Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review.
Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review.
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DOI：
10.1016/j.jacc.2023.03.424
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发表时间：
2023-06-06
影响因子：
24
通讯作者：
Solomon, Michael A.
中科院分区：
文献类型：
--
作者：
Jentzer, Jacob C.;Noseworthy, Peter A.;Kashou, Anthony H.;May, Adam M.;Chrispin, Jonathan;Kabra, Rajesh;Arps, Kelly;Blumer, Vanessa;Tisdale, James E.;Solomon, Michael A.
电风暴（ES）是一种危及生命的电不稳定状态，其特征是在24小时内发生3次或3次以上持续性室性心律失常（VA）。大多数ES病例发生在基础结构性心脏病的背景下，该心脏病提供了一种致瘤基质，通常由过度的交感神经激活或其他加重因素引起。除了对经常存在的植入式心律转复除颤器进行仔细询问和编程外，还需要识别潜在的心脏基质和可逆触发因素。药物治疗包括膜活性抗血小板药物、β-肾上腺素能阻滞剂、镇静剂，以及通常用于心脏失代偿引起的低血压的血流动力学支持。这些干预措施的强度应与ES综合征的严重程度以及VA复发和不良结局的风险相匹配。可以使用分步护理算法，包括对高风险表现或复发性VA的逐步治疗。许多ES患者被考虑进行导管消融，并且血流动力学受损的风险较高，这可能证明在选定患者中使用临时机械循环支持是合理的。一个多学科的合作方法来管理ES是必不可少的。ES后的结局很差，包括频繁复发的VA和由于进行性心力衰竭和其他心脏原因导致的死亡。评估心脏移植或姑息治疗往往是适当的，即使是对患者谁生存的最初发作。在这个国家的最先进的审查，ES的评价和管理的各个方面进行了描述，使供应商提供全面的照顾，这些患者的危重疾病引起的复发性VA。
Electrical storm (ES) is a life-threatening state of electrical instability characterized by 3 or more episodes of sustained ventricular arrhythmia (VA) within 24 hours. Most cases of ES arise in the setting of underlying structural heart disease which provides an arrhythmogenic substrate, often provoked by excessive sympathetic activation or other aggravating factors. Identification of the underlying cardiac substrate and reversible triggers is needed, in addition to diligent interrogation and programming of the implantable cardioverter-defibrillator that is often present. Medical management includes membrane-active anti-arrhythmic drugs, beta-adrenergic blockade, sedation, and often hemodynamic support for hypotension from cardiac decompensation. The intensity of these interventions should be matched to the severity of the ES syndrome and risk of recurrent VA and adverse outcomes. A stepped-care algorithm can be used, involving escalating treatments for higher-risk presentations or recurrent VA. Many patients with ES are considered for catheter ablation and are at elevated risk of hemodynamic compromise, which may justify the use of temporary mechanical circulatory support in selected patients. A multidisciplinary collaborative approach to the management of ES is essential. Outcomes after ES are poor, including frequent recurrences of VA and deaths due to progressive heart failure and other cardiac causes. Evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode. In this State-of-the-Art review, all aspects of the evaluation and management of ES are described to enable providers to provide comprehensive care for these patients with critical illness caused by recurrent VA.
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