Autonomic Modulation for the Treatment of Ventricular Arrhythmias: Therapeutic Use of Percutaneous Stellate Ganglion Blocks

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Case 1: A 52‐year‐old man with nonischemic cardiomyopathy with a left ventricular ejection fraction of 30–35%, and prior ventricular tachycardia status postsecondary prevention ICD implantation suffered sudden cardiac arrest as a passenger in a car. A week prior to the index hospitalization, he suffered his first VT episode while exercising. Emergency services found the man to be in polymorphic VT (Fig. 1A). Following successful defibrillation (5 attempts) and intubation, he was transferred to our institution. In the subsequent hours, the patient continued to experience polymorphic VT with progressively worsening cardiac shock. Antiarrhythmic therapies included intravenous amiodarone and lidocaine. Due to progressive hypotension, he was started on epinephrine, phenylephrine, and vasopressin drips and then initiated on peripheral venoarterial extra corporeal membrane oxygenation (ECMO). During his first 12 hours in the hospital, he had 16 episodes of VT without any sign of improvement despite aggressive medical and mechanical support. Since the patient was deemed to be too unstable to undergo catheter ablation of his PVC triggers, wait in the current state for heart transplantation or to be transitioned to a univentricular support system such as durable left ventricular assist device (LVAD), a decision was made to pursue bilateral percutaneous anesthetic stellate ganglion nerve block.
A 22‐gauge, 3.5 spinal needle was placed under continuous ultrasound guidance on the left side anterior to the C7 tubercle with vessels in view and avoided throughout the placement. Then 10 mL of 2% lidocaine was injected following negative aspiration. Diffusion of the injectate was observed at the target location (Fig. 2). The procedure was then repeated on the right side utilizing the outlined technique.
Immediately following the nerve block, we observed a drop in the heart rate and a reduction in premature ventricular complexes (PVC; Fig. 1). The patient was weaned off pressors 48 hours after the procedure. There was a notable increase in PVCs on day 3. On day 4, the patient was transitioned from ECMO to a temporary extracorporeal LVAD. During LVAD placement, he underwent extensive surgical endocardial and epicardial ablation. After bypass wean and volume loading of the right ventricle, the patient developed VT, which recurred on every attempt to wean from cardiopulmonary bypass. A right ventricular extracorporeal device was also placed and the patient was maintained on biventricular support awaiting heart transplantation.
Case 2: A 62‐year‐old man with a history of chronic obstructive lung disease, type 2 diabetes, and hypertension was admitted to an outside facility with a non‐ST elevation myocardial infarction. He was found to have left ventricular systolic dysfunction with an LVEF of 25% and 3‐vessel coronary artery disease. Due to his obstructive coronary disease, he underwent coronary artery bypass surgery. His postoperative course was complicated by a cardiac arrest necessitating transfer to our facility. Repeat cardiac catheterization confirmed patent grafts. The patient, however, developed recurrent polymorphic VT arrests with progressive cardiac shock. He was placed on venoarterial ECMO and initiated on intravenous amiodarone and lidocaine as well as vasopressin for continued hypotension. Despite initiation of ECMO therapy, he continued to have recurrent ventricular arrhythmias over the subsequent 4 days. In 24 hours prior to stellate ganglion block the patient had frequent PVCs (average 14 PVC per minute) and a total of 13 episodes of PVC triggered polymorphic VT (Fig. 3). Since the patient was deemed to be too unstable for catheter ablation or durable mechanical support, he underwent bilateral stellate ganglion block.
We used the same approach detailed in case one; however, bupivacaine (0.25%) was used in lieu of lidocaine. After injection, the patient remained free of ventricular arrhythmia for 5 days. Nine days later, he underwent an electrophysiology study.
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