Weathering the storm: Combining microaxial left ventricular assist device support with bilateral stellate ganglion blockade to treat recalcitrant ventricular tachycardia

Abstract

We present a case of a 45-year-old female with advanced heart failure due to nonischemic cardiomyopathy, an ejection fraction of 15% complicated by ventricular arrhythmias degenerating into an electrical storm. The treatment approach involved antiarrhythmic medications, inotrope support, diuretics, and the placement of an Impella 5.5 device for mechanical circulatory support. Due to persistent polymorphic ventricular tachycardia, a bilateral stellate ganglion blockade was performed along with intensified antiarrhythmic therapy and deep sedation. This case highlights the role of axillary mechanical circulatory support with the Impella 5.5 in providing unfettered hemodynamic stability and the potential added benefit of stellate ganglion blockade in managing malignant ventricular arrhythmias.

Background

Atrial and ventricular arrhythmias frequently occur in cases of cardiogenic shock and can lead to a decline in hemodynamic stability. Contributing factors include myocardial ischemia, volume overload, and metabolic disturbances.¹ Progressive arrhythmia burden, as in our patient, can degenerate into an electrical storm. Electrical storm is a potentially life-threatening condition characterized by the occurrence of 3 or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate shocks delivered by an implantable cardioverter-defibrillator within a 24-hour period.² In individuals experiencing cardiogenic shock, the standard clinical approach often involves the use of temporary mechanical circulatory support (tMCS) for hemodynamic stabilization. However, this is often considered salvage and applied in late stages (e.g., SCAI Stage D or E). We highlight the application of Impella 5.5 in the successful treatment of ventricular arrhythmias, showcasing its efficacy in providing circulatory support and contributing to positive patient outcomes.

Case presentation

A 45-year-old female presented with a history of nonischemic cardiomyopathy, a mechanical mitral valve replacement, and a biventricular ICD programmed with atrial-sensed, ventricular-paced (A-V) rhythm at 60 beats/min. She was admitted due to a progressive decline in her cardiac function, manifesting as acute on chronic combined systolic and diastolic heart failure reduced ejection fraction, with an ejection fraction of 15% classified as New York Heart Association Class 4, American Heart Association D, Stevenson C, and Interagency Registry for Mechanically Assisted Circulatory Support 5. She was being evaluated for heart transplant or durable left ventricular assist device.

On the evening of admission, she experienced a VF arrest complicated by cardiogenic shock, necessitating a transfer to the intensive care unit. ECG showed extreme QTc prolongation of >600 ms (Figure 1). The electrolyte levels were within normal ranges (potassium 4.5 mmol/liter, sodium 137 mmol/liter, magnesium 2.0 mg/dl, and calcium 9.0 mg/dl). The patient was maintained on intravenous antiarrhythmic support with Amiodarone at 1 mg/min, 200 mg bid oral dosing, and low dose Dobutamine at 2 mcg/kg/min for hemodynamic support. She was taking Zofran and sertraline, but they were discontinued due to their potential to worsen her underlying condition (Figure 2, Figure 3, Figure 4).

Figure 1.

Bi-V paced 12 lead surface ECG showing QTc prolongation of >600 ms.

Figure 2.

Telemetry strip showing sustained polymorphic ventricular tachycardia.

Figure 3.

Multidisciplinary care and escalating interventions for cardiogenic shock at our center. GDMT, guideline directed medical therapy.

Figure 4.

USG-guided stellate ganglion blockade. CA, carotid artery; IJV, internal jugular vein; USG, ultrasound guided.

Consideration was given to pacing at a faster rate at 100 beats/min, to shorten the QT interval. Due to recalcitrant polymorphic VT (torsades des pointe [TdP]), she underwent a bilateral stellate ganglion blockade (SGB) using a stellate ganglion catheter with ropivacaine infusion. Deep sedation and intubation with propofol were temporarily also utilized before definitive treatment. An inpatient heart transplant evaluation was initiated, and the patient was approved and listed for a heart transplant. Simultaneously, antiarrhythmic therapy was intensified with procainamide at 2 mg/min, lidocaine infusion at 0.5 mg/min, and a slow intravenous magnesium infusion at 4 g. Amiodarone was continued intravenously at 0.5 mg/min. She continued to have recurrent episodes of VT/VF arrest, leading to the placement of an Impella device before transplantation 15 days later.

Discussion

In the context of Acute Decompensated Heart Failure, our patient experienced a critical progression of ventricular arrhythmia, evolving from an electrical storm to Torsades de Pointes, requiring tMCS with Impella for stabilization as a bridge to heart transplantation.

TdP is a variant of polymorphic VT characterized by a twisting pattern of the QRS complexes on an electrocardiogram. It can progress to VF, leading to syncope and, in severe cases, sudden death.³ The sympathetic nervous system, particularly the cardiac autonomic nervous system, plays a crucial role in ventricular arrhythmias, making it a therapeutic target. Deep sedation, especially using propofol, is effective and safe in temporarily managing VT before definitive treatment. Propofol's rapid onset, short half-life, and amnesic effects are advantageous in cardiovascular settings. It reduces sympathetic activity and enhances vagal tone, potentially via effects on baroreflex sensitivity and mitochondrial potassium gated adenosine triphosphate channels.⁴

Another approach is the SGB which is a minimally invasive technique aiming to interrupt sympathetic activity, potentially managing ventricular arrhythmias and electrical storms. SGB targets the stellate ganglion (C7-T1), controlling sympathetic output to the heart, upper extremities, neck, and face, potentially reducing myocardial sympathetic tone, and improving outcomes.

Achieving and sustaining a stable sinus rhythm becomes imperative in the management of individuals with end-stage heart failure. Catheter ablations of VT are a well-established treatment method for achieving rhythm stabilization, but they can be challenging in patients experiencing cardiac decompensation and hemodynamic instability.⁵ This case, however, highlights the sole use of axillary placed Impella 5.5 support in a patient with malignant ventricular arrhythmia and early implementation before progressive cardiometabolic complications and end-organ damage.

Based on our prior experience, we felt that the patient would have biventricular optimization with left ventricular offloading and a limited hemolysis profile with Impella 5.5 alone.6, 7 The Impella 5.5 played an immediate and crucial role in maintaining hemodynamic stability, allowing the patient to ambulate despite small salvos of VT.

Impella support in this patient over the duration of 2 weeks allowed us an opportunity to observe the reversal of her pulmonary hypertension, stabilization of her electrical storm by minimizing high-dose vasoactive support needs, and maintaining her physical therapy status before organ transplantation. SGB is effective in reducing the number of episodes and therapies for VT. SGB has proven effective in decreasing the frequency of VT episodes and the need for other therapies. SGB successfully reduced the burden of polymorphic VT, preventing the necessity for extracorporeal membrane oxygenation in our patient.

Limitations

As a single-center descriptive experience, we understand that some readers may not have the ability to place the Impella 5.5 in this situation. As such, extracorporeal membrane oxygenation is our alternative option and provides similar support, with an increased risk profile. We look to examine a new pathway for stabilization in cardiogenic shock patients with malignant arrhythmia with the support of the Impella device.

Conclusion

Despite limited data in this bridge-to-transplant population, our institution has achieved success with the Impella 5.5 in complex clinical cases. We highlight the important role of team-based care and management in high-risk patients in the setting of malignant ventricular arrhythmias. This population has a high mortality rate and can potentially benefit from early implementation of tMCS with Impella 5.5 as a bridge to optimization, ablation, explant, or heart transplantation.

Ethical Approval and Consent to Participate

Informed consent has been obtained from the patient.

Disclosure statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr Rohan Goswami is a speaker for Abiomed. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

We would like to thank the Division of Heart Failure and Transplant and Division of Cardiovascular Surgery at Mayo Clinic in Florida.

The authors received no financial support for the research and publication of this article.