Efficacy of Stellate Ganglion Blockade in Managing Electrical Storm: A Systematic Review

Abstract

Background: The efficacy of percutaneous stellate ganglion block (SGB) for managing electrical storm (ES) is not well understood.

Objective: To characterize the efficacy of SGB as a treatment for ES.

Methods: We conducted literature searches using PubMed/Medline and Google Scholar, for mixed combinations of terms including "stellate ganglion block", *ganglion block (ade)", "sympathetic block (ade)" and "arrhythmia", "ventricular arrhythmia (VA)" or "tachycardia" (VT), "ventricular fibrillation" (VF), "electrical storm". Inclusion criteria were presentation with guideline-defined ES and treatment with SGB. Exclusion criteria: presentation with any supraventricular arrhythmia, VA without ES, or surgical sympathectomy. Studies lacking basic demographic data, arrhythmia description, and outcomes were excluded.

Results: Of 3,374 publications reviewed, 38 patients from 23 studies met study criteria (52 ± 19.1 years, 11 F, 17 with ischemic cardiomyopathy). Anti-arrhythmics were used in all patients. Mean Left ventricular ejection fraction was 31 ± 10%. ES was triggered by acute myocardial infarction in 15 patients and QT prolongation in 7 patients. The most common local anesthetic used for SGB was bupivacaine (0.25-0.5%). SGB resulted in a significant decrease in VA burden (12.4±8.8 vs. 1.04±2.12 episodes/day, p< 0.001) and number of external and ICD shocks (10.0±9.1 vs. 0.05±0.22 shocks/day, p< 0.01). Following SGB, 80.6% of patients survived to discharge.

Conclusion: SGB is an effective acute treatment for ES. However, larger prospective randomized studies are needed to better understand the role of SGB in ES and other VAs.

Keywords: Stellate ganglion block; autonomic nervous system; electrical storm; neuromodulation; sympathetic nerves.

Figures

Figure 1. Impact of stellate ganglion block on ventricular arrhythmia episodes and defibrillator shocks

Reduction in the number of ventricular arrhythmia episodes (A.) and number of internal or external defibrillator shocks (B.) before and after stellate ganglion block (SGB) are shown. Panel A (n=24) and panel B (n=11).

Figure 2. Relationship between arrhythmia burden reduction and left ventricular dysfunction

A. The relationship between left ventricular ejection fraction (LV EF) and the relative reduction in ventricular arrhythmia (VA) episodes (n=18), r2=0.05, p=0.384). B. Reduction in arrhythmia episodes was independent of the presence and etiology of cardiomyopathy (CMY), n=24, p=0.78).

Figure 3. Schematic of cardiac innervation and site of stellate ganglion block

Stellate ganglion block directly impacts both efferent and afferent neurotransmission to the heart. The site of action and components are shown. Aff, afferent; β, β-adrenergic receptor; C, cervical; DRG, dorsal root ganglion; LCN, local circuit neuron; M, muscarinic receptor, Sympath, sympathetic, and T, thoracic.