Abstract
Purpose of Review
To highlight the indications, procedural considerations, and data supporting the use of stellate ganglion blockade (SGB) for management of refractory ventricular arrhythmias.
Recent Findings
In patients with refractory ventricular arrhythmias, unilateral or bilateral SGB can reduce arrhythmia burden and defibrillation events for 24–72 h, allowing time for use of other therapies like catheter ablation, surgical sympathectomy, or heart transplantation. The efficacy of SGB appears to be consistent despite the type (monomorphic vs polymorphic) or etiology (ischemic vs non-ischemic cardiomyopathy) of the ventricular arrhythmia. Ultrasound-guided SGB is safe with low risk for complications, even when performed on anticoagulation.
Summary
SGB is effective and safe and could be considered for patients with refractory ventricular arrhythmias.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Pokorney SD, Mi X, Hammill BG, Allen LaPointe NM, Curtis LH, Al-Khatib SM. Use of antiarrhythmic medications in Medicare part D patients with an implantable cardioverter-defibrillator and ventricular tachycardia. Am J Cardiol. 2017;119(9):1401–6.
Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998. Circulation. 2001;104(18):2158–63.
Conti S, Pala S, Biagioli V, Del Giorno G, Zucchetti M, Russo E, et al. Electrical storm: a clinical and electrophysiological overview. World J Cardiol. 2015;7(9):555–61.
Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ, Raitt MH, et al. Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med. 2008;359(10):1009–17.
Nademanee K, Taylor R, Bailey WE, Rieders DE, Kosar EM. Treating electrical storm : sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation. 2000;102(7):742–7.
Waldron NH, Fudim M, Mathew JP, Piccini JP. Neuromodulation for the treatment of heart rhythm disorders. JACC Basic Transl Sci. 2019;4(4):546–62.
•• Fudim M, Boortz-Marx R, Ganesh A, Waldron NH, Qadri YJ, Patel CB, et al. Stellate ganglion blockade for the treatment of refractory ventricular arrhythmias: a systematic review and meta-analysis. J Cardiovasc Electrophysiol. 2017;28(12):1460–7. Annotation: Systematic review and meta analysis of published case reports of stellate ganglion blockade for ventricular arrhythmia.
Narouze S. Ultrasound-guided stellate ganglion block: safety and efficacy. Curr Pain Headache Rep. 2014;18(6):424.
Molnár I, Deák BZ, Hegyi G, Kovács Z, Kapócs G, Szőke H. Effects of neural therapy on quality of live in patients with inoperable lower extremity artery disease. Ideggyogyaszati szemle. 2018;71(11–12):393–402.
Heinig B, Koch A, Wollina U. Palmar hyperhidrosis treated by noninvasive ultrasound stellate ganglion block. Wiener medizinische Wochenschrift (1946). 2018;168(9–10):250–3.
Lo JC, Nguyen D, Matthews TK. Usefulness of stellate ganglion block for refractory angina pectoris. Proc (Baylor Univ Med Cent). 2018;31(3):370–1.
•• Fudim M, Qadri YJ, Waldron NH, Boortz-Marx RL, Ganesh A, Patel CB, et al. Stellate ganglion blockade for the treatment of refractory ventricular arrhythmias. JACC Clin Electrophysiol. 2020;6(5):562–71. Largest single center case series of bilateral stellate ganglion blockade for ventricular arrhythmia.
•• Tian Y, Wittwer ED, Kapa S, McLeod CJ, Xiao P, Noseworthy PA, et al. Effective use of percutaneous stellate ganglion blockade in patients with electrical storm. Circ Arrhythm Electrophysiol. 2019;12(9):e007118. Largest single center case series of stellate ganglion blockade for ventricular arrhythmia.
Schwartz PJ, Snebold NG, Brown AM. Effects of unilateral cardiac sympathetic denervation on the ventricular fibrillation threshold. Am J Cardiol. 1976;37(7):1034–40.
Schwartz PJ, Stone HL, Brown AM. Effects of unilateral stellate ganglion blockade on the arrhythmias associated with coronary occlusion. Am Heart J. 1976;92(5):589–99.
• Ajijola OA, Yagishita D, Reddy NK, Yamakawa K, Vaseghi M, Downs AM, et al. Remodeling of stellate ganglion neurons after spatially targeted myocardial infarction: neuropeptide and morphologic changes. Heart Rhythm. 2015;12(5):1027–35. Preclinical evidence to support the neuronal remodelling following cardiac insult.
Saddic LA, Howard-Quijano K, Kipke J, Kubo Y, Dale EA, Hoover DB, et al. Progression of myocardial ischemia leads to unique changes in immediate early gene expression in the spinal cord dorsal horn. Am J Physiol Heart Circ Physiol. 2018.
Gao C, Howard-Quijano K, Rau C, Takamiya T, Song Y, Shivkumar K, et al. Inflammatory and apoptotic remodeling in autonomic nervous system following myocardial infarction. PLoS One. 2017;12(5):e0177750.
Aleanakian R, Chung BY, Feldmann RE Jr, Benrath J. Effectiveness, safety, and predictive potential in ultrasound-guided stellate ganglion blockades for the treatment of sympathetically maintained pain. Pain practice : the official journal of World Institute of Pain. 2020;20:626–38.
Jeon Y. Therapeutic potential of stellate ganglion block in orofacial pain: a mini review. Journal of dental anesthesia and pain medicine. 2016;16(3):159–63.
Makharita MY, Amr YM, El-Bayoumy Y. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain physician. 2012;15(6):467–74.
Nabil Abbas D, Abd El Ghafar EM, Ibrahim WA, Omran AF. Fluoroscopic stellate ganglion block for postmastectomy pain: a comparison of the classic anterior approach and the oblique approach. Clin J Pain. 2011;27(3):207–13.
Borchers AT, Gershwin ME. Complex regional pain syndrome: a comprehensive and critical review. Autoimmun Rev. 2014;13(3):242–65.
Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses. 2009;72(6):657–61.
Lipov E, Lipov S, Stark JT. Stellate ganglion blockade provides relief from menopausal hot flashes: a case report series. Journal of women’s health (2002). 2005;14(8):737–41.
Summers MR, Nevin RL. Stellate ganglion block in the treatment of post-traumatic stress disorder: a review of historical and recent literature. Pain practice : the official journal of World Institute of Pain. 2017;17(4):546–53.
Gofeld M, Bhatia A, Abbas S, Ganapathy S, Johnson M. Development and validation of a new technique for ultrasound-guided stellate ganglion block. Reg Anesth Pain Med. 2009;34(5):475–9.
Shibata Y, Fujiwara Y, Komatsu T. A new approach of ultrasound-guided stellate ganglion block. Anesth Analg. 2007;105(2):550–1.
Elmofty DH, Eckmann M. Do not follow the bone, follow the nerve ultrasound-guided stellate ganglion block: a reconfirmation. Br J Pain. 2019;13(4):226–9.
Hansen TG. Ropivacaine: a pharmacological review. Expert Rev Neurother. 2004;4(5):781–91.
Cheng J, Salmasi V, You J, Grille M, Yang D, Mascha EJ, et al. Outcomes of sympathetic blocks in the management of complex regional pain syndrome: a retrospective cohort study. Anesthesiology. 2019;131(4):883–93.
Şahin ÖF, Tarıkçı Kılıç E, Aksoy Y, Kaydu A, Gökçek E. The importance of perfusion index monitoring in evaluating the efficacy of stellate ganglion blockage treatment in Raynaud's disease. The Libyan journal of medicine. 2018;13(1):1422666.
Yamazaki H, Nishiyama J, Suzuki T. Use of perfusion index from pulse oximetry to determine efficacy of stellate ganglion block. Local and regional anesthesia. 2012;5:9–14.
Shiokawa Y, Masahiro Morimoto, Hiromichi Kamamoto, H. Kamamoto, T. Uchida, and Y. Koga. Usefulness of perfusion index in evaluation of stellate ganglion block. Acta Medica Kinki Univ 2009;34(2):83–86.
Ginosar Y, Weiniger CF, Meroz Y, Kurz V, Bdolah-Abram T, Babchenko A, et al. Pulse oximeter perfusion index as an early indicator of sympathectomy after epidural anesthesia. Acta Anaesthesiol Scand. 2009;53(8):1018–26.
•• Goel V, Patwardhan AM, Ibrahim M, Howe CL, Schultz DM, Shankar H. Complications associated with stellate ganglion nerve block: a systematic review. Reg Anesth Pain Med. 2019;44:669–78. A systematic review of procedure related complications associated with stellate ganglion blockade.
Hardy PA, Wells JC. Extent of sympathetic blockade after stellate ganglion block with bupivacaine. Pain. 1989;36(2):193–6.
Rathmell JP. Atlas of image-guided intervention in regional anesthesia and pain medicine: Lippincott Williams & Wilkins; 2011.
Al-Qurayshi Z, Kandil E, Randolph GW. Cost-effectiveness of intraoperative nerve monitoring in avoidance of bilateral recurrent laryngeal nerve injury in patients undergoing total thyroidectomy. Br J Surg. 2017;104(11):1523–31.
Narouze S, Benzon HT, Provenzano D, Buvanendran A, De Andres J, Deer T, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (second edition): guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Regional anesthesia and pain medicine. 2018;43(3):225–62.
Neal JM, Barrington MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, et al. The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: executive summary 2017. Reg Anesth Pain Med. 2018;43(2):113–23.
Ha HR, Candinas R, Stieger B, Meyer UA, Follath F. Interaction between amiodarone and lidocaine. J Cardiovasc Pharmacol. 1996;28(4):533–9.
Eipe N, Gupta S, Penning J. Intravenous lidocaine for acute pain: an evidence-based clinical update. Bja Education. 2016;16(9):292–8.
Bigger Jr JT, and Elsa-Grace V. Giardina. The pharmacology and clinical use of lidocaine and procainamide. MCV/Q, Medical College of Virginia Quarterly 1973;9(1):65–76.
Wulf H, Maier C, Schele HA, Wabbel W. Plasma concentration of bupivacaine after stellate ganglion blockade. Anesth Analg. 1991;72(4):546–8.
Ajijola OA, Yagishita D, Patel KJ, Vaseghi M, Zhou W, Yamakawa K, et al. Focal myocardial infarction induces global remodeling of cardiac sympathetic innervation: neural remodeling in a spatial context. Am J Physiol Heart Circ Physiol. 2013;305(7):H1031–40.
Do DH, Bradfield J, Ajijola OA, Vaseghi M, Le J, Rahman S, et al. Thoracic epidural anesthesia can be effective for the short-term management of ventricular tachycardia storm. Journal of the American Heart Association. 2017;6(11).
Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (fourth edition). Reg Anesth Pain Med. 2018;43(3):263–309.
Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: causes and management. Br J Anaesth. 2012;109(2):144–54.
Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan A, et al. Bilateral cardiac sympathetic denervation for the management of electrical storm. J Am Coll Cardiol. 2012;59(1):91–2.
Coleman MA, Bos JM, Johnson JN, Owen HJ, Deschamps C, Moir C, et al. Videoscopic left cardiac sympathetic denervation for patients with recurrent ventricular fibrillation/malignant ventricular arrhythmia syndromes besides congenital long-QT syndrome. Circ Arrhythm Electrophysiol. 2012;5(4):782–8.
Hofferberth SC, Cecchin F, Loberman D, Fynn-Thompson F. Left thoracoscopic sympathectomy for cardiac denervation in patients with life-threatening ventricular arrhythmias. J Thorac Cardiovasc Surg. 2014;147(1):404–9.
Téllez LJ, Garzón JC, Vinck EE, Castellanos JD. Video-assisted thoracoscopic cardiac denervation of refractory ventricular arrhythmias and electrical storms: a single-center series. J Cardiothorac Surg. 2019;14(1):17.
Vaseghi M, Barwad P, Malavassi Corrales FJ, Tandri H, Mathuria N, Shah R, et al. Cardiac sympathetic denervation for refractory ventricular arrhythmias. J Am Coll Cardiol. 2017;69(25):3070–80.
Vaseghi M, Gima J, Kanaan C, Ajijola OA, Marmureanu A, Mahajan A, et al. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm. 2014;11(3):360–6.
Franklin AD, Llobet JR, Sobey CM, Daniels JM, Kannankeril PJ. Stellate ganglion catheter effective for treatment of ventricular tachycardia storm in a pediatric patient on extracorporeal membrane oxygenation: a case report. A&A practice. 2019;13(7):245–9.
Hulata DF, Le-Wendling L, Boezaart AP, Hurley RW. Stellate ganglion local anesthetic blockade and neurolysis for the treatment of refractory ventricular fibrillation. A & A case reports. 2015;4(5):49–51.
Scalercio L, Vitter J, Elliott CE. Placement of a continuous stellate ganglion block for treatment of refractory ventricular fibrillation in the setting of known Prinzmetal angina during pregnancy: a case report. A&A practice. 2019;12(4):106–8.
Bomberg H, Bayer I, Wagenpfeil S, Kessler P, Wulf H, Standl T, et al. Prolonged catheter use and infection in regional anesthesia: a retrospective registry analysis. Anesthesiology. 2018;128(4):764–73.
Luke WR, Daoud EG, Latif OS. Emergent phenol injection of bilateral stellate ganglion for management of refractory malignant ventricular arrhythmias. Am J Case Rep. 2020;21:e921465.
Abbas DN, Reyad RM. Thermal versus super voltage pulsed radiofrequency of stellate ganglion in post-mastectomy neuropathic pain syndrome: a prospective randomized trial. Pain physician. 2018;21(4):351–62.
Forouzanfar T, van Kleef M, Weber WE. Radiofrequency lesions of the stellate ganglion in chronic pain syndromes: retrospective analysis of clinical efficacy in 86 patients. Clin J Pain. 2000;16(2):164–8.
Kastler A, Aubry S, Sailley N, Michalakis D, Siliman G, Gory G, et al. CT-guided stellate ganglion blockade vs. radiofrequency neurolysis in the management of refractory type I complex regional pain syndrome of the upper limb. Eur Radiol. 2013;23(5):1316–22.
Hayase J, Vampola S, Ahadian F, Narayan SM, Krummen DE. Comparative efficacy of stellate ganglion block with bupivacaine vs pulsed radiofrequency in a patient with refractory ventricular arrhythmias. J Clin Anesth. 2016;31:162–5.
Markman TM, Hamilton RH, Marchlinski FE, Nazarian S. Case series of transcutaneous magnetic stimulation for ventricular tachycardia storm. Jama. 2020;323(21):2200–2.
Acknowledgments
We would like to thank Laura H. Qadri for the graphical support.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Device-Based Approaches for Hypertension
Rights and permissions
About this article
Cite this article
Ganesh, A., Qadri, Y.J., Boortz-Marx, R.L. et al. Stellate Ganglion Blockade: an Intervention for the Management of Ventricular Arrhythmias. Curr Hypertens Rep 22, 100 (2020). https://doi.org/10.1007/s11906-020-01111-8
Accepted:
Published:
DOI: https://doi.org/10.1007/s11906-020-01111-8