Percutaneous left stellate ganglion block for refractory ventricular tachycardia in structural heart disease: our single-centre experience

Abstract

Introduction: When electrical storm (ES) is amenable to neither antiarrhythmic drugs, nor deep sedation or catheter ablation, autonomic modulation may be considered. We report our experience with percutaneous left stellate ganglion block (PSGB) to temporarily suppress refractory ventricular arrhythmia (VA) in patients with structural heart disease.

Methods: A retrospective analysis was performed at our institution of patients with structural heart disease and an implantable cardioverter defibrillator (ICD) who had undergone PSGB for refractory VA between January 2018 and October 2021. The number of times antitachycardia pacing (ATP) was delivered and the number of ICD shocks/external cardioversions performed in the week before and after PSGB were evaluated. Charts were checked for potential complications.

Results: Twelve patients were identified who underwent a combined total of 15 PSGB and 5 surgical left cardiac sympathetic denervation procedures. Mean age was 73 ± 5.8 years and all patients were male. Nine of 12 (75%) had ischaemic cardiomyopathy, with the remainder having non-ischaemic dilated cardiomyopathy. Mean left ventricular ejection fraction was 35% (± 12.2%). Eight of 12 (66.7%) patients were already being treated with both amiodarone and beta-blockers. The reduction in ATP did not reach statistical significance (p = 0.066); however, ICD shocks (p = 0.028) and ATP/shocks combined were significantly reduced (p = 0.04). At our follow-up electrophysiology meetings PSGB was deemed ineffective in 4 of 12 patients (33%). Temporary anisocoria was seen in 2 of 12 (17%) patients, and temporary hypotension and hoarseness were reported in a single patient.

Discussion: In this limited series, PSGB showed promise as a method for temporarily stabilising refractory VA and ES in a cohort of male patients with structural heart disease. The side effects observed were mild and temporary.

Keywords: Autonomic modulation; Stellate ganglion; Sympathetic denervation; Ventricular tachycardia.

Fig. 1

Coumel’s triangle of arrhythmogenesis provides a model for summarising the chief factors underlying ventricular arrhythmia in structural heart disease. Autonomic modulation by means of percutaneous stellate ganglion block and left cardiac sympathetic denervation aim to suppress the extrinsic sympathetic nervous system. This is suspected to be a prime modulator of arrhythmia by influencing both the trigger through altering myocardial calcium handling, which predisposes to early and later afterdepolarisations, as well as the substrate by altering conduction in the scar border zone

Fig. 2

Antitachycardia pacing (ATP) and implantable cardioverter defibrillator (ICD) shocks/external cardioversions delivered in the week before and following percutaneous left stellate ganglion block (PSGB). ^aSymptomatic recurrent slow ventricular tachycardia (VT) was not always registered by the ICD and thus the VT burden could not be reconstructed. ^bEstimated VT burden. The exact burden could not be retrospectively reconstructed due to limitations of the inpatient recording system