Early ganglion stellate blockade as part of two-step treatment algorithm suppresses electrical storm and need for intubation

Abstract

Background: For the treatment of patients with electrical storm (ES), we established a two-step algo rithm comprising standard anti-arrhythmic measures and early ultrasound-guided stellate ganglion blockade (SGB). In this single-center study, we evaluated the short-term efficacy of the algorithm and tested the hypothesis that early SGB might prevent the need for intubations. Methods: Overall, we analyzed data for 70 ES events in 59 patients requiring SGB (mean age 67.7 ± 12.4 years, 80% males, left ventricular ejection fraction 30.0% ± 9.1%), all with implantable cardioverter-defibrillators (ICDs). Results: The mean time from ES onset to SGB was 13.2 ± 12.3 hours. Percentage and mean absolute reduction in shocks at 48 hours after SGB reached 86.8% ( 6.3 shocks), and anti-tachycardiac pacing (ATP) declined by 65.9% ( 51.1 ATPs; all P < 0.001). Patients with the highest sustained ventricular arrhythmia (VA) burden (shocks 10/48 h; ATPs 10e99/48 h and 100/48 h) experienced the highest percentage decrease in ICD therapy (shocks 99.1%; ATPs 92.1% and 100.0%, respectively). For clinical response by defined criteria and two outcome periods (1/no sustained VA 48 hours post SGB, and 2/no ICD shock or <3 ATPs/day from day 3 to discharge/catheter ablation/day 8), 75.7% and 76.1% experienced complete response, respectively. Catecholamine support, no/low-dose b-blocker therapy, polymorphic/ mixed-type VA, and baseline sinus rhythm versus atrial fibrillation were more frequent in patients with early arrhythmia recurrence. Temporary Horner's syndrome occurred in 67.1%, and no other adverse events were recorded. Intubation and general anesthesia during and after SGB were not needed. Conclusion: The presented two-step algorithm for treating ES proved efficacious and safe. The results support implementation of early SGB in routine ES management.