2019 FSA Posters

P050: INTRAOPERATIVE STELLATE GANGLION BLOCK TO TREAT REFRACTORY VENTRICULAR TACHYARRHYTHMIA
Justin Beitel, MD, Anwar Mack, MD, Monica Mordecai, MD; Mayo Clinic

Introduction: The use of stellate ganglion block (SGB) to treat ventricular tachycardia and ventricular fibrillation (VF) has been discussed in the cardiology literature but there is sparse evidence of its use in the perioperative setting. We report one such case where SGB was used to treat refractory VF in a patient following bypass after LVAD exchange. Our patient was a 73 year-old male with medical history significant for hypertension, multiple myocardial infarctions, aortic insufficiency status post aortic valve replacement, ischemic cardiomyopathy status post HeartWare HVAD implant and recurrent ventricular arrhythmias status post biventricular Implantable cardioverter defibrillator (BIV ICD) placement. The patient was admitted with suspected LVAD pump thrombosis. Initial medical management was attempted; however, subsequently they required surgery for LVAD exchange.

Methods/Results: Preoperative Echocardiogram demonstrated HVAD in place, Left ventricular enlargement, Ejection Fraction 11%, 23mm St. Jude Medical porcine aortic valve prosthesis with mild anterior paravalvular leak. Intraoperatively fibrillation was induced by surgeon while on bypass. During the transition off of bypass he remained unresponsive to various treatments including: Defibrillation, Amiodarone, Esmolol, Lidocaine, Magnesium, and Procainamide. Ultimately, bilateral SGB was preformed using ultrasound and 10cc of 0.5% Ropivacaine was used. The patient converted to sinus rhythm.

Discussion: Refractory ventricular tachyarrhythmias can be very difficult to manage in post-cardiac bypass patients. Whereas SGB is  more commonly used for treatment of chronic pain, it also effectively blocks the cardiac acceleratory fibers.1 A literature review found one similar case where SBG was used to treat refractory VT that had persisted for 36 hours.2 Cardiology literature discusses the use of SGB for treatment of cardiac electrical storm, which is the occurrence of at least three ventricular arrhythmias leading to defibrillation or antitachycardia pacing within 24 hours.3 Although the use of SBG can be effective in treatment of ventricular arrhythmias, it is still commonly used as a final alternative when conventional therapy fails.

References:

Rajesh MC, Deepa KV, Ramdas EK. Stellate ganglion block as rescue therapy in refractory ventricular tachycardia. Anesth Essays Res. 2017 Jan-Mar, 11(1): 266-267

Loyalka P, Hariharan R, Gholkar G, Gregoric I, Tamerisa R, Nathan S, Kar B. Left stellate ganglion block for continuous ventricular arrhythmias: during percutaneous left ventricular assist device support. Texas Heart Institute Journal. 2011 38(4): 409-411.

Abrich V, Beshai J. Left Stellate Ganglion Block: Increasing Clinician awareness in the eye of the electrical storm – Expert analysis. American College of Cardiology – Latest in Cardiology. 2017. https://www.acc.org/latest-in-cardiology/articles/2017/01/10/12/11/left-stellate-ganglion-block