University of California, San Diego

Pulsed-Radiofrequency Lesion Of The Le7 Stellate Ganglion Provides Durable Suppression Of Drug-Resistant Ventricular Arrhythmia Jeffrey Walker MD, Jeffrey Chen MD, Farshad Ahadian MD

University of California, San Diego

IntroducMon

Case

Electrical Storm (ES) is defined by life-threatening recurrent ventricular tachycardia (VT) or fibrillaMon (VF). Various treatments have been used for ES, including: anM-arrhythmic medicaMons, surgical sympathectomy, electrical cardioversion or defibrillaMon, ablaMon, and conMnuous le7-sided stellate ganglion block and neurolysis.[1] Local anestheMc blockade of the le7 stellate ganglion produces effecMve but transient suppression of ventricular arrhythmias.[2,3] Surgical sympathectomy has been used for long-term management of ES, but may be contraindicated in criMcally ill paMents or due to anatomic abnormaliMes. Pulsed radio frequency ablaMon (PRFA) may provide an effecMve and durable treatment alternaMve.[4-6]

85 year old male with ischemic cardiomyopathy, aorMc stenosis, hypertension, non-insulin dependent diabetes, and hypothyroidism who developed post-CABG VT and VF refractory to pharmacological intervenMons, requiring transvenous pacing at 100bpm. Due to his criMcal status electrophysiologic intervenMons and ICD placement were not feasible. On post-op day 7, a le7 stellate ganglion block with bupivacaine suppressed VT and VF for 4 hours. On post-op day 10 the le7 stellate ganglion was treated with PRFA. Under fluoroscopic guidance, three, three-minute PRFA lesions (5Hz, 50 msec pulse width) were applied in a triangular configuraMon along the anterolateral aspect of T1 vertebral body using a 22 gauge, 10 cm radio frequency cannula with 10 mm acMve Mp. Fi7een minutes post-block, pacing was disconMnued, revealing normal sinus rhythm (NSR) henceforth. VasoacMve and anMarrhythmics infusions were subsequently weaned and disconMnued and the paMent was extubated on post-op day 11. Unfortunately, on post-op day 12, the paMent expired a7er rupture of a newly diagnosed AAA. Notably, NSR persisted through the rupture and throughout the resuscitaMon efforts, despite extreme hypotension.

Conclusion PRF is a safe and effecMve alternaMve for management of drugresistant ventricular arrhythmias.



Baseline

Post PRFA

References 1. Hulata, D. F., Le-Wendling, L., Boezaart, A. P., & Hurley, R. W. Stellate Ganglion Local AnestheMc Blockade and Neurolysis for the Treatment of Refractory Ventricular FibrillaMon. A&A Case Reports. 2015;4(5):49-51. 2. Hayase J, Patel J, Narayan SM, Krummen DE. Percutaneous stellate ganglion block suppressing VT and VF in a paMent refractory to VT ablaMon. J Cardiovasc Electrophysiol. 2013;24(8):926-928. 3. Patel RA, Priore DL, Szeto WY, Slevin KA. Le7 stellate ganglion blockade for the management of drug-resistant electrical storm. Pain Med. 2011;12(8):1196-1198. 4. Ahadian FM. Pulsed radiofrequency neurotomy: Advances in pain medicine. Curr Pain Headache Rep. 2004;8(1):34-40. 5. Pulsed Radiofrequency Techniques in Clinical PracMce. Ahadian F. Chapter in: Handbook of DiagnosMc and TherapeuMc Spine Procedures. Mosby, St. Louis, Missouri, 2002. 6. Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep. 2008;12(1):37-41.