A case of successful percutaneous ethanol stellate ganglion block on ventricular tachycardia storm

Abstract

Stellate ganglion block is useful as emergency therapy in patients with ventricular tachycardia storm but is limited due to low availability of experienced teams in the condition of intensive care units. This method used urgently reduced life-threatening ventricular tachycardia when conservative and interventional methods were ineffective.

<Learning objective: 1 Percutaneous stellate ganglion block should be considered in patients who suffered from ventricular tachycardia storm. 2 The ultrasound-guided technique is safer and more effective than other techniques. 3 Using ethanol as injection volume had a stronger beneficial effect than lidocaine.>

Introduction

The stellate ganglion (SG) is formed by the fusion of the lower cervical and first thoracic sympathetic ganglion [1]. As a single structure, among the cervical ganglia, it has an average of 2.5 cm in length, 1 cm in width, and 0.5 cm in thickness. The stellate ganglion innervates the vertebral artery, the organs of the thoracic cavity (esophagus, trachea, thymus gland, and aorta), and the heart muscle. Although SG block (SGB) has been practiced for many years, there is no clarity about the safe method for a successful block. The SGB can be executed at the C6 or C7 level with the help of imaging tools such as ultrasonography and radiography [2].

Ventricular tachycardia (VT) storm – is an emergency and life-threatening condition that involves repetitive ventricular tachyarrhythmia. The concept of a specific sympathetic imbalance on VT storm (increased activity of the left stellate ganglion) is the basis of surgical treatment – left-sided sympathetic denervation [3]. There are currently no randomized clinical trials in which a systematic evaluation of the effectiveness of surgical treatment would be carried out. However, Moss et al. [4] in 1971 reported the first successful use of left-sided sympathectomy in individual symptomatic patients, who were resistant to treatment with beta-blockers. The frequency of complications associated with surgery, an experienced surgeon should be around zero, and ptosis of the left eyelid – less than 3%. After SGB, symptoms of the disease are much weaker and the quality of life is much better, where after implantable cardioverter-defibrillator (ICD) implantation, complications can be much serious as inadequate therapy, electrode fractures, or infection. Today, in the leading centers of rhythm disturbances, percutaneous left-sided sympathectomy is the procedure of choice in patients with a malignant course of the disease, accompanied by repeated cardioverter-defibrillator shocks during recurrence of VT.

Case report

This case involves a 65-year-old man in the intensive care unit (ICU) after suffering ST-segment elevation myocardial infarction (STEMI) on April 18, 2018, in which there was a loss of consciousness on the painful attack. During the following 2 weeks, STEMI had relapsed. On coronary angiography, a single vascular lesion of the left anterior descending artery was revealed. On echocardiography, a mural thrombus with a size of 32 × 25 mm was detected on the left ventricle wall (LV). The ejection fraction of LV was 46.6% by the Simpson method. On the scale GRACE - 139 points – the average probability of death, on CRUSADE - 44 points – a high risk of ventricular bleeding. The hybrid operation was recommended: a coronary artery bypass grafting with a thrombectomy and linear repairing aneurysm of LV. The patient was hospitalized for open-heart surgery on May 10, 2018. On May 13, 2018, after going to the toilet, a paroxysm of VT developed with the transition to ventricular fibrillation (VF), defibrillation was carried out by 200 J. From May 13 to May 15, he sustained 16 polymorphic VT/VF episodes and frequent premature ventricular complexes (PVCs) occurring from aneurysm location (Fig. 1), in which all of the high rate episodes were successfully terminated by electrical cardioversion. Amiodarone, lidocaine, and intravenous beta-blocker (esmolol) therapy were ineffective. The hybrid operation was performed on May 16, 2018. Despite this, the VT storm was repeated. Due to the poor patient's status and the presence of frequent VT storms, he was not found to be eligible for an ICD implantation at that time. It was explained that continuous incidence of an ICD shock also known as “shock paradox” is associated with high mortality and device downgrading. Then, it was decided to carry out sympathetic denervation of the heart by ultrasound-guided blocking the stellate ganglion in the ICU. The patient was placed in the supine position, a pillow placed under the shoulder, and the neck extended and turned to the opposite side. The patient was given oxygen with a nasal cannula at a flow rate of 2l per minute. The patient underwent local anesthesia with novocaine 5.0 ml. The procedure wаs started bу placing the needle tip аntеrоlаteral to the lоngus соlli muscle, dееp tо the prеvеrtebrаl fаsсia in оrdеr tо аvоid spread аlong the carotid sheath, but supеrficiаl tо the fаsciа investing the longus colli muscle (to prevent injecting into the muscle). Identifying the correct fascial plane achieved with portable ultrasound guidance shown in Fig. 2A (iQ Butterfly, Butterfly Network, Guilford, CT, USA), thus facilitating the caudal spread of the injectate to reach the stellate ganglion at the C7-T1 level. This allowed for a more effective and stable sympathetic block with the use of a small injected volume. As an injection, we firstly used 2%−5.0 ml of lidocaine. The efficacy was assessed as reducing the frequency of PVCs, which had previously been encountered more often. The disappearance of PVCs on the cardiac monitor started at 5 min and lasted up to 4 h. Then ventricular ectopy activated again. The procedure was continued by the injection of ethanol 96%, in quantity 5.0 ml for a lasting effect (Fig. 2B). The first procedure suppressed VT storm, completely. Thereafter the patient was stable on amiodarone and beta-blocker therapy. During the next 3 weeks, only a few PVCs and other morphology were recorded on 24-h Holter monitoring (see Table 1), neurological complications were not detected. Considering the presence of attacks of life-threatening ventricular arrhythmias, accompanied by severe hemodynamic disturbances, the ICD was implanted on 2nd day after the procedure. Three and six months after the procedure, no episodes of VT/VF were detected (see Table 1).

Fig. 1.

12-lead electrocardiogram of ventricular tachycardia arising from the apex of left ventricle.

Fig. 2.

Surrounding anatomic structures on transverse (A) and a real-time needle path (B) view at the C7 level. The dotted circular line indicates the area of the stellate ganglion. SCM, sternocleidomastoid muscle; LC, longus colli muscle; CA, carotid artery.

Table 1.

A short review of follow up after the procedure.

Data	Diagnostic Testing	Interventions
7th day in hospital	On ECG monitor: frequent bigeminy PVCs with the transition to VT. After the left SGB with ethanol, ventricular ectopy was completely suppressed for 10 min. Neurologist: symptoms of neurological disorder not found.	The left stellate ganglion block was perfomed. Amiodarone 900 mg a day with a regime; Lidocaine 120 mg i/v a day; Esmolol 60 mg i/v a day; The patient was referred for the ICD implantation.
3 weeks after the procedure	On 24 h ECG monitoring – sinus rhythm. About 397 (0,45% of total beats) single and couple monomorphic PVCs. No VT/VF episodes. On ICD – 2 non-sustained VT episodes (5 complexes). Neurologist: symptoms of neurological disorder not found.	Amiodarone 200 mg a day with a regime; Bisoprolol 10 mg a day; Antiplatelet and HF theraphy.
3 month after the procedure	On 24 h ECG monitoring – sinus rhythm. About 293 (0,34% of total beats) single monomorphic PVCs. No VT/VF episodes. On ICD – VT episodes were not detected.	Continuation of antiarrhythmic, antiplatelet and heart failure theraphy.
6 month after the procedure	On 24 h ECG monitoring – sinus rhythm. About 112 (0,1% of total beats) single monomorphic  PVCs. No VT/VF episodes. On ICD – VT episodes were not detected.	Continuation of antiarrhythmic, antiplatelet and heart failure theraphy.

ECG, electrocardiography; ICD, implantable cardioverter-defibrillator; PVC, premature ventricular complex; SGB, stellate ganglion block; VF, ventricular fibrillation; VT, ventricular tachycardia.

Discussion

We report a patient with severely depressed LV function, ischemic etiology, presenting with VT storm, which was resistant to conventional pharmacotherapy, consequently treated with stellate ganglion blocks. Nowadays, there is an increasing interest in the modulation of the autonomic nervous system (ANS) in the treatment of ventricular tachyarrhythmia [5], [6], [7]. The simplest and most commonly used method of ANS modulation is the administration of a beta-blocker [5]. Despite their clinical efficacy, beta-blockers have several limitations related to difficulties in reaching the target dose. Moreover, beta-blockers affect only the noradrenaline-mediated neurotransmission, while their effect on other neurotransmitters remains unchanged. Thus, the techniques that modify autonomic system functions attract a great deal of interest. There are many reports on the effectiveness of surgical and percutaneous sympathetic denervation in patients with VT storm. One randomized clinical study reported its beneficial effect in patients after myocardial infarction [8]. Nevertheless, its usefulness as emergency therapy in patients with VT storm is limited due to the low availability of experienced surgical teams in the condition of ICU [7]. On the other hand, percutaneous SGB is a routinely performed procedure in chronic pain management, even on an outpatient basis. Furthermore, the implementation of SGB into the arsenal of antiarrhythmic treatment methods seems to be reasonable. However, its use is limited by the lack of randomized clinical studies or multicenter registries. Moreover, there is no established technique for SGB. Usually performing left SGB is preferred, although some papers report on bilateral or right-sided SGB. Since there is an asymmetry in the innervation of the heart, that means the left and right sympathetic nerves affect different areas of the heart and impose different functional effects as well. The optimal side of SGB may depend on the underlying disease, type of arrhythmia, and its origin [7]. In the presented case only left-sided SGB was effective. Usually performing left SGB is preferred, while bilateral SGB increases risk of severe complications, such as Horner syndrome. But, we will try to perform bilateral, if left-sided SGB did not provide such a beneficial effect. Although lidocaine had a beneficial effect that lasted for less time, whereas ethanol had a persistent action in this case. Although ethanol is an effective sclerosing agent, it causes side effects (tissue necrosis, inflammation) when it is injected intramuscularly. In our case, such adverse effects were not recorded. Moreover, in a meta-analysis on SGB, bupivacaine and ropivacaine were the most frequently used local anesthetics [6]. Exclusion criteria to performing SGB include patients presenting with any supraventricular tachycardia, ventricular arrhythmias without VT storm (e.g. PVCs), or patients treated only with surgical sympathectomy. Abnormal automaticity mechanism is recommended to perform SGB procedure, while trigger activity is a controversial case, and it needs larger, randomized-controlled research to confirm its role in the management of such situations.

Conclusion

Percutaneous SGB should be considered as an emergency therapy at the bedside in the ICU and is feasible for patients who are suffering recurrent VT. This method used urgently reduced life-threatening VT, when conservative and interventional methods were ineffective. A 96% ethanol injection had a more lasting effect than lidocaine. SGB should be carried out by ultrasound guidance, to ameliorate the safety of the procedure, there should be simultaneous direct visualization of vascular structures and sоft tissue struсturеs. Due to this, the risk of vascular and soft tissue dаmage may bе minimized. There is an urgеnt nееd for further studies that will determine the value of SGB in emergency settings.

Declaration of Competing Interest

None declared.