This document discusses ventricular tachycardia (VT) clusters and incessant VT. It defines a VT cluster as 3 or more sustained VTs within 24 hours. Treatment options discussed include antiarrhythmic drugs, ablation, anesthesia, and LVAD. Amiodarone, lidocaine, and procainamide dosages are provided. Left stellate ganglion blockade is suggested as superior to antiarrhythmic drugs for electrical storms. The document also discusses therapies for VT including ablation and digitalis toxicity management.

1. Ventricular tachycardia
VT Cluster (VTC)
• SAMIR EL ANSARY
• ICU PROFESSOR
• AIN SHAMS
• CAIRO

2. VT Cluster (VTC)
• A VTC is defined as ≥ 3 sustained VTs/24
h.
• Ventricular tachycardia that repeatedly
recurs and persists for more than half of
a 24-h period despite repeated attempts
to terminate the arrhythmia is
designated “incessant.”

3. VT Cluster (VTC)
• Irrespective of the number of VTs, only 30.2%
of patients survived and 15.5% survived
without heart transplantation four years after
the first cluster.
• Incessant VT typically takes one of two forms.
The most common situation is for VT to be
sustained, terminated by external
cardioversions, but recurrent.
• The time between cardioversion and
recurrence may be seconds, minutes or more.

4. VT Cluster (VTC)
• A second form, common with the
idiopathic VTs, manifests as repeated
bursts, with runs of VT that
spontaneously terminate for a few
intervening sinus beats, followed by the
next tachycardia burst.
• Cardioversion is futile, but may be
periodically required if bursts of VT
occasionally degenerate to ventricular
fibrillation.

5. VT Cluster (VTC)
• When incessant VT is polymorphic, drug induced
torsade de pointes associated with QT prolongation,
or myocardial ischemia are the major concerns.
• Runs of polymorphic VT may even repeatedly initiate
monomorphic VT in patients with reentry circuits in
regions of scar.
• Suppression of torsade de pointes with intravenous
administration of magnesium sulfate and/or
overdrive pacing may restore stability.

6. VT Cluster (VTC)
Treatment Options:
• Antiarrythmic drugs
• Beta Blockade
• General anesthesia (to reduce sympathetic
tone)
• Intra aortic balloon counterpulsation
• Catheter ablation – percutaneous/ epicardial
• LVAD

7. Dosage
• Amiodarone — Amiodarone is given as a 150
mg (or 5 mg/kg) IV bolus over 10 minutes;
additional boluses of 150 mg over 10 minutes
are given every 10 to 15 minutes as needed.
Alternatively, an infusion of 360 mg (1
mg/min) over six hours followed by 540 mg
(0.5 mg/min) over the remaining 18 hours can
be used.
• The maximum total dose (including doses
given during resuscitation) is 2.2 grams in 24
hours.

8. Dosage
• Lidocaine
• Lidocaine is given by IV push in a dose of
0.5 to 0.75 mg/kg; repeated every 5 to
10 minutes as needed.
•
• At the same time, a continuous IV
infusion of 1 to 4 mg/min is begun.
• The maximum total dose is 3 mg/kg
over one hour.

9. Dosage
• Procainamide:
• Loading dose:
• 15-18 mg/kg administered as slow
infusion over 25-30 minutes or 100-200
mg/dose repeated every 5 minutes as
needed to a total dose of 1 g.

10. Dosage
• Procainamide:
• Reduce loading dose to 12 mg/kg in severe renal or
cardiac impairment.
Maintenance dose: 1-4 mg/minute by continuous
infusion.
• Maintenance infusions should be reduced by one-
third in patients with moderate renal or cardiac
impairment and by two-thirds in patients with severe
renal or cardiac impairment.

11. Dosage
• Procainamide:
ACLS guidelines: Infuse 20
mg/minute until arrhythmia is
controlled, hypotension occurs, QRS
complex widens by 50% of its
original width, or total of 17 mg/kg is
given.

12. SHock Inhibition Evaluation
with AzimiLiDe (SHIELD) Investigators
• uppression of ventricular tachycardia/fibrillation
(VT/VF) leading to implanted cardioverter
defibrillator (ICD) therapies.
• Of 633 ICD recipients, 148 (23%) experienced at least
one ES (electrical storm) over 1-year follow-up.
• Compared with placebo, azimilide reduced the risk of
recurrent ES by 37% (p=0.11) nonsignificantly.
• CONCLUSION: ES is common and unpredictable in
ICD recipients and it is a strong predictor of
hospitalization.

13. Left stellate ganglionic blockade
• Sympathetic blockade is superior to the
antiarrhythmic therapy recommended by the
ACLS guidelines in treating ES patients.
• The role of increased sympathetic activity in
the genesis of ES.
• Sympathetic blockade not class 1
antiarrhythmic drugs should be the treatment
of choice for ES.

14. Therapies for VT
ABLATION
Ablation is indicated in patients who are otherwise at low risk
for SCD and have sustained predominantly monomorphic VT
that is drug resistant, who are drug intolerant, or who do not
wish long-term drug therapy.
Ablation is indicated in patients with bundle-branch reentrant
VT.
Ablation is indicated as adjunctive therapy in patients with an
ICD who are receiving multiple shocks as a result of sustained
VT that is not manageable by reprogramming or changing drug
therapy or who do not wish long-term drug therapy.
Ablation is indicated in patients with WPW syndrome
resuscitated from sudden cardiac arrest due to AF
and rapid conduction over the accessory pathway
causing VF.

15. Therapies for VT
Ablation
Ablation can be useful therapy in patients who are
otherwise at low risk for SCD and have symptomatic
nonsustained monomorphic VT that is drug resistant, who
are drug intolerant or who do not wish long-term drug
therapy.
Ablation can be useful therapy in patients who are
otherwise at low risk for SCD and have frequent
symptomatic predominantly monomorphic PVCs that are
drug resistant or who are drug intolerant or who do not wish
long-term drug therapy.
Ablation can be useful in symptomatic patients
with WPW syndrome who have accessory
pathways with refractory periods less than
240 ms in duration.

16. Incessant VT
Revascularization and beta blockade followed by
intravenous antiarrythmic drugs such as
procainamide or
amiodarone are recommended for patients with
recurrent
or incessant polymorphic VT due to acute MI.
Intravenous amiodarone or procainamide followed by
VT
ablation can be effective in the management of
patients
Acute Management of Specific Arrhythmias

17. Incessant VT
Intravenous amiodarone and intravenous beta
blockers
separately or together may be reasonable in
patients
with VT storm.
Overdrive pacing or general anesthesia may
be considered for patients with frequently
recurring or incessant VT.
Spinal cord modulation may be considered for
some
patients with frequently recurring or incessant
Acute Management of Specific Arrhythmias

18. Digitalis Toxicity
An antidigitalis antibody is recommended for patients
who
present with sustained ventricular arrhythmias, advanced
AV
block, and/or asystole that are considered due to digitalis
toxicity.
Patients taking digitalis who present with mild cardiac
toxicity (e.g., isolated ectopic beats only) can be
managed
effectively with recognition, continuous monitoring of
cardiac
rhythm, withdrawal of digitalis, restoration of normal
electrolyte levels (including serum potassium greater
VA & SCD Related to Specific Populations

19. Digitalis Toxicity
Magnesium or pacing is reasonable
for patients
who take digitalis and present with
severe
toxicity
(sustained ventricular arrhythmias,
advanced AV block, and/or asystole).
VA & SCD Related to Specific Populations

20. Digitalis Toxicity
Dialysis for the management of
hyperkalemia may be
considered for patients who take
digitalis and present with
severe toxicity (sustained ventricular
arrhythmias; advanced
AV block, and/or asystole).
VA & SCD Related to Specific Populations

21. Digitalis Toxicity
Management by lidocaine or
phenytoin is not recommended
for patients taking digitalis and who
present with severe
toxicity (sustained ventricular
arrhythmias, advanced AV
block, and/or asystole).
VA & SCD Related to Specific Populations

22. Drug Interacting Drug Effect
QT-prolonging
antiarrhythmics
Diuretics Increased T de P risk due to
diuretic-induced hypokalemia
Beta blockers Amiodarone, clonidine, digoxin, dilitiazem,
verapamil
Bradycardia when used in
combination
Digoxin Amiodarone, beta blockers, clonidine,
dilitiazem, verapamil
Verapamil Amiodarone, beta blockers, clonidine, digoxin,
dilitiazem
Diltiazem Amiodarone, beta blockers, clonidine, digoxin,
verapamil
Sildenafil Nitrates Increased and persistent
vasodilation; risk of
myocardial ischemia
Clonidine Amiodarone, beta blockers, digoxin, dilitiazem,
verapamil
Amiodarone Beta blockers, clonidine, digoxin, dilitiazem,
verapamil
Drug Interactions Causing Arrhythmias

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Wellcome in our new group ..... Dr.SAMIR EL ANSARY

24. GOOD LUCK
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com