Calming the electrical storm: Use of stellate ganglion block and thoracic epidural in intractable ventricular tachycardia

Case Report IntroductIonThe term "electrical storm" (ES) describes a state of electrical instability of the heart characterized by clustering of recurrent episodes of ventricular tachycardia (VT) or ventricular fibrillation in a short period of time.We report a case where stellate ganglion block (SGB) and thoracic epidural analgesia (TEA) were used to manage this sympathetic storm. case rePortA 67-year-old hypertensive and diabetic male weighing 60-kg status postcoronary artery bypass graft surgery to left anterior descending and left circumflex arteries 4 years ago, presented to our institute with a history of chest pain, palpitations, and dyspnea since the last 30 days.Electrocardiogram revealed monomorphic VT during one such episode with a pulse of 170/ min and a blood pressure of 110/70 mmHg.He was started on injection Amiodarone 150 mg intravenous (IV) bolus over 10 min followed by infusion of 1 mg/min IV for 6 h then 0.5 mg/min IV for 18 h.The arrhythmia did not revert with this.Injection Metoprolol 5 mg, injection Lignocaine 100 mg, and injection Magnesium sulfate 2 g IV were tried but to no avail.Transthoracic echocardiography (TTE) revealed hypokinesia of apex, anterior, posterior, and inferior walls and septum with a reduced ejection fraction of 25%.No clots were seen during this examination.No previous TTE report was available for comparison.Cardiac enzyme assay was normal and ruled out any active ischemia.He had stopped consuming his routine antiplatelet medications since the last fortnight.Hypokalemia, hypomagnesemia, and hyperthyroidism were excluded as triggering factors for arrhythmias on laboratory investigations.He was subsequently given Direct current (DC) synchronized cardioversion with 100 J, and normal sinus rhythm (NSR) was achieved.He went into monomorphic VT 8 times on day 1 [Figure 1] and was reverted only with increasing dose of synchronized cardioversion each time.Decision was made to try sympatholysis with a left-sided SGB (LSGB) on day 2.After checking coagulation parameters, explaining the procedure to the patient and relatives, and taking due consent, the procedure was performed under ultrasound guidance with 10 ml of 0.375% Ropivacaine which was deposited with the tip of the needle in the longus colli muscle after negative aspiration of blood.Spread of the drug was confirmed by bulging of the longus colli compartment and spread of drug on ultrasonography (USG).Horner's syndrome confirmed the success of the block.The patient showed an arrhythmia-free interval of 12 h, but the monomorphic VT continued thereafter with a frequency of 6-7 episodes per day only amenable to synchronized cardioversion.He was intubated during one of these episodes and put on Imbalances in the autonomic nervous system contribute to ventricular tachyarrhythmias.Sympatholysis with thoracic epidural analgesia or a stellate ganglion block attenuates myocardial excitability and the proarrhythmic effects of sympathetic hyperactivity.