an electrical storm ( es ) in ischaemic heart disease usually manifest as recurrent ventricular arrhythmias that are resistant to the antiarrhythmic drugs .
we report an incident of es in a patient , which was treated with left stellate ganglion block ( lsgb ) under ultrasound guidance followed by left cardiac sympathetic denervation ( lcsd ) under general anaesthesia .
a 52-year - old male , weighing 55 kg , received stents in left anterior descending artery ( lad ) and first diagonal artery and a permanent pacemaker ( vdd ) following anteroseptal myocardial infarction ( mi ) with complete heart block 2 years ago .
postoperative course was complicated with recurrent ventricular tachycardia ( vt ) and syncopal attacks requiring hospitalization and dc cardioversion on four occasions .
cardiology evaluation revealed pulse rate of 70/min and systemic blood pressure ( bp ) of 100/70 mmhg .
findings on transthoracic echocardiography were a dilated left ventricle with a very low ejection fraction ( 20% ) , akinesia of lad territory and grade-1 mitral regurgitation . preoperative medication consisted of oral amiodarone 300 mg and sustained release metoprolol 50 mg once and twice a day respectively . during electrophysiological studies
, vt could be easily induced , and the vt circuits were mapped and ablated at the anterobasal left ventricle . after an arrhythmia - free interval of 24 hours , he started having repeat episodes of monomorphic vt , degenerating into polymorphic vt and vf , requiring frequent cardioversions [ figure 1 ] .
monomorphic ventricular tachycardia at 220 bpm with positive concordance of qrs complexes and inferior axis are seen in the precordial leads .
these episodes soon degenerated into polymorphic vt and ventricular fibrillation hypokalemia , hypomagnesemia and hypothyroidism were excluded as triggering factors for arrhythmias on laboratory investigations .
severe hypotension and episodes of transient loss of consciousness warranted ventilatory therapy and inotropic support with epinephrine 0.1 mcg / kg / min . the trachea was intubated after administration of 200 mcg of fentanyl , 3 mg midazolam , 30 mg propofol and muscle relaxation with vecuronium 10 mg .
sedation was maintained using infusions of midazolam 1 mg / hour and fentanyl 60 mcg / hour . as the vt was resistant to treatment with magnesium , amiodarone and lidocaine lsgb was performed under ultrasound guidance using a 7.5 mhz probe ( site - rite ultrasound system , bard access , inc .
a 23-g 4-cm long needle was advanced through the prevertebral fascia till its tip was placed in the longus colli muscle .
injection of 6-ml 0.25% bupivacaine solution resulted in bulging of the longus colli compartment and caudad and cephalad spread , which was verified on ultrasound .
warming of left upper limb and left horner 's syndrome confirmed the success of lsgb .
patient remaining arrhythmia - free for 2 hours immediately after the blockade and incidents of vt were dramatically reduced subsequently for 12 hours . considering the benefits of lsgb toward pacifying the es
, we decided to perform lcsd under general anaesthesia via supraclavicular surgical approach . placing high thoracic epidural catheter and
video - assisted thoracoscopy ( vat)-guided ablation of left upper thoracic sympathetic ganglia were other options , which , however , were considered inappropriate given the unstable hemodynamic condition of patient and deranged left ventricular function .
upon arrival in the operation suite , his heart rate and systemic blood pressure were 78 bpm and 90/68 mmhg , respectively .
monitoring essentially consisted of electrocardiogram ( leads ii and v5 ) and invasive arterial blood pressure .
since the endotracheal tube was in situ , anaesthesia was deepened with bolus administration of fentanyl 200 mcg , midazolam 2 mg , propofol 25 mg and vecuronium 6 mg and maintained with sevoflurane adjusting concentration to maintain bis between 50 and 60 .
cervicothoracic sympathectomy was performed through neck excising left stellate ganglion and second thoracic ganglion with sympathetic chain .
no further deterioration occurred in the intraoperative period and the patient was transferred back to the icu for elective ventilation .
trachea was extubated 8 hours after surgery and inotropic support was tapered off over next 24 hours .
he was discharged in a hemodynamically stable condition and remained symptom - free without any incident of vt for past 8 months .
an es is defined as recurrent hemodynamically unstable vt and/or ventricular fibrillation ( vf ) , thrice or more in 24 hours , requiring intervention of the defibrillator ( anti - tachycardia pacing or shock ) .
ongoing myocardial ischaemia or reentrant circuits in an old infarct scar are considered causative factors for es , which are associated with augmented sympathetic activity and increased propensity for ventricular arrhythmias.recurrent vt or vf may result in left ventricular systolic dysfunction and myocardial injury exacerbating heart failure . identifying and reversing the causative factors is important during treatment .
specific precipitants include acute myocardial ischaemia , heart failure , hypokalemia , hypomagnesemia , arrhythmogenic drug therapy , hyperthyroidism , infection and fever .
treatment options for es include correcting the causative factors , providing hemodynamic support , instituting antiarrhythmic therapy , placing implantable cardioverter - defibrillator ( icd ) , achieving cardiac sympathetic denervation and interrupting the reentrant arrhythmia pathways using radiofrequency ablation .
nademanee et al . , reported that cardiac sympathetic blockade is superior to the antiarrhythmic therapy in treating es and have advocated lsgb for reducing the sympathetic surge .
there are a few publications on efficacy of the lsgband thoracic epidural anaesthesia ( tea)in lowering the incidents of ventricular arrhythmias during es .
these therapeutic approaches reduce adrenergic tone that is most likely responsible for the reported efficacy .
lsgb also reduces the risk of cardiac arrhythmias by shortening the qtc interval . the antiarrhythmic effect of lsgb
lcgb provides distinct but transient abolition of es which can be utilized as the therapeutic test for sympathetic denervation .
lcsd interrupts the major source of norepinephrine released in the heart , increases the threshold for vf and ventricular refractoriness .
wilde et al . , described that surgical lcsd in three young adults with polymorphic ventricular tachycardia resulted in postoperative cessation of symptoms .
icd is another treatment option , which , however , may worsen the arrhythmias in catecholaminergic vt .
repeated shocks delivered through the icd may aggravate sympathetic stimulation , ventricular arrhythmias and initiate a series of more shocks and es.the lcsd may complement the use of an icd , because the denervation markedly decreases the catecholaminergic load on the heart , which may facilitate smooth functioning of the icd in interrupting vf and restoring the sinus rhythm . performing lsgb under the ultrasound guidance
volume of local anaesthetic solution is an important concern during the cervicothoracic ganglion blockade against the likelihood of toxicity .
wulf et al . observed toxic plasma levels of bupivacaine in 30% of patients given injection of 10 ml of 0.5% bupivacaine during sgb
. a large volume of local anaesthetic , as much as 20 ml may be required to achieve desired blockade during blind injection as uncertainty exist over the placement of needle tip in the vicinity of the stellate ganglion . on the contrary
, 5 - 6-ml solution may be sufficient to block the ganglia as it can be injected precisely in the longus colli muscle under the ultrasound guidance .
success rate of the blockade technique is enhanced by visualizing distention of the longus colli compartmental space under the pretracheal fascia , directly under the ultrasound imaging .
blind landmark technique of lsgb is fraught with complications like accidental injection into the vertebral artery and injury to superior thyroid artery leading to hematoma formation in 25% of patients . esophageal injury and pneumothorax
sympathetic denervation in the presence of es poses a challenge to the anaesthesiologist , as the stress of surgery may further derange the cardiac function and aggravate the arrhythmia storm .
although high tea may lower the cardiac sympathetic tone , the unstable hemodynamic condition precluded us from inserting the catheter as turning the patient in lateral decubitus or sitting position would have worsened the situation .
surgical lcsd involves excision of cervicothoracic and upper thoracic ganglia along with the intervening sympathetic chain , which may be accessed via video - assisted thoracoscopy ( vat ) or through a supraclavicular incision following an extrapleural approach without performing thoracotomy .
vat sympathectomy demands changing over the endotracheal tube with a double lumen endobronchial tube for one - lung ventilation and turning the patient in right lateral decubitus , which would have deteriorated hemodynamic and respiratory parameters in our patient .
hence we preferred to perform the lcsd via supraclavicular approach . avoiding sympathetic stimulation arising from light anaesthesia , tachycardia , hypothermia , hypoxaemia and hypercapnia
electrolyte imbalances like hypokalemia , hypomagnesaemia , and hypocalcaemia can contribute to delayed myocardial repolarization and should be treated promptly .
short - acting anaesthetics such as propofol and benzodiazepines have been found to successfully convert and suppress occurrence of vt during es .
lsgb followed by surgical lcsd is an effective treatment modality to reduce the incidents of malignant ventricular arrhythmias .
lsgb may serve a simple bedside tool to identify the patients who are likely to respond to the more definite but more invasive modality of lcsd .
the ultrasonography during lsgb enhances the success rate of the technique , reduces the quantity of local anaesthetic required to produce desired effects and prevents technical complications .
supraclavicular surgical access to the upper thoracic sympathetic chain obviates the necessity for one lung ventilation and lateral decubitus during surgery in a hemodynamically unstable patient .
 an electrical storm is usually associated with catecholaminergic surge following myocardial ischaemia and manifest as recurrent ventricular arrhythmias , requiring frequent dc shocks . delivering repeated dc shocks 
 induces myocardial damage and further worsens the arrhythmias , which are resistant to the antiarrhythmic drugs . 
 cardiac sympathetic blockade abates the excessive catecholaminergic drive and help pacifying the malignant ventricular arrhythmias . 
 we treated the electrical storm in a 52-year - old male with ultrasound - guided left sympathetic ganglion block followed by surgical left cardiac sympathetic denervation . 
 the patient remained symptom - free without any incident of ventricular arrhythmias for 8 months after the surgery . 
 the ultrasonography during blockade of the stellate ganglion enhances the success rate of the technique , reduces the quantity of local anaesthetic required to produce desired effects and prevents technical complications . 
 supraclavicular surgical access to the upper thoracic sympathetic chain obviates the necessity for one lung ventilation and lateral decubitus during surgery , when the patient is in hemodynamically unstable condition . 
 sympathectomy can be performed under general anaesthesia taking cautions to avoid sympathetic stimulation in intraoperative period . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION