1. An Electrical Storm 9 th May 2014 U Buckley, D Eaton, J Galvin, T Keelan Mater Misericordiae Hospital, Dublin

2. 55 year old female Atrial septal defect & mitral valve repair in 1990’s Out of hospital cardiac arrest 2011 on clarithromycin AED torsade de pointe LV dysfunction – 40% Long QT on ECG at 490ms Fhx sudden cardiac death – 2 first degree relatives ICD – single chamber device implanted

3. Left sided invasive ductal carcinoma requiring radiotherapy Post operatively cardiac arrest requiring 6 shocks to defibrillate (ICD off for surgery) Device repositioned & tunnelled lead to right Inappropriate therapy from the device Nov 2013 Reprogrammed Increased meds Rising threshold and drop in R wave Beta-blockade Appropriate therapy from the device Jan 2014

4. Further 5 shocks from device First looked inappropriate 4 others were appropriate Check Coronary Angiogram Medications optimized Switched to propranolol Mexilitene after loading with intravenous lignocaine Further fine ventricular fibrillation undetected by the device Atrial lead inserted & new RV lead Further Appropriate therapies

5. Video Assisted Transaxillary Transthoracic Left Cervical Sympathectomy

6. LCSD lengthening repolarization Prolong refractory periods Increase VF threshold Defibrillation threshold testing was performed Genetic testing sent No Horner's Syndrome 8 weeks on and no further ventricular arrhythmias Natural history of electrical storm or success?

7. Management of Ventricular Arrhythmic Storms 1. Beta blockers 2. Antiarrhythmics 3. Reprogramme Device 4. Manage reversible proarrhythmic causes 5. Ablation 6. Deep sedation/skeletal muscle relaxants 7. Stellate ganglion blocking 8. Cervical Sympathectomy Neuromodulation Presynaptic Postsynaptic Central inhibition

8. Sympathetic Activation

9. Previous Surgical Options Supraclavicular Open thoracotomy Posterior approach Chemical ablation Resection

10. How much of the chain is enough? T1-4 C8 Can the nerves grow back? Lessons from orthotopic heart transplantation Left versus bilateral sympathectomy

11. Surgical Failure Multiple shocks prior to surgery Decompensated end stage intractable heart failure Lack of sympathetic triggers Circulating catecholamines Failure to dissect the nerve of Kuntz