2020 FSA Posters
P089: STELLATE GANGLION BLOCK FOR REFRACTORY VENTRICULAR TACHYCARDIA
Jose L Mora, MD; Daniel A Perez, MD; Ralf E Gebhard, MD; Jackson Memorial Hospital
Introduction: In patients with refractory ventricular tachycardia (VT), which may also be referred to as electrical storm (≥3 episodes of sustained VT over a 24-hour period), the use of a stellate ganglion block (SGB) may serve as a diagnostic and temporizing measure prior to definitive therapy.
Case Presentation: This is a case of a 60 year old male with a PMH of a pulmonary embolus on apixaban, CAD with history of a STEMI with bare metal stent placed in the LAD, heart failure with reduced ejection fraction (EF of 15%) requiring a cardiac resynchronization therapy-defibrillator (CRT-D) who presents to the emergency room with a chief complaint of chest pain and defibrillator activation. On presentation, the patient was found to be in sustained VT that was refractory to lidocaine and amiodarone boluses. The patient was started on amiodarone and lidocaine infusions as well as oral propranol with abortion of the arrhythmia and return to normal sinus rhythm. The patient was then transferred to the ICU undergoing AV pacing. 48 hours later, the patient had further episodes of sustained VT despite his anti-arrhythmic therapy. This prompted the treating physician to consult the Acute Pain Service for SGB.
The patient underwent ultrasound-guided left SGB. The technique was performed using a 22 gauge, 50 millimeter, short bevel needle. Eighteen milliliters of 0.5% ropivicaine were administered around the stellate ganglion. The block was performed over the course of 3 minutes with no procedural complications.
Over the subsequent 8 hours following the SGB, the patient had no further episodes of VT. The patient underwent a left stellate ganglionectomy as performed by the cardiothoracic surgeons. The patient was eventually discharged in stable condition without evidence of life threatening arrhythmias.
Discussion: The annual incidence of refractory VT can vary between 2-10% and carries with it a severely increased risk of mortality. It has been well documented that the sympathetic nervous system (SNS) plays a vital role in the propagation of refractory VT. As the least invasive method currently available to target the SNS, an SGB will provide valuable information as to whether a patient is likely to benefit from definitive cardiac denervation procedures. An SGB can even be used as ongoing treatment as was shown in case report published in the Journal of Cardiovascular Electrophysiology in 2013 when a patient with refractory VT was deemed not a surgical candidate was managed with bi-weekly bilateral SGB.1 Although research is lacking in this area, for patients experiencing episodes of refractory VT, SGB serves as a safe and effective therapy to guide further treatment.
References:
1) Hayase, Justin, et al. “Percutaneous SGB Suppressing VT and VF in a Patient Refractory to VT Ablation.” Journal of Cardiovascular Electrophysiology, U.S. National Library of Medicine, Aug. 2013,
2) Tian Y, Wittwer ED, Kapa S, McLeod CJ, Xiao P, Noseworthy PA, Mulpuru SK, Deshmukh AJ, Lee H-C, Ackerman MJ, Asirvatham SJ, Munger TM, Liu X-P, Friedman PA, Cha Y-M. Effective use of percu-taneous SGB in patients with electrical storm. Circ Arrhythm Electrophysiol. 2019;12:e007118. doi: 10.1161/CIRCEP. 118.007118