Ventricular Tachycardia in Electrical Storm with Structural Heart Disease: Next-Line Protocol After Landiolol Fails to Suppress Recurrent VT

This protocol applies to the patient with electrical storm — three or more episodes of sustained ventricular arrhythmia within 24 hours — arising from sustained monomorphic ventricular tachycardia in the presence of structural heart disease, where first-line pharmacological therapy has not achieved arrhythmia suppression.

Clinical Scenario

Electrical storm is defined as three or more episodes of sustained ventricular arrhythmia occurring within 24 hours, each separated by at least 5 minutes. When the arrhythmia is sustained monomorphic ventricular tachycardia in a patient with underlying structural heart disease, a defined escalation pathway guides management.

First-Line Treatment — Goal Not Reached

Initial therapy with intravenous landiolol (an ultra-short-acting β1-selective blocker) did not achieve the required endpoint: complete suppression of the ventricular arrhythmia with no recurrent ventricular tachycardia. Failure to reach this target is the criterion that triggers escalation to the next-line protocol.

Next-Line Approach — Partial Overview

When electrical storm is refractory to drug treatment, catheter ablation of the arrhythmia substrate is the direction of the next-line strategy. The complete protocol specifies the full escalation sequence, patient selection, and any additional measures for refractory cases.

Treatment Goals

Reduction in ventricular tachycardia burden and prevention of electrical storm recurrence.

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References

DOI: 10.1093/eurheartj/ehac262

An electrical storm is common in ICD patients and has been defined as three or more episodes of sustained VA occurring within 24 h, requiring either anti-tachycardia pacing (ATP) or cardioversion/defibrillation, with each event separated by at least 5 min.

Antiarrhythmic therapy with beta-blockers (non-selective preferred) in combination with intravenous amiodarone is recommended in patients with SHD and electrical storm unless contraindicated.

Catheter ablation is recommended in patients presenting with incessant VT or electrical storm due to SMVT refractory to AADs.

Deep sedation/intubation should be considered in patients with an intractable electrical storm refractory to drug treatment.

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