Safety and Efficacy of Ultrasound-Guided Sympathetic Blockade by Proximal Intercostal Block in Electrical Storm Patients

Uyanga Batnyam; Kamen V Vlassakov; Ahmad Halawa; Erica Seligson; Brigham Regional Anesthesia Group (BRAG); Liting Chen; Brahim Redouane; David Janfaza; Usha B Tedrow

doi:10.1016/j.jacep.2023.12.006

Safety and Efficacy of Ultrasound-Guided Sympathetic Blockade by Proximal Intercostal Block in Electrical Storm Patients

JACC Clin Electrophysiol. 2024 Apr;10(4):734-746. doi: 10.1016/j.jacep.2023.12.006. Epub 2024 Jan 31.

Authors

Uyanga Batnyam¹, Kamen V Vlassakov², Ahmad Halawa¹, Erica Seligson²; Brigham Regional Anesthesia Group (BRAG)²; Liting Chen³, Brahim Redouane¹, David Janfaza², Usha B Tedrow⁴

Collaborators

Brigham Regional Anesthesia Group (BRAG):
Jose Zeballos, Archana O'Neill, Devon Flaherty, Carolyn Buckley, Philipp Lirk, Yun-Yun Chen, Talora Steen, Kavin Bains, Alexander Stone, Philipp Gerner, Amar Desai, Joseph Homsi

Affiliations

¹ Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
² Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
³ Department of Anesthesiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Chicago, Illinois, USA.
⁴ Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: utedrow@bwh.harvard.edu.

PMID: 38300210
DOI: 10.1016/j.jacep.2023.12.006

Abstract

Background: Electrical storm (ES) patients who fail standard therapies have a high mortality rate. Previous studies report effective management of ES with bedside, ultrasound-guided percutaneous stellate ganglion block (SGB). We report our experience with sympathetic blockade administered via a novel alternative approach: proximal intercostal block (PICB). Compared with SGB, this technique targets an area typically free of other catheters and support devices, and may pose less strict requirements for anticoagulation interruption, along with lower risk of focal neurological side effects.

Objectives: The authors sought to describe the safety and efficacy of PICB in patients with refractory ES.

Methods: We reviewed our institutional data on ES patients who underwent PICB between January 2018 and February 2023 to analyze procedural safety and short- and long-term outcomes.

Results: A total of 15 consecutive patients with ES underwent PICB during this period. Of those, 11 patients (73.3%) were maintained on PICB alone, and 4 patients (26.6%) were maintained on combined block with SGB and PICB. Overall, 72.7% patients who were maintained on PICB alone and 77.8% patients who were maintained on bilateral PICB had excellent arrhythmia suppression. After PICB, implantable cardioverter-defibrillator therapies were significantly reduced (P < 0.05), with 93.3% of patients receiving PICB having no implantable cardioverter-defibrillator shock until discharge or heart transplant. Anticoagulation was continued in all patients and there were no procedure-related complications. Apart from mild transient neurological symptoms seen in 3 patients, no significant neurological or hemodynamic sequelae were observed.

Conclusions: In patients with refractory ES, continuous PICB provided safe and effective sympathetic block (77.8% ventricular arrhythmia suppression), achievable without interruption of anticoagulation, and without significant side effects.

Keywords: electrical storm; proximal intercostal block; stellate ganglion block; ventricular fibrillation; ventricular tachycardia.

MeSH terms

Adult
Aged
Autonomic Nerve Block* / methods
Female
Humans
Intercostal Nerves
Male
Middle Aged
Retrospective Studies
Stellate Ganglion / drug effects
Tachycardia, Ventricular / therapy
Treatment Outcome
Ultrasonography, Interventional*
Ventricular Fibrillation / therapy