Refractory ventricular tachycardia storm with 42 ICD shocks in 24 h: A case report

An electrical storm (ES) represents a critical arrhythmic emergency, often associated with high morbidity and mortality rates in patients with underlying structural heart disease. Despite therapeutic advancements, its management remains challenging. The present case report describes an exceptional case of ES marked by 42 appropriate implantable cardioverter-defibrillator (ICD) shocks within a period of 24 h, one of the highest documented burdens underscoring the limitations of conventional therapy and the importance of timely interventional strategies. A 71-year-old male patient with ischemic cardiomyopathy and prior MitraClip implantation presented with recurrent ICD shocks. Despite optimized device programming and dual antiarrhythmic therapy (amiodarone and lidocaine), he experienced 42 appropriate ICD discharges in a single day. His course rapidly progressed to severe hemodynamic instability, necessitating intubation, mechanical ventilation, deep sedation, and neuromuscular blockade. Telemetry demonstrated the transient suppression of ventricular tachycardia with pacing, followed in select episodes by degeneration into ventricular fibrillation, likely reflecting underlying substrate instability rather than device malfunction or direct pacing-induced proarrhythmia. This pattern suggested complex device-arrhythmia interactions and provided diagnostic insight. Following the failure of all conventional treatments, the patient was transferred for urgent electrophysiological intervention including catheter ablation and bilateral cardiac sympathetic denervation. Unfortunately, the patient did not survive. This case highlights an extreme and refractory form of ES in a patient with structural heart disease. The severity and resistance to medical therapy reinforce the need for early recognition and timely escalation to interventional approaches such as ablation and sympathetic denervation. Additionally, the captured telemetry offers unique electrophysiological insight into pacing-triggered ventricular arrhythmogenesis. The present case report contributes valuable clinical and diagnostic learning for physicians managing complex ventricular arrhythmias in advanced cardiac patients.