P037: CONTINUOUS STELLATE GANGLION BLOCK AS TREATMENT FOR VENTRICULAR TACHYCARDIA STORM IN A PATIENT WITH LEFT VENTRICULAR MASS
Asad H Bashir, MD; Barys Ihnatsenka, MD; University of Florida
Introduction: Ventricular tachycardia storm (VTS) is a life-threatening medical emergency that is defined as ≥3 episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) occurring within 24 hours and requiring intervention . Sustained VT is when the rhythm lasts longer than thirty seconds or hemodynamic instability occurs . The most common cause of VT is underlying ischemic heart disease.  In patients with underlying structural heart disease, sustained monomorphic ventricular tachycardia (SMVT) is usually seen attributable to a myocardial substrate . VT and VF cause most cases of sudden cardiac death with an estimated rate of 300,000 deaths each year in the United States.  Treatment for sustained VT can include medication management, ablation therapy or implantable devices. Here we present a case of VTS refractory to medical management which was temporarily treated with a continuous stellate ganglion block prior to pacemaker placement.
Methods: A 51-year-old female with a newly diagnosed ventricular mass had developed VTS with SMVT unresponsive to medical management. Cardiac MRI showed a 5.6 x 4.4 by 2.6 cm mass in the left ventricle. She was treated with an amiodarone infusion upon presentation to the hospital followed by a lidocaine infusion in the intensive care unit and direct current cardioversion. Despite those treatment modalities patient remained in VT and our team was consulted for the management of VTS.
We placed a left stellate ganglion catheter with 0.2% ropivacaine infusion. The anterior paratracheal approach utilizing anatomic landmarks and ultrasound guidance was used to complete the block. Post catheter placement there was an immediate response with HR decreasing to the range of 50-60. The lidocaine infusion was subsequently discontinued due to concern for local anesthetic toxicity. Our patient had the catheter in place for 6 days providing sinus rhythm while the primary team formulated options for subsequent treatment. The patient underwent an open thoracotomy procedure with cardiopulmonary bypass to obtain a biopsy, during which ventricular leads were placed as well. The mass was diagnosed as an oligometastatic melanoma to the heart. Post lead placement she was able to be V paced in the ICU allowing heart rate control as needed and eventually received a pacemaker with electrophysiology team upon recovery from her surgery.
Results: The stellate ganglion block provided immediate decrease in heart rate. Patient was also noted to develop features of left sided Horner syndrome attributed to the sympathetic block.
Discussion/Conclusion: In conclusion, sustained ventricular arrhythmia in a patient with large ventricular mass can be a challenging case requiring an interdisciplinary team. The use of a continuous stellate ganglion block can provide an effective treatment option in patients with ventricular tachycardia storm unresponsive to initial medical management. Possible mechanism of action is sympathetic block of the cervical sympathetic chain (mid and inferior ganglion). If local anesthetic infiltration is successful in reducing heart rate, ganglion ablation with alcohol is another therapeutic option which may be considered. Future research can further assist in understanding the efficacy of this treatment and to determine ideal patient populations for its use.