Ganglion stellate blockade in the treatment algorithm of the malignant electric storm: one center, five years and 72 procedures in 59 patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Malignant electric storm (ES) is a life-threatening condition with a high mortality rate. With years of increasing numbers of implanted ICDs, we witness increasing numbers of patients treated for ES. The role of local suppression of sympathetic nerve activity using ultrasound-guided anesthetic ganglion stellate blockade (GSB) is still under investigation with the first favorable published data from prospective cohorts.

Objective

To present data from a cohort of consecutive patients treated for ES at our cardiac center using a two-stage algorithm including GSB.

Method and Cohort

Between 2017 and 2021, 59 patients were treated using the two-stage algorithm ( when the first stage of standard procedures failed - ions, antiarrhythmic drugs, ischemia correction, heart rate modification, sedation, and GSB was performed as the second stage of the algorithm when ventricular arrhythmia recurred) in 72 GSB procedures.

57 GSB in men (79.2%)/15 GSB (20.8%) in women. Mean age 68.1 +/- 12.1 years. Mean LV EF 29.6 +/- 8.9%. 22 GSB in diabetic patients (30.6%). Ischemic etiology of ES in 41 cases (56.9%). Monomorphic ventricular tachycardia dominated among arrhythmias with 53 cases ( 73.6%). Betablocker and amiodarone were administered in 67 and 56 cases, respectively ( 93.1 and 77.8%).

A statistically significant decrease of 87.7% in ventricular arrhythmias treated with shock ICD or ATP was seen ( decrease from 57.2 to 1.43 episodes 48 hours before vs. 48 hours after GSB, p<.0001) (Table 1).

Hemodynamically unstable patients on continuous catecholamines responded significantly less to the two-step algorithm, including GSB. Horner’s syndrome and other demographic and medication parameters did not appear to predict a better response to GSB (Table 2 ). No serious adverse events were observed. In one case, intermittent ( couple hours) vocal chord paresis after bilateral GSB has been observed.

Conclusion

The two-stage algorithm for the treatment of ES, including ganglion stellate blockade, has shown stable high efficacy over the years with exceptional safety. However, the actual efficacy must be proven in a double-blinded study to allow the widespread method to the clinical practice.

Structure, organization, and practical functioning of the sports cardiology center of the Nemocnice Agel Trinec Podlesi

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiological care of athletes worldwide is focused on prevention of cardiovascular disease, diagnosis, and follow-up of abnormalities in preventive screening, and subsequent therapy of detected pathologies with risk assessment for sport. The Czech Society of Sports Medicine and the Czech Cardiology Society responded to this process by establishing sports cardiology centers in the early 2020s. The centers were established in Olomouc, with two centers in Prague and Trinec.

Structure and organization

The Trinec Centre of Sports Cardiology (CSK) is organized based on tribal doctors of the Cardiocentre of the Agel Třinec-Podlesí Hospital and external cardiological collaborators from Silesia and Moravia. These doctors are trained in sports cardiology.

The practical functioning of the center is based on gradual steps: A) The patient logs in to our way through the web interface, where the essential information and previous examinations are given. B) The center's coordinator will incorporate these input data, will ensure communication with the client, other necessary information or examination, and after consultation with cardiologists, who subspecialize in the subunits, will establish a treatment plan. C) The CSK nurse ensures the organizational aspects of the established procedure. D) After the follow-up examination, the client has a final consultation with the sports cardiologist, where the suitability or limitations for sport and other recommendations for dispensation are always indicated. See Figure 1.

Cohort of athletes

Retrospective analysis of athletes from 1/2020 - 10/2021: 71 athletes, 26.0 +/- 1.5 years (15-61), 10 females (16%)/61 males: sport type: Endurance 31%, Mixed 66%. Most common indication: 46% coming in for abnormal preparticipation screening. At the conclusion of the investigation, only two were ineligible for sport, 32 eligible with condition

Conclusion

Structured, well-organized, and high-quality cardiac care for athletes is the main focus of the centers' work. In addition, the vision of our center is to provide tertiary cardiac care for athletes to reduce the risk of health complications in athletes. Therefore, our department is targeting EAPC accreditation for a sports cardiology center.

The effect of MitraClip mitral valve repair on a number of ventricular tachycardia episodes

Background

Mitral valve repair with MitraClip is an established method in the treatment of severe mitral regurgitation. Effect on mitral regurgitation severity, NYHA class and left ventricular function is known, as well as on mortality and number of hospitalizations. Otherwise, there is a lack of evidence, if a successful repair can affect the number of episodes of malignant arrhythmias.

Purpose

To compare the number of ventricular arrhythmias and ICD therapies before and after successful mitral valve repair with MitraClip in retrospective analysis.

Methods

We analysed patients after a MitraClip mitral valve repair in whom an ICD was implanted at least 1 month before the procedure. Out of 217 patients, there were 47 with ICD, traceable history and successful repair (MR grade ≤2.5 after the procedure). We searched all recorded ICD controls for evidence of ventricular arrhythmias and ICD therapies (ATP or shock). Statistical analysis was performed comparing the number of ventricular arrhythmias and ICD therapies “per month-per patient” before and after the procedure.

Results

We didn't found any statistical difference in number of malignant arrhytmia events before and after the procedure (mean 0.024±0.069 vs 0.029±0.079, p=0.46), neither in ATP therapies (mean 0.038±0.146 vs 0.542±3.249, p=0.39) nor in shocks (mean 0.063±0.225 vs 0.148±0.499, p=0.33). After dividing patients into two groups – with or without previous myocardial infarction, there was also no statistical difference in both groups. In “MI” group: a number of ventricular arrhythmia (mean 0.016±0.036 vs 0.016±0.047, p=0.95), ATP therapies (mean 0.029±0.109 vs 0.073±0.285, p=1.0), shocks (mean 0.049±0.184 vs 0.048±0.172, p=0.77). In “no MI” group: a number of ventricular arrhythmia (mean 0.035±0.098 vs 0.047±0.108, p=0.22), ATP therapies (mean 0.05±0.19 vs 1.203±5.024, p=0.16), shocks (mean 0.083±0.277 vs 0.289±0.733, p=0.17).

Conclusion

Our results don't reflect any influence of MitraClip mitral valve repair on ventricular arrhythmias, ATP therapies or shocks before and after the procedure. Another and deeper analysis should be performed to understand these results.

Funding Acknowledgement

Type of funding sources: None.

Malignant arrythmic storm, stellate ganglion and diabetes mellitus

Funding Acknowledgements

Type of funding sources: None.

Introduction

Malignant arrhythmic storm (MAS) increases mortality more than three-fold according to current data. In the acute setting, besides resolving reversible causes, antiarrhythmics are the mainstay of treatment. The role of suppressing the local sympathetic nervous system activity, using stellate ganglion block (SGB) for example, is still being investigated. 

Purpose

To show short-term efficacy of SGB in suppressing the ventricular arrhythmia recurrence in MAS. To identify subgroups of patients with better clinical response after SGB.

Methods

All consecutive patients with MAS, with standard treatment failure and ventricular arrhythmia recurrence, treated with ultrasound guided SGB, instilating 7ml of 0,5% Bupivacain.

58 MAS treated with SGB durin 2017 – 2020. There were 49 men (84,5%), average age 68,7 +/- 11,4, with average left ventricular EF 28,9 +/- 8,43%. There were 17 diabetics (29,3%). 

Results

When we compare the numbers of defibrillations for sustained ventricular tachycardia 48 hours before and 48 hours after SGB, being the primary therapeutic endpoint in MAS, we see a 96,7% reduction (p < 0,001). When we evaluate ventricular arrhythmias treated with both antitachycardia pacing and shocks, then we see 90% reduction (p < 0,001). The effect of SGB in ventricular arrhythmia suppression was statistically significant during the entire follow-up of 8 days.

When we analyzed the cohort, looking for groups showing better response after SGB in terms of ventricular arrhythmia reduction, the only group showing statistical significance in this regard are patients with diabetes mellitus. 

Conclusions

In our cohort, stellate ganglion block is exceptionally effective in the treatment algorithm of malignant arrhythmic storm. SGB shows significantly higher efficacy in the subgroup of patients with diabetes mellitus. Abstract Figure. VA before and after BSG

Data for 3D left atrial printing acquired using open source and free software, with the aim to determine the proper size of left atrial appendage occlured

Background

The occlusion of the left atrial appendage is the treatment of choice in patients with high both thrombembolic and bleeding risks. The optimal method for size selection and occluder placement is still evolving. Based on published data, the ability to print a 3D atrial model might be helpful in these processes. Minimizing the cost of this approach may contribute to a massive extension of the methodology.

Aim

To present a process of data acquisition for 3D left atrial printing without the need of using a premium software.

Method

Patients indicated for percutaneous left atrial appendage closure are prepared according to standard recommendations. Afterwards, DICOM CT scans were used for our purpose. This data was transfered to the segmentation software. With the help of 3D Slicer 4.10 (slicer.org), the cardiac chambers were segmented from the contrast CT (DS CorCTA 1.0 B26f BestDiast 72%). The “Paint” function was specifically used for segmentation, marking each chambe. “GrowFromSeeds” utility was then used to automatically initialize chambers with the option of manual correction. Segments were subsequently transfered to the 3D model format (STL, 3MF). The difficulty was, that from the aforementioned contrast CT, we were only able to acquire the left atrial “cavity”, not reflecting the true dimensions of the walls. Therefore, we subtracted this shape from a cuboid. Then, using function “Hollow” in 3D Builder, we gradually removed the outer part of the cuboid around the subtracted cavity, resulting in a true left atrial wall. This enabled a valid sizing of the appendage. Since this procedure was part of a blinded study, a small cuboid marker (10x10x3mm) was added to the cast for patient identification and correct 3D printing.

For the printing itself, a flexible material with 30–35D hardness was used to simulate compliant cardiac tissue.

Conclusion

The segmentation of the left atrium using open source and free 3D software enables to minimize printing costs which may lead to extension of this method to everyday clinical practice.

Figure 1. Sequention of work

Funding Acknowledgement

Type of funding source: None

P5698What predicts the inefficiency of stellate ganglion block in the treatment of electrical storm?

Introduction

Electrical storm (ES) is an emergent condition which requires a sofisticated approach. Massive sympathetic surge almost always connected with ES precipitates recurrent ventricular arrhythmias. Performing stellate ganglion block (SGB) to alleviate the sympathetic activity on myocardium is becoming a standard of care in many centers. However, there is no clear data to predict in which patients the SGB will be ineffective.

Purpose

To identify predictors of SGB failure in patients with ES.

Methods

We analyzed our case series of SGB – the procedure was performed in 31 patients with ES in our center from March 2017 to December 2018.

Results

Mean left ventricular ejection fraction was 27% (±9%), 74% of patients had ischaemic cardiomyopathy. The most frequent type of arrhythmia was monomorphic ventricular tachycardia (VT), occurring in 71% of patients, followed by polymorphic VT in 13% of cases. After SGB, the burden of ventricular arrhythmias failed to decrease by at least 50% in 10% of cases - these patients were marked as non-responders. Slow monomorphic VT (under 160/min) was observed in all of these patients. On the other hand, fast monomorphic VT or polymorphic VT seemed to respond very well to SGB. We also observed, that patients with ES after acute coronary syndromes were good responders as well. The effect of SGB was not related to age, gender, EF LK or the etiology of cardiomyopathy.

Conclusions

According to our experience, the failure of SGB in the treatment of ES is not frequent. It typically occurs in patients with slow monomorphic VT. It is probable that such arrhythmias are sustained primarily due to the extensive myocardial substrate, and not because of the sympathetic surge. The situation is quite the opposite in patients with fast VT and acute ischemia.

P5690Comparison of two methods to navigate the stereotactic body radiotherapy ablation for ventricular tachycardia, the invasive electrophysiological study and substrate identification

Purpose

To compare two methods used for identifying the arrhythmogenic substrate - invasive electrophysiological study versus PET-CT scar identification. The substrate is then targeted by stereotactic body radiotherapy (SBRT) in patients with previously unsuccessful radiofrequency catheter ablation.

Methodology

Patients with ischemic cardiomyopathy, LVEF less than 40% and unsuccessful conventional treatment resulting in recurring ventricular tachycardias, were divided into two groups with different methods of obtaining arrhythmogenic substrate. In the group A, invasive electrophysiological mapping was used, while in the group B, scar identification by PET-CT was done, enhanced with non-invasive body surface ecg mapping of all inducible ventricular tachycardias. This target obtained was then attacked with SBRT. We compared the size of the planned target volume (PVT), the SBRT duration, the calculated dose for the esophagus, stomach and lung and the incidence of acute complications.

Cohort description

Patients in group A were recruited from April 2014 to December 2018, patients in group B from June to December 2018. Group A (8 patients) – mean age 66, NYHA class 2.4, LVEF 29,4%. Group B (6 patients) – mean age 71, NYHA class 2.1, LVEF 25,2%. All patients were men.

Results

There was a statistically significant difference in PTV – Group A (mean 24.1ml, SD = 3,9), Group B (mean 76.0ml, SD 14.1), p<0,001 (two-sample t-test). There was no difference in the calculated secondary radiation doses acquired by surrounding organs. The most frequent adverse event was acute anorexia, occurring in 4 patients from Group A and in 2 patients from Group B. The anorexia subsided in one week time. One patient from Group B suffered from esophageal ulcer, which developed 6 months after the therapy.

Conclusion

Using invasive electrophysiology mapping to identify arrhythmogenic substrate for SBRT yields significantly smaller volume of targeted tissue. Despite this finding, we did not find any difference neither in radiation dose delivered to the surrounding organs, nor in the radiation duration.

P4609The use of stellate ganglion block in the management of electrical storm reduces VA burden by 92% and completely excludes the need for general anesthesia

Background

The electrical ventricular storm (ES) is a life-threatening condition. The treatment is based on addressing the triggering cause, influencing reversible factors, patient sedation, and antiarrhythmics. Suppressing the massive sympathetic surge is a keystone in the emergent management. Stellate ganglion block (SGB) might serve this purpose.

Purpose

To show the efficacy of ultrasound-guided SGB in the management of ES.

Methods

Retrospective analysis of case series. All ES patients in whom SGB was used. SGB was performed after the initial failure of reversible factors modification + sedation + antiarrhythmics. We compared the mean VA burden 2 days before vs. 7 days after SGB (to show the long effect of SGB).

31 patients (5 females). Procedure date between 01.03.2017 and 21.11.2018. Mean LVEF 27±9%. Etiology: 74% ischemic vs. 26% non-ischemic cardiomyopathy. Antiarrhythmic treatment: amiodarone 27 pt. (87%), trimecaine 3pt (10%), digoxin 2 pt. (6%), beta-blocker 28 pt. (90%).

Results

The ES management including SGB resulted in a significant decrease (92%) in VA burden (mean 26,0 episodes/day vs. 0,6 episodes/day; p<0.001). Separately, ATP episodes were reduced by 99%, external or ICD shocks by 76%. There was no need for general anesthesia as a last resort in refractory ES. 30-days mortality 12,9%. No significant adverse events have been noticed, 10 pt. (32,3%) have developed Horner syndrome, which always disappeared in 24 hours.

Conclusion

Ultrasound-guided SGB in the management of ES is safe and very effective. Randomized prospective studies are required to precisely determine the effect of SGB.

[Improvement of quality of life after ablation of longstanding persistent versus paroxysmal atrial fibrillation: results of 2-year follow-up]

AIMS

The purpose of the study was to assess quality of life and socio-economic parameters in patients after ablation of paroxysmal versus longstanding persistent atrial fibrillation (AF).

METHODS

The study included 89 patients with paroxysmal AF and 56 patients with longstanding persistent AF who underwent ablation within 1 year, and were afterwards prospectively followed up for 2 years. Quality of life was evaluated by the EQ-5D questionnaire before and every 6 months after ablation.

RESULTS

Objective, respectively subjective quality of life at baseline was lower in patients with longstanding persistent AF (67 +/- 16 vs 71 +/- 10; p = 0.01, resp. 64 +/- 12 vs 67 +/- 16; p = 0.07); however, after 2 years, it exceeded that of the patients with paroxysmal AF (80 +/- 17 vs 75 +/- 18; p = 0.03; resp. 73 +/- 13 vs 70 +/- 17; p = 0.18). The baseline-2 year difference in improvement was higher in patients with longstanding persistent AF in both objective (p = 0.001) and subjective component (p = 0.05). Both groups displayed significant decrease in the days of hospitalization, and the days of working incapacity.

CONCLUSION

Patients with longstanding persistent AF exhibit worse baseline quality of life than the patients with paroxysmal AF, and higher quality of life improvement after ablation.

[Recurrent arrhythmias after catheter ablation of originally paroxysmal atrial fibrillation and results of repeat ablation]

AIMS

The aim is a description of the recurrent arrhythmias after previous ablation of paroxysmal atrial fibrillation (AF), and the results of a repeat catheter ablation.

METHODS

A repeat ablation was performed in 76 patients (18 females, 54 +/- 11 years) in 96 procedures, which was 21% out of 362 patients, who had undergone the first ablation for a paroxysmal AF. The endpoints of the repeat ablation were re-isolation of the pulmonary veins (PV) and termination of a spontaneous or induced arrhythmia and restoration of a stable sinus rhythm (SR), and possibly achievement of noninducibility of any arrhythmia.

RESULTS

Clinical left atrial tachycardia (LAT) was present in 10 (13%) patients before the first, and in 5 (25%) patients before the second repeat ablation. Arrhythmia arising from an arrhythmogenic PV due to the conduction recovery into the left atrium (LA) was found in 50 (66%) patients during the first, and in 7 (35%) patients during the second repeat ablation. Arrhythmias, predominantly of the reentry mechanism and originating in the LA free wall, were found in 26 (34%), respectively 13 (65%) during the first or the second repeat ablation. All arrhythmias from PVs were terminated by a PV encircling ablation. Substrate-related arrhythmias were terminated by ablation except for 2 (3%) patients during the first and 3 (15%) patients during the second repeat ablation. Persistent AF was mainly terminated via conversion into a LAT. In these cases, the ablation sites leading to the SR restoration were, similarly to the primary LATs, located predominantly in the LA anterior wall. During the 22 +/- 13 months follow-up, 68 (89%) patients were free of AF, 54 (71%) patients off the antiarrhythmic drugs and 14 (18%) patients with the class I or III antiarrhythmic drugs.

CONCLUSION

AF associated with PV-LA re-connection dominated prior to the first repeat ablation, then the proportion of the substrate-related arrhythmias from the LA free wall increased. Clinical efficacy of the repeat ablation is high.

[Catheter ablation of chronic atrial fibrillation using circumferential and complex linear lesions in the left atrium: modes of arrhythmia termination and long-term clinical outcome]

OBJECTIVE

The aim of the article is to present the method and results of catheter ablation for chronic atrial fibrillation.

METHOD

Catheter ablation for chronic atrial fibrillation was performed in 82 patients (18 females, aged 54 +/- 10 years), in 112 ablation procedures. Mean duration of the chronic phase of atrial fibrillation was 28 +/- 28 months. Before ablation, amiodarone was administered without effect to 74 (90%) patients, and was counter-indicated in 8 (10%) patients. Ablation strategy consisted of circumferential lesions around the pulmonary veins and of complex linear lesions in the left atrium. Full pulmonary vein antra isolation, and sinus rhythm restoration, or at least converting atrial fibrillation into the left atrial tachycardia, were the procedure end points.

RESULTS

Sinus rhythm was restored by ablation at least in one of the ablation procedures in 43 (52%) patients. During the follow-up period spanning 17.3 +/- 11.6 months after the last ablation, stable sinus rhythm was achieved in 63 (77%) patients, of whom 38 (60%) had their sinus rhythm restored by ablation and another 14 (22%) their atrial fibrillation converted into the left atrial tachycardia. Of the 63 patients with stable sinus rhythm, class I or III antiarrhythmic medication has been maintained in 21 (33%) patients, and amiodarone has been taken by 13 (21%) patients.

CONCLUSION

Catheter ablation of chronic atrial fibrillation is potentially highly effective in long-term restoration of sinus rhythm.