galand. Antiarrhythmic Drugs Are not the Only Option in Electrical Storm: Extracorporeal Membrane Oxygenation as a Life-saving Alternative. Revista Española de Cardiología (English version), Elsevier España, 2019, 72 (2), pp.184.
�10.1016/j.rec.2018.08.007�. �hal-01880046�
Accepted manuscritpt
Letter to the Editor
AntiarrhythmicDrugsArenottheOnlyOptioninElectricalStorm:
ExtracorporealMembrane OxygenationasaLife-savingAlternative
Losfa´rmacosantiarrı´tmicosnosonlau´nicaopcio´nenla tormentaele´ctrica:Eloxigenadorextracorpo´reode membranaesunaalternativa
TotheEditor,
We read with great interest the scientific letter by Garcı´a Carren˜ oetal.1publishedinRevistaEspan˜oladeCardiologı´a.Inthat study, the authors retrospectivelyanalyzed their patients who underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO)implantationinthecontextofelectricalstorm.Seven patients were included, all but 1 withischemic heart disease.
Following VA-ECMO implantation, 4 patients had a ventricular tachycardiaablationprocedureand2died.Themediandurationof supportwas9days.TheauthorsconcludethatVA-ECMOsupport should be systematically evaluated in patients with refractory ventricular tachycardia and cardiogenic shock since it ensures hemodynamicsupportinthesecritically-illpatients,allowingVT ablationtobesafelyperformed.
We completely agree with these statements. Indeed, we recently published a similar study including 26 patients with refractoryelectricalstormandcardiogenicshockimplantedwitha VA-ECMO.2 Interestingly,stable sinusrhythm wasimmediately obtainedafterVA-ECMOimplantationintwo-thirdsofthepatients and occurred afteramedian timeof 3hoursfortheremaining ones.Fiftypercentofthepatientseventuallydied,noneduetothe VA-ECMO,butmostlyduetomultipleorganfailure.Theaverage durationofVA-ECMOsupportwas6.73.6days.Ofnote,survival was significantly better in patients with repetitive ventricular tachycardia/fibrillationalternatingwithperiodsofsinusrhythmat the time ofVA-ECMO implantationthan in those withrefractory ventricularfibrillation.Tothebestofourknowledge,our
study is
thelargestdatabaseofVA-ECMOimplantationinpatientswithelectrical storm published thus far.
Ourresultshadanimpactinthefieldofintensivecaremedicine, buthadlesseffectincardiology,sincecardiologists,andespecially electrophysiologists,aremorelikelytoattemptmultipleantiar- rhythmictherapies,performelectricalcardioversions,andconsid- er ablation, rather than call interventional cardiologists or surgeonstoimplantaVA-ECMOforanarrhythmicproblem.This reluctance probably explains why VA-ECMO is an underused deviceinpatientswithelectricalstorm.Patientsendupdyingfrom
multipleorganfailure,asaconsequenceofsuboptimallymanaged electricalstorm,whilethecomplicationsofVA-ECMOarerare,as demonstrated by Garcı´a Carren˜ o et al.1 and by our study.2 Physiciansshouldkeepinmindthatinpatientswithintractable electrical storm and cardiogenic shock refractory to usual management,VA-ECMOprovidesefficienthemodynamicsupport andhelpstorapidlyrestoresinusrhythm,probablyduetorapid improvement of myocardial perfusion and a decrease in left ventricularend-diastolicpressure.
TheevidencesupportingtheuseofVA-ECMOinelectricalstorm isscarceandisespeciallyfocusedontheuseofVA-ECMOduring ventriculararrhythmiaablationandnotasanadjunctivetherapy perse.3,4Thus,wecongratulateRevistaEspan˜oladeCardiologı´afor showing interest in this topic and the authors for once again demonstrating that electricalstorm can,of course, bemanaged pharmacologicallyandbyablation,butalsobyVA-ECMOimplanta- tion,sinceitmightprovidesuccessfuloutcomes,preventingsecon- daryorgandamageandmaintainingsufficientcardiacunloading. Q2 Raphae¨lP.Martins
Q1 ,a,b,c,*ErwanFlecher,a,b,c
Sole`neLePennec-Prigent,a,b,candVincentGalanda,b,c
aUniversite´ deRennes,Rennes,France
bServicedeCardiologie,CentreHospitalierUniversitairedeRennes, Rennes,France
cInstitutNationaldelaSante´ etdelaRechercheMe´dicale(INSERM), U1099,Rennes,France
* Correspondingauthor:
E-mailaddress:raphael.martins@chu-rennes.fr(R.P.Martins).
REFERENCES
1. Garcı´aCarren˜oJ,Sousa-CasasnovasI,VicentAlaminosML,AtienzaFerna´ndezF, Martı´nezSelle´sM,Ferna´ndezAvile´sF.ExtracorporealMembraneOxygenationin PatientsWithElectricalStorm:ASingle-centerExperience.RevEspCardiol.2018.
http://dx.doi.org/10.1016/j.rec.2018.07.001.
2. LePennec-PrigentS,FlecherE,AuffretV,etal.EffectivenessofExtracorporealLife SupportforPatientsWithCardiogenicShockDueToIntractableArrhythmicStorm.
CritCareMed.2017;45:e281–e289.
3. BarattoF,PappalardoF,OlorizT,etal.ExtracorporealMembraneOxygenationfor HemodynamicSupportofVentricularTachycardiaAblation.CircArrhythmElectro- physiol.2016.9:pii:e004492.
4. Tsai FC,Wang YC,HuangYK, etal. Extracorporeallife supportto terminate refractoryventriculartachycardia.CritCareMed.2007;35:1673–1676.
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