Kerry Mancuso, ACNP
Nebraska Medicine - Nebraska Medical Center
Omaha, NE
Disclosure information not submitted.
Thomas Nicholas, MD
Associate Professor, Section Head of Regional Anesthesiology and the Acute Pain Service
Nebraska Medicine, United States
Disclosure information not submitted.
Title: Continuous Stellate Ganglion Block for Incessant VT on MCS for Cardiogenic Shock
Case Report Body: INTRODUCTION: Incessant VT refractory to antiarrhythmics is difficult to treat. With mechanical circulatory support (MCS) and a stellate ganglion block a patient’s life threatening arrythmia can be managed.
Description: A 37-year-old male with a PMH of stage 4 CKD, IgA nephropathy, hypertension, and tobacco use disorder presented to the hospital with a ten-day history of chest pain. The patient emergently underwent successful PCI to the LAD for thrombus and micro catheter advancement to an embolus in the circumflex. Initially, he was supported with an Intra-Aortic Balloon Pump and inotropes but then required VA ECMO (veno-arterial extracorporeal membrane oxygenation) cannulation. He developed polymorphic VT that was stabilized with an amiodarone infusion. An axillary LV impella was placed to transition off VA ECMO, but the polymorphic VT then became refractory to defibrillation and antiarrhythmics including amiodarone, lidocaine, propranolol, and quinidine. He was then converted to a RVAD (right ventricular assist device) with ECMO while continuing LV support with the impella. Due to ongoing electrical storm, two stellate ganglion blocks were performed with 10ml of 0.25% bupivacaine. Decadron 2mg and Clonidine 100ug were used as block adjuncts. The patient had 12 hours of arrhythmia free periods. The following day ventricular tachycardia returned therefore, a longer lasting perineural catheter was placed and 0.1% bupivacaine was infused. After each block, the patient became responsive to electrical cardioversion. Low dose dexmedetomidine was used to further suppress any sympathetic drive of the arrythmia. Horner's syndrome with left pupil miosis and eyelid ptosis was present indicating a successful block. Otherwise, he tolerated the infusion for seven days with no recurrent VT. A repeat TTE showed LVEF improvement to 25% with normal RV function so he was able to have the RVAD and LV impella removed. He was discharged home post ICD placement on 25mg of metoprolol XL.
Discussion: Advanced heart failure therapies are often considered in these types of cases, but his candidacy was made difficult due to current tobacco abuse disorder and lack of health insurance. With the use of temporary MCS and stellate ganglion blocks we were able to restore a patient’s cardiac rhythm and myocardial function to discharge home.