Controlling the Chaos: An Integrated Strategy of Prophylactic Pacing and Primary PCI for an Ischemia-Driven Electrical Storm: a Case Report

Background: Electrical storm complicating ST-elevation myocardial infarction (STEMI) presents a formidable challenge, often refractory to standard antiarrhythmic therapy. Management requires a proactive, multimodal strategy where mechanical reperfusion is the definitive goal. We describe a case utilizing a novel, three-pronged approach to navigate this high-stakes clinical scenario. Case presentation: A 48-year-old Korean male with an acute inferior STEMI secondary to a right coronary artery (RCA) occlusion developed an electrical storm with recurrent ventricular fibrillation (VF). Management on the catheterization table involved a unique "triple threat" strategy: (1) Prophylactic Placement of a Transvenous Pacing Wire: A temporary pacemaker was immediately placed in the right ventricle upon arrival to the lab to provide an electrical safety net against post-defibrillation bradycardia or asystole. (2) Aggressive Defibrillation Protocol: Refractory VF was managed with intravenous amiodarone and optimization of the defibrillation vector. (3) Prioritized Emergent Primary Percutaneous Coronary Intervention (PCI): Revascularization was pursued as the primary antiarrhythmic therapy. With the extracorporeal membrane oxygenation (ECMO) team on standby, successful stenting of the RCA resulted in immediate termination of the electrical storm. Following successful primary PCI with thrombus aspiration and stenting of the RCA, a subsequent transthoracic echocardiogram revealed moderately reduced left ventricular (LV) systolic function and the presence of significant spontaneous echocardiographic contrast (SEC). This finding introduced a new dimension to the patient's risk profile, necessitating a focused strategy for long-term thromboembolic prophylaxis. Conclusion: This case highlights an innovative and proactive strategy for managing ischemia-driven electrical storms. The anticipatory placement of a temporary pacemaker, combined with an aggressive defibrillation protocol, creates a stabilized environment that facilitates the true definitive therapy: rapid and successful mechanical reperfusion. The identification of post-procedural risk markers such as SEC is critical for tailoring long-term therapeutic strategies.