50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Introduction

Sympathetic cardiac input can precipitate cardiac arrythmias and is supplied in part via the stellate ganglion (SG). Inhibition of this pathway by a stellate ganglion block (SGB) can decrease sympathetic overactivity.
Stellate ganglion blocks are infrequently utilized as a rescue therapy for promoting cessation of ventricular tachycardia (VT) storm.
Relative to SGB, stellate ganglion catheters (SGCs) offer the benefit of extended duration of SG sympatholysis and decreased risk associated with repetitive blocks.

Case Presentation & Hospital Course

A 43-year-old male with PMH of HFrEF (20%), ischemic cardiomyopathy d/t Kawasaki disease, chronic total LAD occlusion, and MI who sustained VT and underwent VT ablation 4 years prior with ICD placement then presented with recurrent persistent VT despite ICD shocks.

Intubation, sedation, and ICU admission were required.
VT was refractory to VT ablation, three cardioversions, and infusions and boluses of amiodarone, procainamide, and lidocaine.
Support with ECMO was considered if patient continued to experience VT storm.
Regional anesthesiology service was consulted to attempt a SGB.
A left-sided SGB was associated with temporary cessation of his refractory VT during the duration of the block.
The following day, after return of VT, a left SGC was placed.

Intervention

Using a high-frequency linear US probe, the left stellate ganglion was visualized at the C6 level. Other structures were analyzed under color (Doppler) mode to find a safe area for needle insertion.
An 18-ga Tuohy needle was inserted under in-plane US guidance posterolaterally to anteromedially as shown in Image 1.
After negative aspiration, a bupivacaine-epinephrine mixture was injected under US visualization around the SG to confirm appropriate spread below the carotid artery and above the longus colli muscle and then a nerve catheter was threaded (see Image 2) and programmed for intermittent hourly boluses.

Results

Following SGC placement and ensuing hourly intermittent boluses of ropivacaine as well as continuation of his sedation, intubation, and anti-arrhythmic medical therapies, no further VT episodes occurred in the following seven days which bridged the patient to a successful heart transplant.

Learning Points

The stellate ganglion regulates cardiovascular sympathetic activity. Increased sympathetic tone can promote arrhythmogenesis. Therefore, SG blockade could decrease arrhythmogenesis.
Stellate ganglion catheters may be a useful emerging tool for provisional suppression of medically refractory VT storm until more definitive treatment can be pursued.
A stellate ganglion catheter offers an extended duration of sympathetic outflow attenuation versus a stellate ganglion block. Goals for therapy and time until definitive management of VT storm should be considered to limit additional risk of repeating SGBs.

SUCCESSFUL USE OF A STELLATE GANGLION CATHETER FOR SUPPRESSION OF REFRACTORY VT STORM