Marco Grazi, MD; Gianfranco Lauri, MD; Corrado Carbucicchio, MD; Giancarlo Marenzi, MD
Potential Financial Conflicts of Interest: None disclosed.
Grazi M., Lauri G., Carbucicchio C., Marenzi G.; Use of Levosimendan for Treatment of Cardiogenic Shock Associated With Electrical Storm. Ann Intern Med. 2009;150:738-740. doi: 10.7326/0003-4819-150-10-200905190-00024
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Published: Ann Intern Med. 2009;150(10):738-740.
Background: Management of recurrent episodes of ventricular tachycardia and ventricular fibrillation (VT/VF) in patients with implantable cardioverter-defibrillators (ICDs) is troublesome (1). Vasopressors and inotropic agents are often needed in these patients to maintain blood pressure, but the drugs can induce atrial and ventricular arrhythmias and lead to further myocardial injury and increased mortality (2).
Objective: To report 2 cases of recurrent VT/VF, complicated by cardiogenic shock, that resolved after intravenous administration of levosimendan.
Case Report: Two men (age 48 and 62 years) with severe idiopathic and ischemic dilated cardiomyopathy (left ventricular ejection fractions of 0.12 and 0.18, respectively) and biventricular ICDs were admitted to the cardiac care unit because of clusters of VT/VF with repeated ICD shocks (Figure) refractory to all pharmacologic therapies and to previous attempts of radiofrequency catheter ablation. Progressive clinical worsening and development of cardiogenic shock, with prolonged systemic hypotension, oligoanuria, pulmonary rales over the lung fields, and metabolic acidosis, occurred in both patients. Intravenous infusion of levosimendan was started in both patients and maintained for 30 and 36 hours, respectively. During the infusion period, several additional VT/VF episodes occurred and were terminated by appropriate ICD interventions. The following day, the patients improved dramatically, with normalization of arterial pressure, correction of acidosis and lactate values (from 6.0 to 0.8 mmol/L and from 4.3 to 1.9 mmol/L, respectively), resolution of signs of heart failure, and restoration of urine output, as well as a progressive decrease in the creatinine level in 1 patient (from 251.63 μmol/L [3.3 mg/dL] to 76.25 μmol/L [1.0 mg/dL]). No further episodes of VT/VF took place for the remainder of hospitalization (19 and 10 days, respectively).
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