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

Controlling the Chaos: An Integrated Strategy of Prophylactic Pacing and Primary PCI for an Ischemia-Driven Electrical Storm: a Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Controlling the Chaos: An Integrated Strategy of Prophylactic Pacing and Primary PCI for an Ischemia-Driven Electrical Storm: a Case Report Doan Duc Dung, Hoang Phu Quy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8172664/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract 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. Myocardial Infarction STEMI Ventricular Fibrillation Electrical Storm Percutaneous Coronary Intervention Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction The paradigm for managing ST-elevation myocardial infarction (STEMI) has evolved significantly from the era of expectant management and thrombolysis to the current standard of primary percutaneous coronary intervention (PCI). Primary PCI offers a definitive mechanical solution to restore coronary patency, thereby salvaging myocardium and improving clinical outcomes. Despite these advancements, the fundamental principles of rapid diagnosis and timely reperfusion remain paramount. The electrocardiogram (ECG) serves as the primary diagnostic tool, facilitating immediate activation of care pathways. However, a significant burden of morbidity and mortality in the acute phase of STEMI is attributable not to the ischemic injury alone, but to the resultant electrical instability. Ventricular fibrillation (VF), a frequent complication, represents a major cause of sudden cardiac death in this population, underscoring the critical need for vigilant monitoring and immediate intervention.¹,² Managing a patient through an electrical storm on the catheterization table requires not only rapid interventional skills but also a sophisticated strategy to maintain hemodynamic stability and manage recurrent cardiac arrest. This case report illustrates the successful navigation of these challenges. 2. Patient Information A 48-year-old Korean male presented to the emergency department reporting a two-hour history of severe, substernal chest pain, described as a constant, crushing pressure (9/10 intensity) radiating to his left arm. The symptoms were not relieved by rest and were associated with diaphoresis and nausea. He had multiple untreated cardiovascular risk factors, including hypertension, dyslipidemia, and a significant smoking history. He had not taken any medication prior to arrival. Further metabolic profiling confirmed a new diagnosis of type 2 diabetes (random glucose 7.50 mmol/L, HbA1c 6.99%). 3. Clinical Findings On initial physical examination, the patient was alert and in moderate distress due to pain. He was hemodynamically stable with a blood pressure of 130/80 mmHg, a regular heart rate of 75 beats per minute, and oxygen saturation of 96% on ambient air. Cardiopulmonary examination was unremarkable, with normal heart sounds and clear lung fields bilaterally. There were no signs of peripheral hypoperfusion or heart failure. 4. Timeline Date / Time Clinical Event Key Findings / Actions Day 0 – ED Presentation Patient presented with 2-hour onset of severe chest pain Hemodynamically stable; ECG: inferior STEMI (RCA territory) Shortly after arrival Sudden cardiac arrest Coarse VF → CPR → ROSC after one shock Cath Lab – Pre-PCI Prophylactic temporary RV pacing wire inserted To prevent post-defibrillation bradycardia/asystole Cath Lab – During PCI Recurrent VF Managed with IV amiodarone + optimized defibrillation vector; ECMO team on standby Cath Lab – Intervention Primary PCI of the RCA performed Thrombus aspiration + DES placement → TIMI III flow ICU (Day 0–1) Post-PCI stabilization Inferior Q waves; Echo: LVEF ~ 45%, dense LV SEC Day 5 – Discharge Discharged with GDMT DAPT, statin, beta-blocker, ARB, SGLT2i 1-month Follow-up (planned) Repeat echocardiography Reassess LVEF and SEC resolution / LV thrombus 5. Diagnostic Assessment Initial laboratory investigations revealed a white blood cell count of 11.3 G/L. The initial high-sensitivity Troponin T level was 5 ng/L (reference < 14 ng/L), remaining within the normal range. Renal function and electrolytes were normal. The 12-lead ECG was the decisive diagnostic tool. It demonstrated significant ST-segment elevation in the inferior leads (II, III, aVF). The pattern of ST elevation being greater in lead III than in lead II, combined with the absence of significant reciprocal ST depression in leads I and aVL, provided strong evidence for an occlusion of the right coronary artery (RCA) as the culprit lesion (Fig. 1 ). Given the classic ECG findings and clinical presentation, the primary diagnosis of acute coronary occlusion was clear. However, in the setting of chest pain and electrical instability, other life-threatening diagnoses such as acute aortic dissection, massive pulmonary embolism, and acute pericarditis were rapidly excluded by the clinical stability, physical exam, and definitive ECG findings. Based on these definitive ECG findings, the cardiac catheterization laboratory was immediately activated for primary PCI. 6. Therapeutic Intervention The patient's clinical course rapidly deteriorated. Prior to transfer, he experienced a sudden cardiac arrest documented as coarse ventricular fibrillation (Fig. 2 ). Immediate cardiopulmonary resuscitation was initiated, and spontaneous circulation was restored after a single defibrillation shock, marking the onset of an electrical storm. Upon arrival at the catheterization laboratory, and prior to commencing angiography, a transvenous temporary pacing wire was prophylactically placed in the apex of the right ventricle (Fig. 2 ). This crucial step was taken to mitigate the risk of profound post-defibrillation bradycardia or asystole. Shortly after, the patient developed a second episode of VF. Following a failed initial defibrillation attempt, an aggressive protocol was enacted: a 150 mg bolus of intravenous amiodarone was administered, and the defibrillation pads were repositioned. This combined approach successfully restored sinus rhythm. The institutional ECMO team was on standby. With the electrical safety net of the pacemaker in place, the team proceeded emergently with PCI. Coronary angiography confirmed a total thrombotic occlusion (TIMI grade 0 flow) of the mid-RCA. A primary PCI was performed, commencing with successful thrombus aspiration, which restored partial flow. A drug-eluting stent was then deployed, and post-dilation was performed. The final angiographic result was excellent, demonstrating complete restoration of coronary flow (TIMI grade III) with no residual stenosis or dissection (Fig. 3 ). 7. Follow-up and Outcomes Following the procedure, the patient was transferred to the intensive care unit. The post-procedure ECG confirmed resolution of the ST-segment elevation, showing evolving Q waves in the inferior leads (Fig. 4 ). A post-procedural transthoracic echocardiogram revealed severe hypokinesia of the basal and mid-segments of the inferior and posterior walls, consistent with the infarct territory. The left ventricular ejection fraction (EF) was moderately reduced at 45%. A notable finding was the presence of dense Spontaneous Echocardiographic Contrast (SEC) within the left ventricular cavity, indicating significant blood stasis. The patient's subsequent clinical course was stable. He demonstrated excellent tolerance and adherence to his new medical regimen during hospitalization. He was discharged on day five on guideline-directed medical therapy, including dual antiplatelet therapy, a high-intensity statin, a beta-blocker, an angiotensin receptor blocker, and an SGLT2 inhibitor. A follow-up echocardiogram was scheduled in one month to reassess LV function and evaluate for the resolution of SEC or the development of an intracardiac thrombus. 8. Patient Perspective I was told later that my heart had stopped, and I was very close to dying. Everything happened so quickly that I only remember the overwhelming chest pain and, suddenly, waking up in the hospital. I am deeply grateful for the rapid and coordinated actions of the medical team, especially the doctors who treated me in the emergency room and catheterization lab. Knowing that the treatment not only saved my life but also prevented further damage to my heart has given me great comfort. I am truly thankful for the care and attention I received during and after the procedure. 9. Discussion This case illustrates several critical principles in the contemporary management of high-risk STEMI. First, the case reaffirms the primacy of the ECG in the diagnostic and triage pathway. The rapid and accurate interpretation of the ECG not only confirmed the diagnosis of STEMI but also correctly localized the culprit vessel, thereby allowing for anticipation of associated complications, such as the high propensity for atrioventricular block and ventricular arrhythmias associated with RCA occlusions.³,⁴ The decision to proceed directly to reperfusion therapy based on ECG findings, without awaiting biomarker elevation, is the standard of care and was instrumental in this patient's outcome. Second, the management of this patient highlights the importance of preparedness for profound electrical instability. The occurrence of an electrical storm is a marker of high ischemic burden and carries a poor prognosis.⁵,⁶,⁷ The most innovative element was the anticipatory placement of a temporary pacing wire. The successful outcome was contingent upon a well-coordinated team response, including immediate, high-quality resuscitation and defibrillation, which served as a critical bridge to definitive mechanical reperfusion. The resolution of the arrhythmias following successful PCI underscores the causal link between acute ischemia and electrical instability. Finally, and central to the theme of this report, the case emphasizes the necessity of looking beyond the immediate success of reperfusion. The post-procedural identification of SEC is a significant finding. SEC is an acoustic phenomenon representing aggregated erythrocytes and proteins in areas of blood stasis and is a well-established precursor to left ventricular thrombus formation, an independent risk factor for systemic embolism.⁸ While current guidelines for anticoagulation post-MI are primarily driven by the presence of severe LV dysfunction (EF < 30%) or apical wall motion abnormalities, the presence of dense SEC in a patient with moderately reduced EF presents a clinical challenge.⁹,¹⁰ This finding necessitates a heightened level of surveillance. The decision to schedule a follow-up echocardiogram represents a patient-specific risk stratification strategy. Key risk factors for SEC and subsequent embolism include advanced age, atrial fibrillation, reduced left ventricular ejection fraction (LVEF), elevated hemoglobin, and higher D-dimer levels.⁸ Anticoagulant therapy is linked to a reduced risk of embolic events in patients with SEC, but persistent SEC may still occur despite treatment.¹¹,¹² 10. Conclusion This report describes a successful, integrated approach to managing one of the most feared complications of acute myocardial infarction. The proactive use of temporary pacing as a bridge to definitive reperfusion represents a powerful and translatable strategy that can enhance safety and improve outcomes in this critically ill patient population. Abbreviations ECG Electrocardiogram ECMO Extracorporeal membrane oxygenation EF Ejection fraction LAA Left atrial appendage LV Left ventricular LVEF Left ventricular ejection fraction PCI Percutaneous coronary intervention RCA Right coronary artery SEC Spontaneous echocardiographic contrast STEMI ST-elevation myocardial infarction TIMI Thrombolysis in Myocardial Infarction VF Ventricular fibrillation Declarations Ethics approval and consent to participate Not applicable. As this is a case report, ethics approval was not required. The patient provided written informed consent to participate. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Funding Not applicable. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Bougouin W, Marijon E, Puymirat E, Defaye P, Celermajer DS, Le Heuzey JY, et al. Incidence of sudden cardiac death after ventricular fibrillation complicating acute myocardial infarction: a 5-year cause-of-death analysis of the FAST-MI 2005 registry. Eur Heart J. 2014 Jan;35(2):116–22. Krummen DE, Ho G, Villongco CT, Hayase J, Schricker AA. Ventricular fibrillation: triggers, mechanisms and therapies. Future Cardiol. 2016 May;12(3):373–90. Rafie N, Kashou AH, Noseworthy PA. ECG Interpretation: Clinical Relevance, Challenges, and Advances. Hearts. 2021 Dec;2(4):505–13. Pendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, et al. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Int J Cardiol Heart Vasc. 1 2021 Apr 12;33:100767. Szabó Z, Ujvárosy D, Ötvös T, Sebestyén V, Nánási PP. Handling of Ventricular Fibrillation in the Emergency Setting. Front Pharmacol. 2019;10:1640. Elsokkari I, Sapp JL. Electrical storm: Prognosis and management. Progress in Cardiovascular Diseases. 2021 May 1;66:70–9. Eifling M, Razavi M, Massumi A. The Evaluation and Management of Electrical Storm. Tex Heart Inst J. 2011;38(2):111–21. Liang D, Shi R, Zheng KI, Zhou X, Zhu Q, Chen M, et al. Clinical characteristics and outcomes in patients with echocardiographic left ventricular spontaneous echo contrast. International Journal of Cardiology. 2021 May 1;330:245–50. Atar D, Bode C, Stuerzenbecher A, Verheugt FWA. Anticoagulants for secondary prevention after acute myocardial infarction: lessons from the past decade. Fundam Clin Pharmacol. 2014 Aug;28(4):353–63. Udell JA, Wang JT, Gladstone DJ, Tu JV. Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke. PLoS One. 2010 Aug 13;5(8):e12150. Zhou XD, Chen QF, Shan P. Reply to the letter regarding the article ‘The prevalence, predictors, and outcomes of left ventricular thrombus in HFrEF.’ ESC Heart Failure. 2024;11(5):3455–6. Zhou X, Zheng KI, Shan P. Toward reducing thrombus recurrence rate in management of patients with confirmed left ventricular thrombi. ESC Heart Failure. 2021;8(3):2359–60. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 03 Apr, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviews received at journal 02 Feb, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 08 Dec, 2025 First submitted to journal 21 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8172664","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":582262168,"identity":"59c84d6e-9a1b-49ad-a687-81f899e2d14c","order_by":0,"name":"Doan Duc Dung","email":"","orcid":"","institution":"Vinmec International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Doan","middleName":"Duc","lastName":"Dung","suffix":""},{"id":582262169,"identity":"bbac1206-43f8-481c-a30c-afd267e44992","order_by":1,"name":"Hoang Phu Quy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYHACNgaGCgYeUrWcQdbCRowWxjY0I/ACvhs5Zo8L5x2WMedf+/Ax7w6GPH75BvxaJG/kmBvP3HaYx3LGc2Nj3jMMxZJt+HUwGABtkebdlsZjcOMYmzRvG0PihmNEaZmDpGU/cVoabHgMzrdBbSHkfckzz8qkZxwDarnBxmw494xE4oxjCfi18B1P3iZdUCNhb3D+GOODtztsEvubDxCw5gCHATOYIQE0nLFBgoBysBb2BxAt/AdAWojQMQpGwSgYBSMOAAAP+j9WxONVMwAAAABJRU5ErkJggg==","orcid":"","institution":"Vinmec International Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hoang","middleName":"Phu","lastName":"Quy","suffix":""}],"badges":[],"createdAt":"2025-11-21 10:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8172664/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8172664/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101507691,"identity":"720a5c7d-c89a-4304-ba6c-69422e4d157f","added_by":"auto","created_at":"2026-01-30 14:42:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":249007,"visible":true,"origin":"","legend":"\u003cp\u003eProvided strong evidence for an occlusion of the right coronary artery (RCA) as the culprit lesion. It demonstrated significant ST-segment elevation in the inferior leads (II, III, aVF).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8172664/v1/37c0e342247c323ad586dc10.png"},{"id":101507778,"identity":"bd7539b5-e4e9-427e-bcb2-b58880600df4","added_by":"auto","created_at":"2026-01-30 14:42:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":146625,"visible":true,"origin":"","legend":"\u003cp\u003eVentricular Fibrillation with irregular electrical activity and characterized by a ventricular rate of usually greater than 300, with discrete QRS complexes.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8172664/v1/f3c1abbe6af4a0ee354fe07c.png"},{"id":101507861,"identity":"8d9c592c-c1a6-449f-990c-e22ddd2d229b","added_by":"auto","created_at":"2026-01-30 14:43:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1201371,"visible":true,"origin":"","legend":"\u003cp\u003eAngiography confirmed a thrombotic occlusion of the mid-RCA (TIMI grade 0 flow).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8172664/v1/cb70337266cc56ca69c524d8.png"},{"id":101507844,"identity":"c6c6e31f-f857-4e8f-b8f7-c2501a7af7e0","added_by":"auto","created_at":"2026-01-30 14:42:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":234187,"visible":true,"origin":"","legend":"\u003cp\u003eECG post PCI with Q wave in II, III, avF, and no ST elevation.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8172664/v1/6fde3efcce1f92498dc9b92e.png"},{"id":101752237,"identity":"262bf0a5-e806-40dd-844b-bceb26d4393e","added_by":"auto","created_at":"2026-02-03 10:26:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3168789,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8172664/v1/e6d4bd45-4767-4b66-8403-d0c27cff36ed.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Controlling the Chaos: An Integrated Strategy of Prophylactic Pacing and Primary PCI for an Ischemia-Driven Electrical Storm: a Case Report","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe paradigm for managing ST-elevation myocardial infarction (STEMI) has evolved significantly from the era of expectant management and thrombolysis to the current standard of primary percutaneous coronary intervention (PCI). Primary PCI offers a definitive mechanical solution to restore coronary patency, thereby salvaging myocardium and improving clinical outcomes. Despite these advancements, the fundamental principles of rapid diagnosis and timely reperfusion remain paramount. The electrocardiogram (ECG) serves as the primary diagnostic tool, facilitating immediate activation of care pathways. However, a significant burden of morbidity and mortality in the acute phase of STEMI is attributable not to the ischemic injury alone, but to the resultant electrical instability. Ventricular fibrillation (VF), a frequent complication, represents a major cause of sudden cardiac death in this population, underscoring the critical need for vigilant monitoring and immediate intervention.\u0026sup1;,\u0026sup2; Managing a patient through an electrical storm on the catheterization table requires not only rapid interventional skills but also a sophisticated strategy to maintain hemodynamic stability and manage recurrent cardiac arrest. This case report illustrates the successful navigation of these challenges.\u003c/p\u003e"},{"header":"2. Patient Information","content":"\u003cp\u003eA 48-year-old Korean male presented to the emergency department reporting a two-hour history of severe, substernal chest pain, described as a constant, crushing pressure (9/10 intensity) radiating to his left arm. The symptoms were not relieved by rest and were associated with diaphoresis and nausea.\u003c/p\u003e \u003cp\u003eHe had multiple untreated cardiovascular risk factors, including hypertension, dyslipidemia, and a significant smoking history. He had not taken any medication prior to arrival. Further metabolic profiling confirmed a new diagnosis of type 2 diabetes (random glucose 7.50 mmol/L, HbA1c 6.99%).\u003c/p\u003e"},{"header":"3. Clinical Findings","content":"\u003cp\u003eOn initial physical examination, the patient was alert and in moderate distress due to pain. He was hemodynamically stable with a blood pressure of 130/80 mmHg, a regular heart rate of 75 beats per minute, and oxygen saturation of 96% on ambient air. Cardiopulmonary examination was unremarkable, with normal heart sounds and clear lung fields bilaterally. There were no signs of peripheral hypoperfusion or heart failure.\u003c/p\u003e"},{"header":"4. Timeline","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate / Time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Event\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Findings / Actions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 0 \u0026ndash; ED Presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient presented with 2-hour onset of severe chest pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHemodynamically stable; ECG: inferior STEMI (RCA territory)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortly after arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSudden cardiac arrest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoarse VF \u0026rarr; CPR \u0026rarr; ROSC after one shock\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCath Lab \u0026ndash; Pre-PCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProphylactic temporary RV pacing wire inserted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo prevent post-defibrillation bradycardia/asystole\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCath Lab \u0026ndash; During PCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecurrent VF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eManaged with IV amiodarone\u0026thinsp;+\u0026thinsp;optimized defibrillation vector; ECMO team on standby\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCath Lab \u0026ndash; Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary PCI of the RCA performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThrombus aspiration\u0026thinsp;+\u0026thinsp;DES placement \u0026rarr; TIMI III flow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU (Day 0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-PCI stabilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInferior Q waves; Echo: LVEF\u0026thinsp;~\u0026thinsp;45%, dense LV SEC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 5 \u0026ndash; Discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDischarged with GDMT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDAPT, statin, beta-blocker, ARB, SGLT2i\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1-month Follow-up (planned)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRepeat echocardiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReassess LVEF and SEC resolution / LV thrombus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"5. Diagnostic Assessment","content":"\u003cp\u003eInitial laboratory investigations revealed a white blood cell count of 11.3 G/L. The initial high-sensitivity Troponin T level was 5 ng/L (reference\u0026thinsp;\u0026lt;\u0026thinsp;14 ng/L), remaining within the normal range. Renal function and electrolytes were normal.\u003c/p\u003e \u003cp\u003eThe 12-lead ECG was the decisive diagnostic tool. It demonstrated significant ST-segment elevation in the inferior leads (II, III, aVF). The pattern of ST elevation being greater in lead III than in lead II, combined with the absence of significant reciprocal ST depression in leads I and aVL, provided strong evidence for an occlusion of the right coronary artery (RCA) as the culprit lesion (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the classic ECG findings and clinical presentation, the primary diagnosis of acute coronary occlusion was clear. However, in the setting of chest pain and electrical instability, other life-threatening diagnoses such as acute aortic dissection, massive pulmonary embolism, and acute pericarditis were rapidly excluded by the clinical stability, physical exam, and definitive ECG findings.\u003c/p\u003e \u003cp\u003eBased on these definitive ECG findings, the cardiac catheterization laboratory was immediately activated for primary PCI.\u003c/p\u003e"},{"header":"6. Therapeutic Intervention","content":"\u003cp\u003eThe patient's clinical course rapidly deteriorated. Prior to transfer, he experienced a sudden cardiac arrest documented as coarse ventricular fibrillation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Immediate cardiopulmonary resuscitation was initiated, and spontaneous circulation was restored after a single defibrillation shock, marking the onset of an electrical storm.\u003c/p\u003e \u003cp\u003eUpon arrival at the catheterization laboratory, and prior to commencing angiography, a transvenous temporary pacing wire was prophylactically placed in the apex of the right ventricle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This crucial step was taken to mitigate the risk of profound post-defibrillation bradycardia or asystole.\u003c/p\u003e \u003cp\u003eShortly after, the patient developed a second episode of VF. Following a failed initial defibrillation attempt, an aggressive protocol was enacted: a 150 mg bolus of intravenous amiodarone was administered, and the defibrillation pads were repositioned. This combined approach successfully restored sinus rhythm. The institutional ECMO team was on standby.\u003c/p\u003e \u003cp\u003eWith the electrical safety net of the pacemaker in place, the team proceeded emergently with PCI. Coronary angiography confirmed a total thrombotic occlusion (TIMI grade 0 flow) of the mid-RCA. A primary PCI was performed, commencing with successful thrombus aspiration, which restored partial flow. A drug-eluting stent was then deployed, and post-dilation was performed. The final angiographic result was excellent, demonstrating complete restoration of coronary flow (TIMI grade III) with no residual stenosis or dissection (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"7. Follow-up and Outcomes","content":"\u003cp\u003eFollowing the procedure, the patient was transferred to the intensive care unit. The post-procedure ECG confirmed resolution of the ST-segment elevation, showing evolving Q waves in the inferior leads (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA post-procedural transthoracic echocardiogram revealed severe hypokinesia of the basal and mid-segments of the inferior and posterior walls, consistent with the infarct territory. The left ventricular ejection fraction (EF) was moderately reduced at 45%. A notable finding was the presence of dense Spontaneous Echocardiographic Contrast (SEC) within the left ventricular cavity, indicating significant blood stasis.\u003c/p\u003e \u003cp\u003eThe patient's subsequent clinical course was stable. He demonstrated excellent tolerance and adherence to his new medical regimen during hospitalization. He was discharged on day five on guideline-directed medical therapy, including dual antiplatelet therapy, a high-intensity statin, a beta-blocker, an angiotensin receptor blocker, and an SGLT2 inhibitor. A follow-up echocardiogram was scheduled in one month to reassess LV function and evaluate for the resolution of SEC or the development of an intracardiac thrombus.\u003c/p\u003e"},{"header":"8. Patient Perspective","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eI was told later that my heart had stopped, and I was very close to dying. Everything happened so quickly that I only remember the overwhelming chest pain and, suddenly, waking up in the hospital. I am deeply grateful for the rapid and coordinated actions of the medical team, especially the doctors who treated me in the emergency room and catheterization lab. Knowing that the treatment not only saved my life but also prevented further damage to my heart has given me great comfort. I am truly thankful for the care and attention I received during and after the procedure.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"9. Discussion","content":"\u003cp\u003eThis case illustrates several critical principles in the contemporary management of high-risk STEMI. First, the case reaffirms the primacy of the ECG in the diagnostic and triage pathway. The rapid and accurate interpretation of the ECG not only confirmed the diagnosis of STEMI but also correctly localized the culprit vessel, thereby allowing for anticipation of associated complications, such as the high propensity for atrioventricular block and ventricular arrhythmias associated with RCA occlusions.\u0026sup3;,⁴ The decision to proceed directly to reperfusion therapy based on ECG findings, without awaiting biomarker elevation, is the standard of care and was instrumental in this patient's outcome.\u003c/p\u003e \u003cp\u003eSecond, the management of this patient highlights the importance of preparedness for profound electrical instability. The occurrence of an electrical storm is a marker of high ischemic burden and carries a poor prognosis.⁵,⁶,⁷ The most innovative element was the anticipatory placement of a temporary pacing wire. The successful outcome was contingent upon a well-coordinated team response, including immediate, high-quality resuscitation and defibrillation, which served as a critical bridge to definitive mechanical reperfusion. The resolution of the arrhythmias following successful PCI underscores the causal link between acute ischemia and electrical instability.\u003c/p\u003e \u003cp\u003eFinally, and central to the theme of this report, the case emphasizes the necessity of looking beyond the immediate success of reperfusion. The post-procedural identification of SEC is a significant finding. SEC is an acoustic phenomenon representing aggregated erythrocytes and proteins in areas of blood stasis and is a well-established precursor to left ventricular thrombus formation, an independent risk factor for systemic embolism.⁸ While current guidelines for anticoagulation post-MI are primarily driven by the presence of severe LV dysfunction (EF\u0026thinsp;\u0026lt;\u0026thinsp;30%) or apical wall motion abnormalities, the presence of dense SEC in a patient with moderately reduced EF presents a clinical challenge.⁹,\u0026sup1;⁰ This finding necessitates a heightened level of surveillance. The decision to schedule a follow-up echocardiogram represents a patient-specific risk stratification strategy.\u003c/p\u003e \u003cp\u003eKey risk factors for SEC and subsequent embolism include advanced age, atrial fibrillation, reduced left ventricular ejection fraction (LVEF), elevated hemoglobin, and higher D-dimer levels.⁸ Anticoagulant therapy is linked to a reduced risk of embolic events in patients with SEC, but persistent SEC may still occur despite treatment.\u0026sup1;\u0026sup1;,\u0026sup1;\u0026sup2;\u003c/p\u003e"},{"header":"10. Conclusion","content":"\u003cp\u003eThis report describes a successful, integrated approach to managing one of the most feared complications of acute myocardial infarction. The proactive use of temporary pacing as a bridge to definitive reperfusion represents a powerful and translatable strategy that can enhance safety and improve outcomes in this critically ill patient population.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectrocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECMO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExtracorporeal membrane oxygenation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEjection fraction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft atrial appendage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft ventricular\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLVEF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft ventricular ejection fraction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous coronary intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRight coronary artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpontaneous echocardiographic contrast\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTEMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eST-elevation myocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThrombolysis in Myocardial Infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVentricular fibrillation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable. As this is a case report, ethics approval was not required. The patient provided written informed consent to participate.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNot applicable. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBougouin W, Marijon E, Puymirat E, Defaye P, Celermajer DS, Le Heuzey JY, et al. Incidence of sudden cardiac death after ventricular fibrillation complicating acute myocardial infarction: a 5-year cause-of-death analysis of the FAST-MI 2005 registry. Eur Heart J. 2014 Jan;35(2):116\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eKrummen DE, Ho G, Villongco CT, Hayase J, Schricker AA. Ventricular fibrillation: triggers, mechanisms and therapies. Future Cardiol. 2016 May;12(3):373\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eRafie N, Kashou AH, Noseworthy PA. ECG Interpretation: Clinical Relevance, Challenges, and Advances. Hearts. 2021 Dec;2(4):505\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003ePendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, et al. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Int J Cardiol Heart Vasc. \u003csup\u003e1\u003c/sup\u003e2021 Apr 12;33:100767.\u003c/li\u003e\n \u003cli\u003eSzab\u0026oacute; Z, Ujv\u0026aacute;rosy D, \u0026Ouml;tv\u0026ouml;s T, Sebesty\u0026eacute;n V, N\u0026aacute;n\u0026aacute;si PP. Handling of Ventricular Fibrillation in the Emergency Setting. Front Pharmacol. 2019;10:1640.\u003c/li\u003e\n \u003cli\u003eElsokkari I, Sapp JL. Electrical storm: Prognosis and management. Progress in Cardiovascular Diseases. 2021 May 1;66:70\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eEifling M, Razavi M, Massumi A. The Evaluation and Management of Electrical Storm. Tex Heart Inst J. 2011;38(2):111\u0026ndash;21.\u003c/li\u003e\n \u003cli\u003eLiang D, Shi R, Zheng KI, Zhou X, Zhu Q, Chen M, et al. Clinical characteristics and outcomes in patients with echocardiographic left ventricular spontaneous echo contrast. International Journal of Cardiology. 2021 May 1;330:245\u0026ndash;50.\u003c/li\u003e\n \u003cli\u003eAtar D, Bode C, Stuerzenbecher A, Verheugt FWA. Anticoagulants for secondary prevention after acute myocardial infarction: lessons from the past decade. Fundam Clin Pharmacol. 2014 Aug;28(4):353\u0026ndash;63.\u003c/li\u003e\n \u003cli\u003eUdell JA, Wang JT, Gladstone DJ, Tu JV. Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke. PLoS One. 2010 Aug 13;5(8):e12150.\u003c/li\u003e\n \u003cli\u003eZhou XD, Chen QF, Shan P. Reply to the letter regarding the article \u0026lsquo;The prevalence, predictors, and outcomes of left ventricular thrombus in HFrEF.\u0026rsquo; ESC Heart Failure. 2024;11(5):3455\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eZhou X, Zheng KI, Shan P. Toward reducing thrombus recurrence rate in management of patients with confirmed left ventricular thrombi. ESC Heart Failure. 2021;8(3):2359\u0026ndash;60.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Myocardial Infarction, STEMI, Ventricular Fibrillation, Electrical Storm, Percutaneous Coronary Intervention","lastPublishedDoi":"10.21203/rs.3.rs-8172664/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8172664/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e 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.\u003c/p\u003e","manuscriptTitle":"Controlling the Chaos: An Integrated Strategy of Prophylactic Pacing and Primary PCI for an Ischemia-Driven Electrical Storm: a Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 14:41:36","doi":"10.21203/rs.3.rs-8172664/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T21:47:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T15:59:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104924581651312762244709487533019314334","date":"2026-02-05T15:32:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-02T18:30:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44245774599707727938874141917936854475","date":"2026-01-30T11:55:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-28T10:04:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T06:04:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-08T06:03:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-11-21T10:33:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"76620185-9848-4bff-b202-da18a5574274","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-03T21:53:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 14:41:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8172664","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8172664","identity":"rs-8172664","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}