Abstract
<title>Abstract</title> <p>Background Electrical storm (ES) is defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours, typically requiring electrical cardioversion or defibrillation. It represents a life-threatening cardiovascular emergency with high mortality. Existing studies on ES predominantly focus on acute myocardial infarction or postoperative cardiac surgery populations, while there is a paucity of published literature describing perioperative ES during laparoscopic biliary surgery, particularly in patients with a completely normal preoperative electrocardiogram (ECG). Case presentation We report a 58-year-old male admitted for recurrent abdominal pain and jaundice. He had a long-term smoking history and newly diagnosed hypertension, but denied any typical angina symptoms. Preoperative 12-lead ECG was unremarkable, with baseline electrolytes and myocardial biomarkers within normal ranges. During laparoscopic biliary surgery under general anesthesia, two brief episodes of VT occurred shortly after induction, followed by two episodes of VT degenerating into VF intraoperatively, requiring repeated defibrillation. Postoperatively, the patient developed refractory recurrent ES despite optimized management, including potassium and magnesium repletion, intravenous infusion of amiodarone, lidocaine and esmolol, deep sedation, and stellate ganglion block. Common precipitating factors including electrolyte imbalance, acid-base disturbance, anesthetic agent-related arrhythmogenic effect and biliary sepsis were excluded via serial laboratory and clinical assessments. Serial ECG after repeated defibrillation demonstrated dynamic ST-segment depression and peaked T waves in anterior leads, which progressed to poor R wave progression and T-wave inversion. ES persisted on the second and third postoperative days. After multidisciplinary discussion, urgent coronary angiography was performed, revealing 90% stenosis in the mid-left anterior descending (LAD) artery, and distal left circumflex artery (LCX) stenosis with 80% concomitant coronary vasospasm. Intracoronary nitroglycerin injection fully relieved the LCX vasospasm. A drug-eluting stent was successfully implanted in the LAD, with no intraprocedural VT episodes. Following percutaneous coronary intervention (PCI), VT occurred once every two days, but with shorter duration, milder hemodynamic compromise and reduced cardioversion energy requirements. The patient ultimately achieved complete symptom resolution, with gradual recovery of cardiac function during one month follow-up, left ventricular ejection fraction recovered to normal range. Conclusion This case illustrates that clinicians should remain alert to the risk of perioperative malignant arrhythmia in patients with multiple cardiovascular risk factors undergoing non-cardiac surgery, even in the setting of a normal preoperative ECG. For unexplained refractory perioperative ES, urgent coronary angiography may be considered as a diagnostic and therapeutic strategy after exclusion of common etiologies. Coronary vasospasm, undetectable on routine preoperative ECG, is an important potential trigger of perioperative ES, and laparoscopic pneumoperitoneum may serve as a contributing precipitating factor. Trial registration Clinical trial number: Not applicable (case report)</p>