Antiarrhythmic drug therapy is a cornerstone in managing electrical storm (ES). Data on the safety and efficacy of antiarrhythmic drugs besides beta-blockers and amiodarone are limited. This retrospective observational study aimed to assess the potential role of ajmaline in patients with ES refractory to guideline-recommended care. Adult patients admitted to the intensive care unit owing to ES between 2013 and 2023 who received ajmaline for therapy-refractory ES were retrospectively analyzed. 46 of 332 patients with recurrent ventricular tachycardia/ventricular fibrillation (mean age 64 ± 11 years; 93% male; mean left ventricular ejection fraction 33% ± 12%; 78% with implanted implantable cardioverter-defibrillator) were treated with intravenous ajmaline. Most patients (98%) had known structural heart disease. Serious adverse events requiring discontinuation were not observed. Minor adverse events occurred in 3 patients (7%). Complete arrhythmia suppression was achieved in 34 patients (74%), partial suppression in 2 (4%), and ventricular tachycardia slowing in 5 (11%). In 5 patients (11%), ajmaline showed no effect. During hospitalization, 5 patients (11%) died: 2 (4%) because of multiorgan failure and 3 (7%) because of a combined septic and cardiogenic shock despite complete or partial arrhythmia suppression by ajmaline. 28 patients (61%) underwent catheter ablation, and 41 patients (89%) were discharged in stable rhythm. After a 6-month follow-up, 15 patients were lost to follow-up and 24 of the 26 remaining patients were still alive. In selected patients with refractory ES, intravenous ajmaline treatment was associated with a reduction in ventricular arrhythmias and a favorable safety profile. Ajmaline may serve as a valuable bridge to definitive treatment in life-threatening ES.

Anti-arrhythmic drugs (AAD) and catheter ablation are common treatments for rhythm control in patients with atrial fibrillation (AF), but a comprehensive comparison of their benefits and harms is lacking. A systematic review performed by National Institute for Health and Care Excellence (2021) was updated using a database search in MEDLINE, Embase and Cochrane CENTRAL in October 2024. Selection was conducted independently by 2 reviewers. Study characteristics and results were extracted by 1 reviewer and verified by a second. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was determined using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Twenty-two studies (31 references) were included in the review. Evidence showed that there may be more recurrence of AF in patients with treatment-naïve paroxysmal AF (relative risk [RR], 1.76; 95% confidence interval [CI], 1.34-2.32) and AAD-exposed persistent AF (RR, 1.62; 95% CI, 1.40-1.87), and probably more recurrence in patients with paroxysmal AF previously exposed to catheter ablation (RR, 2.12; 95% CI, 1.61-2.80) when treated with AAD compared with catheter ablation. In both paroxysmal- and persistent AF patients, there may also be more all-cause mortality when treated with AAD vs catheter ablation (RR, 1.79; 95% CI, 0.80-4.02 and RR, 1.45; 95% CI, 0.56-3.75, respectively). Incidence of medication side effects, including gastrointestinal symptoms and syncope, ranged between 0.8 and 3%. Incidence of catheter ablation complications, such as pericardial tamponade and phrenic nerve paralysis, between 0.3 and 2.5%. This review found that, in some subgroups of patients, catheter ablation was better than AAD treatment when considering AF recurrence and mortality. However, catheter ablation has rare but serious complications that should be considered when making informed treatment decisions.