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Abstract
Introduction
Case Reports
Discussion
Conclusion
References
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  Table of Contents 
CASE REPORT
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 183-186
 

Stellate ganglion block and neurolysis for refractory ventricular arrhythmia


1 Department of Neuroanesthesia and Pain Medicine, Fortis Hospital, Noida, India
2 Department of Anesthesiology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
3 Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala, India
4 Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission01-Feb-2021
Date of Decision05-May-2021
Date of Acceptance10-Jun-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Bhavna Gupta
All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_13_21

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  Abstract 


Enhanced electrical activity, ventricular arrhythmia (VA), and cardiac instability due to increased sympathetic tone may be refractory to standard medical treatment and ablation procedures. Stellate ganglion block (SGB) has been used to treat refractory VA; however, there is insufficient information in the literature on its long-term outcome. Herein, we described three patients that were successfully treated with ultrasound-guided left SGB (LSGB) and chemical neurolysis. Ultrasound-guided LSGB may be considered as rescue or bridge therapy for stabilizing ventricular rhythm before a definitive procedure is planned.


Keywords: Before a definitive procedure is planned, therapy for stabilizing, ventricular rhythm


How to cite this article:
Aggarwal A, Balyan R, Suresh V, Gupta B. Stellate ganglion block and neurolysis for refractory ventricular arrhythmia. Indian Anaesth Forum 2021;22:183-6

How to cite this URL:
Aggarwal A, Balyan R, Suresh V, Gupta B. Stellate ganglion block and neurolysis for refractory ventricular arrhythmia. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:183-6. Available from: http://www.theiaforum.org/text.asp?2021/22/2/183/326969





  Introduction Top


Recurrent and refractory ventricular arrhythmias (VAs) are major hemodynamic events that predict morbidity and mortality in cardiac disease patients.[1] Medical and cardiac-electrophysiological therapies aimed at downscaling these arrhythmias can significantly improve the patient outcomes.[2] The role of the autonomic nervous system (ANS) in the escalation of cardiac arrhythmogenicity must not be overemphasized; however, down-regulatory ANS therapies are not without systemic adverse effects.[3] Novel therapies such as cardiac sympathetic denervation, catheter ablation of arrhythmia trigger zone, thoracic epidural blockade (TEB), spinal cord stimulation (SCS), and stellate ganglion blocks (SGB) assume relevance in this context.[4]

SGB, a widely used diagnostic/treatment modality for vascular insufficiency and sympathetically mediated upper extremity pain, has gained considerable acclaim for managing highly selected cases of refractory VA.[5] We report three patients with refractory VA management due to varied etiology, who were treated with left SGB (LSGB) under ultrasonography and fluoroscopy guidance. Written informed consent was obtained from all the participating patients or their legal representatives.


  Case Reports Top


Case 1

A 54-year-old male patient diagnosed with hypertrophic obstructive cardiomyopathy, with left ventricular ejection fraction (LVEF) 45% presented to us with episodes of recurrent symptomatic ventricular tachycardia (VT) [Table 1]. The patient had undergone alcohol septal-ablation and implantable cardioverter-defibrillator (ICD) placement 3 months prior. Subsequently, the patient had undergone radiofrequency ablation of VT trigger zone with 3-dimensional mapping using the CARTO mapping system. Under fluoroscopic and ultrasonographic guidance, we performed an LSGB with bupivacaine 0.5% and subsequently left stellate ganglion chemical neurolysis with phenol [Figure 1]c. Sinus rhythm with intermittent sinus tachycardia was achieved immediately after the procedure. Thereafter, on 8 months periodic follow-up, the patient remained free of VA, and medical management was de-escalated to single oral anti-arrhythmic.
Table 1: Demographic and patient characteristics of the cases studied

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Figure 1: (a and b) Lateral axial view of the ultrasound neck image at the C7 vertebral level. (a) Showing identification of C7 transverse process and surrounding structures for giving stellate ganglion block at an appropriate level. (b) Showing echogenic needle trajectory approaching the target point toward cervical sympathetic chain and stellate ganglion. (c) Oblique and anti-posterior fluoroscopic images of the stellate ganglion block's performance. The stellate ganglion, composed of the inferior cervical ganglion and the first thoracic ganglion, is anterior to the first rib's neck, extending to the lower side of the transverse process of the 7th cervical vertebrae. C-arm was obliquely rotated to the left to allow adequate visualization of the neural fortamine. The needle was directed at the uncinate process's junction with the vertebra

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Case 2

A 62-year-old female patient with acute myocardial infarction (LVEF 25%) underwent percutaneous coronary intervention (PCI). PostPCI, the patient was mechanically ventilated (MV) because of ongoing congestive heart failure. The patient sustained recurrent VT intractable to lignocaine and amiodarone intravenous (IV) infusions in the intensive care unit. Check coronary angiogram revealed no residual or subacute thrombus. We conducted LSGB [Figure 1]a and [Figure 1]b using a local anesthetic (LA) after which, anti-arrhythmic infusions were tapered and discontinued and block repeated after 48 h with similar dose of LA [Table 1]. The patient was serially weaned off from MV and anti-arrhythmic infusions.

Case 3

A 68-year-old patient with triple-vessel coronary artery disease developed recurrent VT with cardiogenic shock immediately following coronary artery bypass graft surgery [Table 1]. Arrhythmia is resistant to medical management (IV amiodarone, lignocaine, and esmolol infusion) and electrical cardioversion. Bedside ultrasound-guided LSGB [Figure 1]a and [Figure 1]b terminated VT, however the patient was on mechanical ventilation and hemodynamics was supported with noradrenaline and intra-aortic balloon pump and arrhythmia were controlled on amiodarone infusion. However, on the 5th postoperative day, this patient succumbed to a resistant cardiogenic shock.


  Discussion Top


Electrical storm (ES) refers to a sustained cardiac electrical instability, with recurrent hemodynamically unstable VA (≥3 episodes in 24 h), which needs intervention with a defibrillator/ICD.[1] Sympatho-excitatory activity is etiopathogenic to ES and VA, often encountered in patients with acute MI, dyselectrolytemia, arrhythmogenic drug therapy, hyperthyroidism, infection, and/or fever.[6] The therapeutic approaches such as LSGB, SCS, and TEB aim at modulating this accelerated adrenergic tone.[3],[4] The LSGB can be used as a rescue therapy following catheter ablation or patients with cardiopulmonary collapse and as a bridge before catheter ablation in drug-resistant VA.

Left stellate ganglion is the site of the majority of efferent sympathetic outflow to the heart.[4] LSGB, devoid of systemic effects of SCS and TEB, and reduces the VA's risk by blocking cardio-accelerator fibers. Mediation of nonnoradrenaline synaptic pathways with Neuropeptide Y and Galanin is unique to postganglionic axons of the stellate ganglion.[7] The standard treatment does not address these mechanisms. LSGB offers the upper hand of interrupting noradrenaline signaling and “blocking” additional signaling pathways, irrespective of the VA triggering mechanisms.[8] The longer duration of LSGB relative to the half-life of LA is most likely related to neuroplasticity that allows the ganglion to reset, reducing sympathetic stimulation. We followed the lateral approach for ultrasonography-guided LSGB associated with less risk of injury to vascular and visceral structures.[9]

Nademanee et al. have demonstrated the superiority of LSGB-like sympathetic block-guided therapy over ACLS-guided therapy in recurrent VA with low 1-week mortality and high 1st-year survival (P < .0001).[6] Recent research and meta-analysis on the influence of SGB in resistant VA have evidenced its efficacy in terms of mortality and de-escalation of medical therapy.[8],[9],[10],[11] Nevertheless, this literature is plagued by a low sample of cases (35 cases from 22 studies/case reports[5] and 38 cases from 23 studies/case reports);[8] selection bias of retrospective data from the positive study result cases; variable outcome parameters and lack of control groups. Our case reports uniquely demonstrate the efficacy of LSGB in VA resistant to ablative interventions and VA refractory to ICD. We also used LSGB as a rescue/bridging therapy in hemody namically unstable patients before trigger-zone ablation/ICD placement. LSGB is also feasible in patients on anti-coagulation where TEB and SCS are contraindicated.[12] Further, the bedside performance of LSGB is an added advantage in unstable patients on MV who cannot otherwise be mobilized to catheterization laboratory. Prospective studies with a larger pool of cases in future can further delineate the exact position of LSGB in resistant VA.


  Conclusion Top


LSGB may serve as a rescue option in refractory cases to standard treatment protocols for patients with VA. It can reasonably be recommended as an alternative therapy or as part of combination therapy for the management of ES or recurrent VA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gao D, Sapp JL. Electrical storm: Definitions, clinical importance, and treatment. Curr Opin Cardiol 2013;28:72-9.  Back to cited text no. 1
    
2.
Albert CM, Stevenson WG. The future of arrhythmias and electrophysiology. Circulation 2016;133:2687-96.  Back to cited text no. 2
    
3.
Shen MJ, Zipes DP. Role of the autonomic nervous system in modulating cardiac arrhythmias. Circ Res 2014;114:1004-21.  Back to cited text no. 3
    
4.
Shivkumar K, Ajijola OA, Anand I, Armour JA, Chen PS, Esler M, et al. Clinical neurocardiology defining the value of neuroscience-based cardiovascular therapeutics. J Physiol 2016;594:3911-54.  Back to cited text no. 4
    
5.
Fudim M, Boortz-Marx R, Ganesh A, Waldron NH, Qadri YJ, Patel CB, et al. Stellate ganglion blockade for the treatment of refractory ventricular arrhythmias: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2017;28:1460-7.  Back to cited text no. 5
    
6.
Nademanee K, Taylor R, Bailey WE, Rieders DE, Kosar EM. Treating electrical storm: Sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation 2000;102:742-7.  Back to cited text no. 6
    
7.
Herring N, Cranley J, Lokale MN, Li D, Shanks J, Alston EN, et al. The cardiac sympathetic co-transmitter galanin reduces acetylcholine release and vagal bradycardia: Implications for neural control of cardiac excitability. J Mol Cell Cardiol 2012;52:667-76.  Back to cited text no. 7
    
8.
Meng L, Tseng CH, Shivkumar K, Ajijola O. Efficacy of stellate ganglion blockade in managing electrical storm: A systematic review. JACC Clin Electrophysiol 2017;3:942-9.  Back to cited text no. 8
    
9.
Ghai A, Kaushik T, Kundu ZS, Wadhera S, Wadhera R. Evaluation of new approach to ultrasound guided stellate ganglion block. Saudi J Anaesth 2016;10:161-7.  Back to cited text no. 9
    
10.
Gadhinglajkar S, Sreedhar R, Unnikrishnan M, Namboodiri N. Electrical storm: Role of stellate ganglion blockade and anesthetic implications of left cardiac sympathetic denervation. Indian J Anaesth 2013;57:397-400.  Back to cited text no. 10
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11.
Tian Y, Wittwer ED, Kapa S, McLeod CJ, Xiao P, Noseworthy PA, et al. Effective use of percutaneous stellate ganglion blockade in patients with electrical storm. Circ Arrhythm Electrophysiol 2019;12:e007118.  Back to cited text no. 11
    
12.
Ganesh A, Qadri YJ, Boortz-Marx RL, Al-Khatib SM, Harpole DH Jr., Katz JN, et al. Stellate ganglion blockade: An intervention for the management of ventricular arrhythmias. Curr Hypertens Rep 2020;22:100.  Back to cited text no. 12
    


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