Subscribe to RSS
DOI: 10.1055/s-0035-1544500
Stellate Ganglion Block as Therapy for Uncontrollable Ventricular Fibrillation in an LVAD Patient
Objectives: Severe ischemic cardiomyopathy is a main cause for implantation of left ventricular assist devices (LVAD). Despite permanent support of the left ventricle, patients remain dependent on sufficient right heart function. Severe ventricular arrhythmia may significantly impact right ventricular output, resulting in reduced LVAD flow and insufficient circulation.
Methods: A 62 years old patient underwent an emergency LVAD-implantation in acute cardiac decompensation due to ischemic cardiomyopathy. After uneventful 48h on ICU and after extubation the patient developed recurrent episodes of ventricular fibrillation (VF) and recurrent defibrillation was required several times a day. With ventricular fibrillation LVAD flow decreased by 50% and resulted in insufficient organ perfusion. Echocardiography showed a correct position of the LVAD-inflow cannula without any aspiration phenomena of the ventricular or septal wall. A coronary angiography revealed marginal bloodflow through a extensively stented LAD, without any options for revascularization. An interventional occlusion of the LAD was declined due to unforseeable risks of further ischemic deterioration of the septal contraction
Results: For restoration of sufficient LVAD flow and circulation, defibrillation was initially required up to 40 times a day. Standard drugs including amiodarone, metoprolol and flecainid were not effective at all. Only continuous i.v. application of lidocaine 2% in high dosages (20 ml/h) helped to reduce the intervalls of fibrillation. However, during the following period of 8 days the patient required still 5–10 defibrillations per day. Since long term i.v. lidocaine therapy led to epileptic seizures, we decided to block the stellate ganglion with local application of 15 ml lidocaine 1% until a horner syndrome developed and changed the medication to propranolol monotherapy (3 mg i.v., 4 x/day). After this approach the episodes of VF immediately disappeared and stable ventricular pacing via ICD was established. Weaning from mechanical ventilation could be achieved.
Conclusion: Stellate ganglion block and accompanying therapy with propranolol should be considered in LVAD-patients with uncontrollable recurrent ventricular fibrillation.