Ultrasound guided stellate ganglion block beyond electrical storm: expanding clinical indications

Abstract Background Percutaneous stellate ganglion block (PSGB) is recommended by the latest American as well as European guidelines for patients with drug and eventually ventricular tachycardia (VT) ablation refractory ventricular arrhythmias (VAs) in form of electrical storm (ES). Yet, due to the strong antiarrhythmic potential, combined with the good safety profile, we’ve recently started to expand its usage to the prophylaxis of VAs in high–risk patients and the prophylaxis/treatment of atrial arrhythmias. Methods We hereby describe our single center experience with PSGB from 2/2021 to 12/2023. Results 51 patients (92% male, mean age 65 ± 12 years) received a total of 69 PSGB performed with the lateral, ultrasound (US) guided technique. All procedures except for 3 in a single patient who had previously received left cardiac sympathetic denervation, were performed on the left side. Most of the patients (63%) suffered ischemic cardiomyopathy (CMP), including 6 with an over imposed acute coronary syndrome; the rest had non ischemic CMP, including 1 patient with acute myocarditis and 1 with hypertrophic CMP. Mean LVEF was 25 ± 13%. Most of the procedures (n=59, 86%) were performed due to refractory VAs, yet, 6 (8%) aimed to prevent VAs in high risk patients, mostly in the setting of recent VAs and need for levosimendan to support cardiac output, in one case due to recent stereotactic VT ablation, to prevent early VAs in the phase of acute radiation induced vascular damage. All 6 were effective in preventing clinically significant VAs. Additionally, 4 PSGBs (6%) were performed due to atrial arrhythmias with high ventricular rate despite intravenous drugs. Specifically, 3 patients had atrial fibrillation, in 2 cases with concomitant need for inotropes, and 1 patient suffered 2:1 atrial flutter. Left–sided PSGB significantly reduced ventricular rate during AF but not during the single case of 2:1 atrial flutter. Most of the procedures consisted in a single bolus anesthetic injection of lidocaine plus ropivacaine, 19 (28%) in an additional continuous infusion, mostly with ropivacaine. No major complications occurred, while minor complications were observed in 12% of PSGBs (mostly transient left arm weakness). Conclusions Our data suggest that US–guided PSGB usage, thanks to its easy feasibility and good safety profile, may expand, beyond ES, to not only VAs prevention in high–risk settings, but also to prophylaxis/treatment of atrial arrhythmias.