Extracorporeal Life Support for Electrical Storm, or for Cardiogenic Shock With Ventricular Arrhythmia?

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Le Pennec-Prigent et al (1), in their article published in a recent issue of Critical Care Medicine, presented their impressive experience on extracorporeal life support (ECLS) in cardiogenic shock associated with electrical storm. After careful reading of the article, several urgent points remain. First, it would be important to know whether ventricular tachycardias (VTs) were mono- or polymorphic, since this may reveal the underlying mechanism and guide treatment (2). Second, which β-blocker was administered? Propanolol may be preferred over metoprolol (3). Third, lidocaine was administered in 35% of the cases. Was this drug given for polymorphic VT in the setting of acute ischemia (ST-segment myocardial infarction/non-ST-segment myocardial infarction)? Otherwise, procainamide might have been a better alternative (4). Additional information on these points may help to judge whether ECLS in this group was necessary and effective, whereas the latter is not easy at all to say in the absence of a control group. Fourth, the authors report restoration of sinus rhythm immediately after implantation of ECLS in the majority of patients, whereas in the remaining patients sinus rhythm returned in about 3 hours. However, in case, the arrhythmia was terminated so fast, what was the reason that median ECLS support lasted 7 days? Together with a median duration of mechanical ventilation of 9 days and a median hospitalization duration of 35 days, I assume that the authors investigated a patient sample of cardiogenic shock, complicated with electrical storm, instead of the other way round, as suggested by the article’s title. Indeed, others acknowledged refractory VT as an obvious feature in a subgroup of patients with cardiogenic shock, which may necessitate ECLS implantation (5).
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