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Lenarczyk R, Zeppenfeld K, Tfelt-Hansen J, Heinzel FR, Deneke T, Ene E, Meyer C, Wilde A, Arbelo E, Jędrzejczyk-Patej E, Sabbag A, Stühlinger M, di Biase L, Vaseghi M, Ziv O, Bautista-Vargas WF, Kumar S, Namboodiri N, Henz BD, Montero-Cabezas J, Dagres N. Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society. Europace 2024; 26:euae049. [PMID: 38584423 PMCID: PMC10999775 DOI: 10.1093/europace/euae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/09/2024] Open
Abstract
Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.
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Affiliation(s)
- Radosław Lenarczyk
- Medical University of Silesia, Division of Medical Sciences, Department of Cardiology and Electrotherapy, Silesian Center for Heart Diseases, Skłodowskiej-Curie 9, 41-800 Zabrze, Poland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- The Department of Forensic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frank R Heinzel
- Cardiology, Angiology, Intensive Care, Städtisches Klinikum Dresden Campus Friedrichstadt, Dresden, Germany
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
- Clinic for Electrophysiology, Klinikum Nuernberg, University Hospital of the Paracelsus Medical University, Nuernberg, Germany
| | - Elena Ene
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Christian Meyer
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Arthur Wilde
- Department of Cardiology, Amsterdam UMC University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Markus Stühlinger
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luigi di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrythmia Center, Division of Cardiology, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ohad Ziv
- Case Western Reserve University, Cleveland, OH, USA
- The MetroHealth System Campus, Cleveland, OH, USA
| | | | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | | | - Benhur Davi Henz
- Instituto Brasilia de Arritmias-Hospital do Coração do Brasil-Rede Dor São Luiz, Brasilia, Brazil
| | - Jose Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Dusi V, Angelini F, Baldi E, Toscano A, Gravinese C, Frea S, Compagnoni S, Morena A, Saglietto A, Balzani E, Giunta M, Costamagna A, Rinaldi M, Trompeo AC, Rordorf R, Anselmino M, Savastano S, De Ferrari GM. Continuous stellate ganglion block for ventricular arrhythmias: case series, systematic review, and differences from thoracic epidural anaesthesia. Europace 2024; 26:euae074. [PMID: 38531027 PMCID: PMC11020261 DOI: 10.1093/europace/euae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/18/2024] [Indexed: 03/28/2024] Open
Abstract
AIMS Percutaneous stellate ganglion block (PSGB) through single-bolus injection and thoracic epidural anaesthesia (TEA) have been proposed for the acute management of refractory ventricular arrhythmias (VAs). However, data on continuous PSGB (C-PSGB) are scant. The aim of this study is to report our dual-centre experience with C-PSGB and to perform a systematic review on C-PSGB and TEA. METHODS AND RESULTS Consecutive patients receiving C-PSGB at two centres were enrolled. The systematic literature review follows the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Our case series (26 patients, 88% male, 60 ± 16 years, all with advanced structural heart disease, left ventricular ejection fraction 23 ± 11%, 32 C-PSGBs performed, with a median duration of 3 days) shows that C-PSGB is feasible and safe and leads to complete VAs suppression in 59% and to overall clinical benefit in 94% of cases. Overall, 61 patients received 68 C-PSGBs and 22 TEA, with complete VA suppression in 63% of C-PSGBs (61% of patients). Most TEA procedures (55%) were performed on intubated patients, as opposed to 28% of C-PSGBs (P = 0.02); 63% of cases were on full anticoagulation at C-PSGB, none at TEA (P < 0.001). Ropivacaine and lidocaine were the most used drugs for C-PSGB, and the available data support a starting dose of 12 and 100 mg/h, respectively. No major complications occurred, yet TEA discontinuation rate due to side effects was higher than C-PSGB (18 vs. 1%, P = 0.01). CONCLUSION Continuous PSGB seems feasible, safe, and effective for the acute management of refractory VAs. The antiarrhythmic effect may be accomplished with less concerns for concomitant anticoagulation compared with TEA and with a lower side-effect related discontinuation rate.
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Affiliation(s)
- Veronica Dusi
- Cardiology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Enrico Baldi
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Toscano
- Department of Anaesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Carol Gravinese
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Sara Compagnoni
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Viale Golgi 19, 27100 Pavia, Italy
| | - Arianna Morena
- Cardiology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Eleonora Balzani
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Matteo Giunta
- Department of Anaesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Andrea Costamagna
- Department of Anaesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Mauro Rinaldi
- Department of Surgical Sciences, University of Turin, Torino, Italy
- Department of Cardiovascular and Thoracic Surgery, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Anna Chiara Trompeo
- Department of Anaesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Roberto Rordorf
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Matteo Anselmino
- Cardiology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
| | - Simone Savastano
- Arrhythmia and Electrophysiology Unit, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gaetano Maria De Ferrari
- Cardiology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Corso Bramante 88/90, 10126 Torino, Italy
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Malik V, Shivkumar K. Stellate ganglion blockade for the management of ventricular arrhythmia storm. Eur Heart J 2024; 45:834-836. [PMID: 38366239 PMCID: PMC10919926 DOI: 10.1093/eurheartj/ehae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Affiliation(s)
- Varun Malik
- Cardiac Arrhythmia Center, University of California, Los Angeles (UCLA), 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Kalyanam Shivkumar
- Cardiac Arrhythmia Center, University of California, Los Angeles (UCLA), 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
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Savastano S, Baldi E, Compagnoni S, Rordorf R, Sanzo A, Gentile FR, Dusi V, Frea S, Gravinese C, Cauti FM, Iannopollo G, De Sensi F, Gandolfi E, Frigerio L, Crea P, Zagari D, Casula M, Sangiorgi G, Persampieri S, Dell’Era G, Patti G, Colombo C, Mugnai G, Notaristefano F, Barengo A, Falcetti R, Perego GB, D’Angelo G, Tanese N, Currao A, Sgromo V, De Ferrari GM. Electrical storm treatment by percutaneous stellate ganglion block: the STAR study. Eur Heart J 2024; 45:823-833. [PMID: 38289867 PMCID: PMC10919918 DOI: 10.1093/eurheartj/ehae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/27/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND AIMS An electrical storm (ES) is a clinical emergency with a paucity of established treatment options. Despite initial encouraging reports about the safety and effectiveness of percutaneous stellate ganglion block (PSGB), many questions remained unsettled and evidence from a prospective multicentre study was still lacking. For these purposes, the STAR study was designed. METHODS This is a multicentre observational study enrolling patients suffering from an ES refractory to standard treatment from 1 July 2017 to 30 June 2023. The primary outcome was the reduction of treated arrhythmic events by at least 50% comparing the 12 h following PSGB with the 12 h before the procedure. STAR operators were specifically trained to both the anterior anatomical and the lateral ultrasound-guided approach. RESULTS A total of 131 patients from 19 centres were enrolled and underwent 184 PSGBs. Patients were mainly male (83.2%) with a median age of 68 (63.8-69.2) years and a depressed left ventricular ejection fraction (25.0 ± 12.3%). The primary outcome was reached in 92% of patients, and the median reduction of arrhythmic episodes between 12 h before and after PSGB was 100% (interquartile range -100% to -92.3%). Arrhythmic episodes requiring treatment were significantly reduced comparing 12 h before the first PSGB with 12 h after the last procedure [six (3-15.8) vs. 0 (0-1), P < .0001] and comparing 1 h before with 1 h after each procedure [2 (0-6) vs. 0 (0-0), P < .001]. One major complication occurred (0.5%). CONCLUSIONS The findings of this large, prospective, multicentre study provide evidence in favour of the effectiveness and safety of PSGB for the treatment of refractory ES.
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Affiliation(s)
- Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Sara Compagnoni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Roberto Rordorf
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Antonio Sanzo
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Francesca Romana Gentile
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Veronica Dusi
- Division of Cardiology, Molinette Hospital, Città della Salute e della Scienza, Torino, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Simone Frea
- Division of Cardiology, Molinette Hospital, Città della Salute e della Scienza, Torino, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Carol Gravinese
- Division of Cardiology, Molinette Hospital, Città della Salute e della Scienza, Torino, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
| | | | | | | | - Edoardo Gandolfi
- Division of Cardiology, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Laura Frigerio
- Division of Cardiology, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
- Division of Cardiology, Maggiore Hospital, Crema, Italy
| | - Pasquale Crea
- Division of Cardiology, G. Martino Hospital, Messina, Italy
| | - Domenico Zagari
- Division of Cardiology, Humanitas Mater Domini, Castellanza, Italy
| | - Matteo Casula
- Division of Cardiology, ‘San Michele’ dell’ARNAS G. Brotzu Hospital, Cagliari, Italy
| | | | | | - Gabriele Dell’Era
- Division of Cardiology, Maggiore della carità Hospital, Novara, Italy
| | - Giuseppe Patti
- Division of Cardiology, Maggiore della carità Hospital, Novara, Italy
- University of Eastern Piedmont ‘Amedeo Avogadro’, Novara, Italy
| | - Claudia Colombo
- Division of Cardiology, ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Mugnai
- Division of Cardiology, Department of Medicine, School of Medicine, University of Verona, Verona, Italy
| | | | - Alberto Barengo
- Division of Cardiology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Roberta Falcetti
- Division of Cardiology, Sant’Andrea University Hospital, Rome, Italy
| | | | - Giuseppe D’Angelo
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Nikita Tanese
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Alessia Currao
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Vito Sgromo
- AREU Azienda Regionale Emergenza Urgenza, AAT Pavia Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Molinette Hospital, Città della Salute e della Scienza, Torino, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
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Toscano A, Giunta M, Capuano P, Balzani E, Salonia C, Balzano S, Angelini F, Dusi V, Brazzi L. Intraoperative Ultrasound-Guided Left Stellate Ganglion Block for Postcardiotomy Cardiogenic Shock: A Shelter from the Storm. Ann Card Anaesth 2024; 27:93-94. [PMID: 38722135 PMCID: PMC10876137 DOI: 10.4103/aca.aca_124_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/22/2023] [Accepted: 10/11/2023] [Indexed: 05/12/2024] Open
Affiliation(s)
- Antonio Toscano
- Department of Anesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Matteo Giunta
- Department of Anesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Paolo Capuano
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, UPMC, Palermo, Italy
| | - Eleonora Balzani
- Department of Surgical Sciences, University of Turin, Torino, Italy
| | - Cristian Salonia
- Department of Anesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Stefano Balzano
- Department of Anesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
| | - Veronica Dusi
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
- Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia, Critical Care and Emergency, ‘Città della Salute e della Scienza’ Hospital, Torino, Italy
- Department of Surgical Sciences, University of Turin, Torino, Italy
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6
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Schwarzkopf P, Feigl GC, Mäcken T, Pracht K, Litz RJ. [Ultrasound-guided low-volume continuous cervical sympathetic nerve block for treatment of an electrical storm]. Anaesthesiologie 2023; 72:647-653. [PMID: 37433939 DOI: 10.1007/s00101-023-01312-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 07/13/2023]
Abstract
In addition to the treatment for complex regional pain syndrome (CRPS), the stellate ganglion block is a treatment option for refractory intermittent ventricular tachycardia (VT). Despite the use of imaging techniques, such as fluoroscopy and ultrasound, numerous side effects and complications have been reported. These are a result of the complex anatomical site and the volume of injected local anesthetics. This article reports on the catheter placement for continuous block of the cervical sympathetic trunk with high-resolution ultrasound imaging (HRUI) in a patient with intermittent VT. The tip of the cannula was placed on the anterior aspect of the longus colli muscle and 20 mg prilocaine 1% (2 ml) was injected. The VT stopped and a continuous infusion of 1 ml/h ropivacaine 0,2 % was started. Nevertheless, during the next hour the patient developed hoarseness and dysphagia, so that a block of the recurrent laryngeal nerve and the deep ansa cervicalis (C1-C3) was carried out. The infusion was paused and restarted later with 0.5 ml/h. The spread of the local anesthetic was controlled by ultrasound. Over the next 4 days the patient showed no VT or detectable side effects. After implantation of a defibrillator 1 day later the patient could then be discharged home on the following day. This case shows that the HRUI can be advantageously used in the catheter placement and also when adjusting the flow rate. In this way the risk of complications and side effects related to the puncture and local anesthetic volume can be reduced.
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Affiliation(s)
- Peter Schwarzkopf
- Klinik für Anästhesiologie, Intensiv‑, Palliativ- und Schmerzmedizin, Sana Kliniken Leipziger Land GmbH, Klinikum Borna, Rudolf-Virchow-Straße 2, 04552, Borna, Deutschland.
| | - Georg C Feigl
- Institut für Anatomie, Universität Witten/Herdecke, Witten/Herdecke, Deutschland
| | - Tim Mäcken
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, BG Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Karsten Pracht
- Klinik für Anästhesiologie, Intensiv‑, Palliativ- und Schmerzmedizin, Sana Kliniken Leipziger Land GmbH, Klinikum Borna, Rudolf-Virchow-Straße 2, 04552, Borna, Deutschland
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7
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van Weperen VYH, Ripplinger CM, Vaseghi M. Autonomic control of ventricular function in health and disease: current state of the art. Clin Auton Res 2023; 33:491-517. [PMID: 37166736 PMCID: PMC10173946 DOI: 10.1007/s10286-023-00948-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/20/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Cardiac autonomic dysfunction is one of the main pillars of cardiovascular pathophysiology. The purpose of this review is to provide an overview of the current state of the art on the pathological remodeling that occurs within the autonomic nervous system with cardiac injury and available neuromodulatory therapies for autonomic dysfunction in heart failure. METHODS Data from peer-reviewed publications on autonomic function in health and after cardiac injury are reviewed. The role of and evidence behind various neuromodulatory therapies both in preclinical investigation and in-use in clinical practice are summarized. RESULTS A harmonic interplay between the heart and the autonomic nervous system exists at multiple levels of the neuraxis. This interplay becomes disrupted in the setting of cardiovascular disease, resulting in pathological changes at multiple levels, from subcellular cardiac signaling of neurotransmitters to extra-cardiac, extra-thoracic remodeling. The subsequent detrimental cycle of sympathovagal imbalance, characterized by sympathoexcitation and parasympathetic withdrawal, predisposes to ventricular arrhythmias, progression of heart failure, and cardiac mortality. Knowledge on the etiology and pathophysiology of this condition has increased exponentially over the past few decades, resulting in a number of different neuromodulatory approaches. However, significant knowledge gaps in both sympathetic and parasympathetic interactions and causal factors that mediate progressive sympathoexcitation and parasympathetic dysfunction remain. CONCLUSIONS Although our understanding of autonomic imbalance in cardiovascular diseases has significantly increased, specific, pivotal mediators of this imbalance and the recognition and implementation of available autonomic parameters and neuromodulatory therapies are still lagging.
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Affiliation(s)
- Valerie Y H van Weperen
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | | | - Marmar Vaseghi
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA.
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Abstract
Therapeutic use of tranexamic acid (TXA) to minimise blood loss is common during a wide range of surgical procedures. This review aims to explore the clinical features of the accidental intrathecal administration of TXA and to identify contributory factors that might prevent future incidents. The author searched published reports of accidental intrathecal administration of TXA using Medline and Google Scholar databases from July 2018 to September 2022, including error reports in any language but excluding errors via nonintrathecal routes. The human factors analysis classification system (HFACS) framework was used to examine and classify the human and systemic factors that contributed to the errors. Twenty-two errors of accidental intrathecal administration were reported during the search period. The analysis showed that the outcome was death in eight patients (36%) and permanent harm in four (19%). The fatality rate was higher among female individuals (6/13 versus 2/8 male individuals). Two-thirds of errors (15/22) occurred during orthopaedic surgery (10) and lower segment caesarean sections (5). Nineteen of 21 patients developed refractory or super refractory status epilepticus, requiring mechanical ventilation and intensive care for 3 days to 3 weeks for those who survived the initial few hours. Severe sympathetic stimulation resulting in refractory ventricular arrhythmias was the final event in some patients, with death within a few hours. Lack of familiarity with clinical characteristics caused delayed diagnosis or confusion with other clinical conditions. A proposed plan to manage intrathecal TXA toxicity is presented, including immediate cerebrospinal fluid lavage; however, there is no specific approach. The HFACS suggested mistaking look-alike TXA ampoules for local anaesthetic was the predominant cause. The author concludes that inadvertent intrathecal TXA is associated with mortality or permanent harm in more than 50% of patients. The HFACS demonstrates that all errors are preventable.
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Affiliation(s)
- Santosh Patel
- From the Department of Anaesthesia, Tawam Hospital, Al Ain, UAE
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9
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Patel RA, Condrey JM, George RM, Wolf BJ, Wilson SH. Stellate ganglion block catheters for refractory electrical storm: a retrospective cohort and care pathway. Reg Anesth Pain Med 2023; 48:224-228. [PMID: 36725213 PMCID: PMC10251217 DOI: 10.1136/rapm-2022-104172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Electrical storm can be challenging to treat, requiring a multidisciplinary team to coordinate medical management and invasive procedures. As the stellate ganglion provides efferent sympathetic outflow to the myocardium, stellate ganglion blocks (SGB) can be used to combat ventricular arrhythmias that arise from sympathetic overactivity. Data are scarce regarding SGB catheters as a treatment for electrical storm. We reviewed our use of SGB catheters for refractory electrical storm using our pathway collaboratively developed by critical care, cardiology, and regional anesthesia teams. METHODS We conducted a retrospective cohort study of patients who underwent an SGB for electrical storm between January 2020 and April 2022 in our cardiovascular intensive care unit. The primary outcome was the sustained cessation of electrical storm for 24 hours. RESULTS Upon chart review, 27 patients were identified and 11 met inclusion criteria. Cessation of electrical storm for 24 hours was achieved in 90% (n=10) of patients after left SGB. Similarly, 90% (n=10) had no documented episodes of ventricular arrhythmias requiring intervention within 6 hours after SGB. CONCLUSIONS SGBs can interrupt or treat electrical storm. SGB catheters allow for prolonged arrhythmia cessation without repeated blocks and decrease the risk of repeat episodes of ventricular arrhythmias.
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Affiliation(s)
- Rishi Ashok Patel
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jackson M Condrey
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Renuka M George
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bethany J Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sylvia H Wilson
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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10
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Chung WH, Lin YN, Wu MY, Chang KC. Sympathetic Modulation in Cardiac Arrhythmias: Where We Stand and Where We Go. J Pers Med 2023; 13:jpm13050786. [PMID: 37240956 DOI: 10.3390/jpm13050786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
The nuance of autonomic cardiac control has been studied for more than 400 years, yet little is understood. This review aimed to provide a comprehensive overview of the current understanding, clinical implications, and ongoing studies of cardiac sympathetic modulation and its anti-ventricular arrhythmias' therapeutic potential. Molecular-level studies and clinical studies were reviewed to elucidate the gaps in knowledge and the possible future directions for these strategies to be translated into the clinical setting. Imbalanced sympathoexcitation and parasympathetic withdrawal destabilize cardiac electrophysiology and confer the development of ventricular arrhythmias. Therefore, the current strategy for rebalancing the autonomic system includes attenuating sympathoexcitation and increasing vagal tone. Multilevel targets of the cardiac neuraxis exist, and some have emerged as promising antiarrhythmic strategies. These interventions include pharmacological blockade, permanent cardiac sympathetic denervation, temporal cardiac sympathetic denervation, etc. The gold standard approach, however, has not been known. Although neuromodulatory strategies have been shown to be highly effective in several acute animal studies with very promising results, the individual and interspecies variation between human autonomic systems limits the progress in this young field. There is, however, still much room to refine the current neuromodulation therapy to meet the unmet need for life-threatening ventricular arrhythmias.
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Affiliation(s)
- Wei-Hsin Chung
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90024, USA
| | - Yen-Nien Lin
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - Mei-Yao Wu
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung 404333, Taiwan
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
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11
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Zhou L, Zhang Y, Cao G, Zhang C, Zheng C, Meng G, Lai Y, Zhou Z, Liu Z, Liu Z, Guo F, Dong X, Liang Z, Wang Y, Guo S, Zhou X, Jiang H, Yu L. Wireless Self-Powered Optogenetic System for Long-Term Cardiac Neuromodulation to Improve Post-MI Cardiac Remodeling and Malignant Arrhythmia. Adv Sci (Weinh) 2023; 10:e2205551. [PMID: 36698262 PMCID: PMC10037959 DOI: 10.1002/advs.202205551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/02/2022] [Indexed: 06/17/2023]
Abstract
Autonomic imbalance is an important characteristic of patients after myocardial infarction (MI) and adversely contributes to post-MI cardiac remodeling and ventricular arrhythmias (VAs). A previous study proved that optogenetic modulation could precisely inhibit cardiac sympathetic hyperactivity and prevent acute ischemia-induced VAs. Here, a wireless self-powered optogenetic modulation system is introduced, which achieves long-term precise cardiac neuromodulation in ambulatory canines. The wireless self-powered optical system based on a triboelectric nanogenerator is powered by energy harvested from body motion and realized the effective optical illumination that is required for optogenetic neuromodulation (ON). It is further demonstrated that long-term ON significantly mitigates MI-induced sympathetic remodeling and hyperactivity, and improves a variety of clinically relevant outcomes such as improves ventricular dysfunction, reduces infarct size, increases electrophysiological stability, and reduces susceptibility to VAs. These novel insights suggest that wireless ON holds translational potential for the clinical treatment of arrhythmia and other cardiovascular diseases related to sympathetic hyperactivity. Moreover, this innovative self-powered optical system may provide an opportunity to develop implantable/wearable and self-controllable devices for long-term optogenetic therapy.
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Affiliation(s)
- Liping Zhou
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Yuanzheng Zhang
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
- Hubei Yangtze Memory LaboratoriesKey Laboratory of Artificial Micro, and Nano‐structures of Ministry of EducationSchool of Physics and TechnologyWuhan UniversityWuhan430072P. R. China
| | - Gang Cao
- Biomedical CenterCollege of Veterinary MedicineHuazhong Agricultural UniversityWuhan430072P. R. China
| | - Chi Zhang
- Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhan430072P. R. China
| | - Chen Zheng
- Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhan430072P. R. China
| | - Guannan Meng
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Yanqiu Lai
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Zhen Zhou
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Zhihao Liu
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Zihan Liu
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Fuding Guo
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Xin Dong
- Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhan430072P. R. China
| | - Zhizhuo Liang
- Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhan430072P. R. China
| | - Yueyi Wang
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Shishang Guo
- Hubei Yangtze Memory LaboratoriesKey Laboratory of Artificial Micro, and Nano‐structures of Ministry of EducationSchool of Physics and TechnologyWuhan UniversityWuhan430072P. R. China
| | - Xiaoya Zhou
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Hong Jiang
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
| | - Lilei Yu
- Department of CardiologyRenmin Hospital of Wuhan UniversityHubei Key Laboratory of Autonomic Nervous System ModulationCardiac Autonomic Nervous System Research Center of Wuhan UniversityTaikang Center for Life and Medical SciencesWuhan UniversityCardiovascular Research InstituteWuhan UniversityHubei Key Laboratory of CardiologyWuhan430060P. R. China
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12
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Lador A, Wang S, Schurmann PA, Chihara R, Dave AS, Valderrábano M. Stellate ganglion instrumentation for pharmacological blockade, nerve recording, and stimulation in patients with ventricular arrhythmias: Preliminary experience. Heart Rhythm 2023; 20:797-805. [PMID: 36863635 DOI: 10.1016/j.hrthm.2023.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Stellate ganglion blockade (SGB) can control ventricular arrhythmias (VAs), but outcomes are unclear. Percutaneous stellate ganglion (SG) recording and stimulation in humans has not been reported. OBJECTIVE The purpose of this study was to assess the outcomes of SGB and the feasibility of SG stimulation and recording in humans with VAs. METHODS Two patient cohorts were included-group 1: patients undergoing SGB for drug-refractory VAs. SGB was performed by injection of liposomal bupivacaine. Incidence of VAs at 24 and 72 hours and clinical outcomes were collected; group 2: patients undergoing SG stimulation and recording during VA ablation; a 2-F octapolar catheter was placed at the SG at the C7 level. Recording (30 kHz sampling, 0.5-2 kHz filter) and stimulation (up to 80 mA output, 50 Hz, 2 ms pulse width for 20-30 seconds) was performed. RESULTS Group 1 included 25 patients [age 59.2 ± 12.8 years; 19 (76%) men] who underwent SGB for VAs. Nineteen patients (76.0%) were free of VA up to 72 hours postprocedure. However, 15 (60.0%) had VAs recurrence for a mean of 5.47 ± 4.52 days. Group 2 included 11 patients (mean age 63 ± 12.7 years; 82.7% men). SG stimulation caused consistent increases in systolic blood pressure. We recorded unequivocal signals with temporal association with arrhythmias in 4 of 11 patients. CONCLUSION SGB provides short-term VA control, but has no benefit in the absence of definitive VA therapies. SG recording and stimulation is feasible and may have value to elicit VA and understand neural mechanisms of VA in the electrophysiology laboratory.
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Affiliation(s)
- Adi Lador
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Sufen Wang
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Paul A Schurmann
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Ray Chihara
- Division of Thoracic Surgery, Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Amish S Dave
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas.
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13
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Savastano S, Schwartz PJ. Blocking nerves and saving lives: Left stellate ganglion block for electrical storms. Heart Rhythm 2022:S1547-5271(22)02695-9. [PMID: 36509320 DOI: 10.1016/j.hrthm.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
Patients who present with electrical storms (ES) due to rapid recurrence of ventricular tachycardia/ventricular fibrillation represent major medical emergencies without easy solutions. Antiarrhythmic drugs have limited value, and ES need to be stopped quickly to prevent irreversible patient deterioration and death. Since the mid-1970s, we have provided the rationale for interrupting cardiac sympathetic nerves and evidence of its antifibrillatory action in different clinical settings. Slowly but progressively, from isolated clinical reports to small case series, increasing evidence has indicated that pharmacologic stellate ganglion block (SGB) is highly effective in interrupting ES. However, medical guidelines have largely ignored SGB, and few centers are prepared to perform SGB in actual emergencies. Our own experience shows that a direct anatomic approach that does not require echocardiographic assistance can be performed rapidly, thus saving time in highly critical patients. In this review, we retrace the evolution in our understanding of the mechanism of action of SGB, discuss the current approaches and their limitations, and review the correct indications that overcome still existing biases. Furthermore, we propose a practical solution to increase the availability of SGB to more patients by extending the number of centers where this approach can be rapidly implemented.
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Affiliation(s)
- Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Milan, Italy.
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14
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Henein MY, Vancheri S, Longo G, Vancheri F. The Impact of Mental Stress on Cardiovascular Health—Part II. J Clin Med 2022; 11:jcm11154405. [PMID: 35956022 PMCID: PMC9369438 DOI: 10.3390/jcm11154405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
Endothelial dysfunction is one of the earliest manifestations of atherosclerosis, contributing to its development and progression. Mental stress induces endothelial dysfunction through increased activity of the sympathetic nervous system, release of corticotropin-releasing hormone from the hypothalamus, inhibition of nitric oxide (NO) synthesis by cortisol, and increased levels of pro-inflammatory cytokines. Mental-stress-induced increased output of the sympathetic nervous system and concomitant withdrawal of the parasympathetic inflammatory reflex results in systemic inflammation and activation of a neural–hematopoietic–arterial axis. This includes the brainstem and subcortical regions network, bone marrow activation, release of leukocytes into the circulation and their migration to the arterial wall and atherosclerotic plaques. Low-grade, sterile inflammation is involved in all steps of atherogenesis, from coronary plaque formation to destabilisation and rupture. Increased sympathetic tone may cause arterial smooth-muscle-cell proliferation, resulting in vascular hypertrophy, thus contributing to the development of hypertension. Emotional events also cause instability of cardiac repolarisation due to brain lateralised imbalance of cardiac autonomic nervous stimulation, which may lead to asymmetric repolarisation and arrhythmia. Acute emotional stress can also provoke severe catecholamine release, leading to direct myocyte injury due to calcium overload, known as myocytolysis, coronary microvascular vasoconstriction, and an increase in left ventricular afterload. These changes can trigger a heart failure syndrome mimicking acute myocardial infarction, characterised by transient left ventricular dysfunction and apical ballooning, known as stress (Takotsubo) cardiomyopathy. Women are more prone than men to develop mental-stress-induced myocardial ischemia (MSIMI), probably reflecting gender differences in brain activation patterns during mental stress. Although guidelines on CV prevention recognise psychosocial factors as risk modifiers to improve risk prediction and decision making, the evidence that their assessment and treatment will prevent CAD needs further evaluation.
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Affiliation(s)
- Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden;
- Brunel University, Middlesex, London UB8 3PH, UK
- St. George’s University, London SW17 0RE, UK
| | - Sergio Vancheri
- Radiology Department, I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S. Elia Hospital, 93100 Caltanissetta, Italy;
| | - Federico Vancheri
- Department of Internal Medicine, S. Elia Hospital, 93100 Caltanissetta, Italy
- Correspondence:
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15
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Elsokkari I, Tsuji Y, Sapp JL, Nattel S. Recent insights into mechanisms and clinical approaches to electrical storm. Can J Cardiol 2021; 38:439-453. [PMID: 34979281 DOI: 10.1016/j.cjca.2021.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 12/14/2022] Open
Abstract
Electrical storm, characterized by repetitive ventricular tachycardia/fibrillation (VT/VF) over a short period, is becoming commoner with widespread use of implantable cardioverter-defibrillator (ICD) therapy. Electrical storm, sometimes called "arrhythmic storm" or "VT-storm", is usually a medical emergency requiring hospitalization and expert management, and significantly affects short- and long-term outcomes. This syndrome typically occurs in patients with underlying structural heart disease (ischemic or non-ischemic cardiomyopathy) or inherited channelopathies. Triggers for electrical storm should be sought but are often unidentifiable. Initial management is dictated by the hemodynamic status, while subsequent management typically involves ICD interrogation and reprogramming to reduce recurrent shocks, identification/management of triggers like electrolyte abnormalities, myocardial ischemia, or decompensated heart failure, and antiarrhythmic-drug therapy or catheter ablation. Sympathetic nervous system activation is central to the initiation and maintenance of arrhythmic storm, so autonomic modulation is a cornerstone of management. Sympathetic inhibition can be achieved with medications (particularly beta-adrenoreceptor blockers), deep sedation, or cardiac sympathetic denervation. More definitive management targets the underlying ventricular arrhythmia substrate to terminate and prevent recurrent arrhythmia. Arrhythmia targeting can be achieved with antiarrhythmic medications, catheter ablation or more novel therapies such as stereotactic radiation therapy that targets the arrhythmic substrate. Mechanistic studies point to adrenergic activation and other direct consequences of ICD-shocks in promoting further arrhythmogenesis and hypocontractility. Here, we review the pathophysiologic mechanisms, clinical features, prognosis, and therapeutic options for electrical storm. We also outline a clinical approach to this challenging and complex condition, along with its mechanistic basis.
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Affiliation(s)
- Ihab Elsokkari
- University of Sydney, Nepean Blue Mountains local health district, Australia
| | - Yukiomi Tsuji
- Department of Physiology of Visceral Function, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - John L Sapp
- Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - Stanley Nattel
- Departments of Medicine and Research Center, Montreal Heart Institute and Université de Montréal and Pharmacology and Therapeutics McGill University, Montreal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany; IHU LIYRC Institute, Bordeaux, France.
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Reinertsen E, Sabayon M, Riso M, Lloyd M, Spektor B. Stellate ganglion blockade for treating refractory electrical storm: a historical cohort study. Can J Anaesth 2021; 68:1683-1689. [PMID: 34312821 DOI: 10.1007/s12630-021-02068-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Stellate ganglion blockade (SGB) has been used to treat electrical storm (ES) refractory to antiarrhythmic therapy or to stabilize patients before more definitive intervention. Nevertheless, its efficacy is not well understood, with only a few case reports and retrospective case series in the literature. METHODS We conducted a historical cohort study on patients with drug-refractory ES who underwent ultrasound-guided unilateral SGB from 1 January 2010 until 19 July 2019 at two hospital sites. Stellate ganglion blockade was performed with variable combinations of bupivacaine, lidocaine, ropivacaine, and dexamethasone. We collected data on demographic and procedural characteristics, the number of arrhythmias and defibrillation episodes, antiarrhythmic and anticoagulant medication, left ventricular ejection fraction (EF), and respiratory support requirement. RESULTS We identified N = 13 patients; their mean (standard deviation [SD]) age was 64 (13) yr, and 10 (77%) were male. The baseline mean (SD) number of overall arrhythmia and defibrillation episodes per day were 9 (6) and 4 (3), respectively; the mean (SD) pre-SGB EF was 23 (7)%. Seven patients (54%) received dexamethasone in addition to local anesthetic for SGB. One patient experienced hypotension after SGB. Arrhythmias and defibrillation episodes significantly decreased at 24, 48, 72, and 96 hr after SGB; at 96 hr, 62% and 92% of patients had no VA and defibrillation episodes, respectively (P < 0.001 for all time points). Ejection fraction and the number of patients receiving antiarrhythmic medications or requiring respiratory support were unchanged. CONCLUSIONS Unilateral SGB was associated with a reduction in arrhythmias and defibrillation episodes, but did not affect antiarrhythmic medication, respiratory support, or EF. Randomized controlled trials on larger cohorts are needed to confirm these findings.
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Affiliation(s)
| | - Muhie Sabayon
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Margaret Riso
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Lloyd
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Boris Spektor
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA.
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