Stellate Ganglion Block as Rescue Therapy in Refractory Ventricular Tachycardia.

Pain physicians and anesthesiologists routinely perform stellate ganglion block for the treatment of painful upper extremity sympathetic dystrophy. Close proximity of ganglion to vascular structures warrants some expertise and training in the procedure. Off late, successful use of the technique in intractable ventricular tachyarrhythmias has come in literature. We have few cases wherein we could successfully ablate intractable ventricular tachycardia with stellate block which was refractory to repeated shocks. We are reporting one such case with the intention of making an awareness in the anesthesia community about this treatment option.

INTRODUCTION

Stellate ganglion block (SGB) for ventricular tachyarrhythmia is now a well-recognized option.[1] Case reports of the same have come in literature in the last few years. Paratracheal approach guided by anatomical landmarks is the conventional technique. But can also be facilitated more accurately with the advent of ultrasonography, computerized tomography, (CT) and magnetic resonance imaging (MRI). Although technically challenging because of close proximity to vascular structures, the procedure can be easily mastered and can be lifesaving in occasional patients.

CASE REPORT

A 63-year-old male hypertensive, diabetic with coronary artery disease patient admitted with a history of palpitation and syncopal attacks. He had coronary artery bypass grafting done 18 years back and is on implanted cardioverter defibrillator. He had angioplasty and stent inserted in the proximal and distal segments of left coronary artery 2 years back. Because of his poor myocardial function, he was advised cardiac transplantation. Electrocardiogram taken at admission showed low rate ventricular tachycardia. Echocardiogram revealed an ejection fraction of 15%. At hospital, he received multiple shocks of 100 joules which only temporarily terminated the ventricular tachycardia. Biochemical parameters showed hypokalemia and accordingly he is on potassium correction drip. Patient was receiving dytor, nebicard, ecosprin, amiodarone, atorvastatin, ecosprin, and ivabrad. Because he is getting continuous ventricular tachycardia, anesthesiologist was called in for percutaneous stellate block for termination of arrhythmia. Patient received left SGB block with 0.2% ropivacaine 10 ml with which we could successfully ablate the arrhythmia [Figures 1 and 2].

Figure 1

ECG before SGB.

Figure 2

ECG after SGB with successful ablation of electrical storm.

DISCUSSION

SGB is a well-accepted technique for diagnostic and therapeutic procedures of sympathetically mediated pain and for vascular insufficiencies of upper extremities. Because it effectively blocks cardio- accelerator fibers, left stellate has used to treat long QT syndrome.[2] A successful stellate block induces a significant decrease in QT and QTc intervals.[2] This can reduce the incidence of syncope and sudden death. However, the routine use of left SGB as a therapeutic modality in acute phase of refractory ventricular arrhythmia is yet to establish in treatment protocol, even though there are few case reports in literature. The same holds true for the textbook description SGB, wherein the indication of this technique does not suggest it for refractory ventricular arrhythmias. Managing patients with electrical storm in line with advanced cardiac life support (ACLS) guidelines is known to have a poor outcome. Hence, there is a scope to evaluate alternative therapeutic options.

Among the different approaches to SGB, we employed the classical anterior paratracheal approach described by Moore and Bridenbaugh.[3] It can also be performed under fluoroscopy, CT, MRI, or ultrasound imaging.[4] Complications such as accidental intravascular injection, brachial plexus and recurrent laryngeal nerve palsy, injury to trachea, and esophagus are known but fortunately rare. Left SGB can also result in an imbalance in myocardial contractility and asynchrony of the left ventricle.[5] Hence, there is an attached risk of residual left ventricular dysfunction. However, there are studies showing that in patients without a significant cardiovascular disease, left stellate block is unlikely to produce any clinically deleterious effects on the left ventricular function.[6] Combination of left and right SGB was also used for the successful reversal of inappropriate sinus tachycardia which was medically refractory.[7] Whether the SGB is superior to ACLS guidelines is yet to establish, but there is at least one study which showed the superiority of sympathetic blockade to the antiarrhythmic protocol of ACLS.[8] Although we had only modest number of cases, we are reporting one such case with the intention of sensitizing larger scientific community. In fact, in one such case, we put a catheter (Contiplex D - B. Braun) near the ganglion and infused with 0.2% ropivacaine in a continuous fashion.

CONCLUSIONS

SGB can be considered a treatment option in refractory ventricular tachycardia which is resistant to pharmacotherapy and repeated shocks. Whether it will evolve as a primary modality of treatment depends on future research and from the results of large case series.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.