1163-268 - A CASE OF FATAL RECALCITRANT POLYMORPHIC VENTRICULAR TACHYCARDIA STORM POST-LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION: LESSONS LEARNED

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Author Block: Dhruvi Patel, Amit Badiye, Eastern Virginia Medical School, Norfolk, VA, USA, Sentara Heart Hospital, Norfolk, VA, USA
Background: Ventricular tachycardia (VT) storm is a serious post-operative complication after left ventricular assist device (LVAD) implant. If uncontrolled, it can lead to right ventricular dysfunction, hemodynamic instability, secondary organ failure, and death. Here, we present a unique case of post-LVAD VT storm with incessant episodes that resulted in a poor outcome, despite emergent, multipronged approach, highlighting numerous management challenges.
Case: 73-year-old male with stage 3b chronic kidney disease, solitary kidney, coronary artery disease with bypass and angioplasty; and stage D heart failure underwent successful HeartMate III LVAD placement. His post-operative course was complicated by cardiogenic shock and acute kidney injury due to cardio-renal syndrome requiring continuous renal replacement therapy (CRRT). On day 26, he began manifesting recurrent episodes of new onset sustained VT requiring multiple direct current cardioversions.
Decision‐making: Patient failed Amiodarone. More than 10gm load was already given. Resultant QT prolongation led to lidocaine infusion—this was stopped due to seizures. Mexiletine and quinidine did not suppress VT. Right ventricular function was supported with inhaled epoprostenol and low dose dobutamine. Given incessant VT, he was intubated and deeply sedated for sympathetic drive suppression. Echocardiogram ruled out cannula malposition—LVAD speed adjusted to prevent suction events. Left stellate ganglion block failed. Even after substrate modification targeting areas of focal abnormal ventricular activation in left ventricle, including distal Purkinje and infero-septal regions, incessant VT continued. Overdrive pacing to suppress triggering premature ventricular contractions after dual chamber externalized pacemaker implantation was unsuccessful. After family discussion, comfort care was initiated and he passed away.
Conclusion: Optimal management of VT storm post-LVAD is challenging. The only identified risk factor for VT in our case was stage 3b renal failure. This case highlights high morbidity and mortality in this challenging population and need for a rapid algorithmic approach.