Refractory Electrical Storm: A Role for Transient Sympathetic Blockade.

Miller DR, et al. Predicting outcomes among patients with atrial fibrillation and heart failure receiving anticoagulation with warfarin. Thromb Haemost. 2015;114:70–7. 4. del Campo M, Roberts G. Changes in warfarin sensitivity during decompensated heart failure and chronic obstructive pulmonary disease. Ann Pharmacother. Audit of the frequency and clinical response to excessive oral anticoagulation in an outpatient population. Tormenta arrı´tmica refractaria: papel del bloqueo simpático transitorio To the Editor, Electrical storm (ES) is defined as the appearance of 3 or more episodes of ventricular tachycardia or fibrillation within 24 hours requiring antitachycardia therapy or cardioversion/ defibrillation. 1 In practice, the number of episodes is usually much higher, producing an extremely serious situation. The role of the sympathetic nervous system in ES is well established, 2 and sympathetic blockade has been shown to effectively control these situations. 3 The first studies with sympathetic blockade centered on its use to treat congenital long-QT syndrome in patients unresponsive to beta-blocker therapy, and it has recently been applied in the treatment of ES. 4 The goal of this study was to present our accumulated experience with transient sympathetic blockade (TSB) in the treatment of a series of patients with refractory ES, defined as ES persisting after conventional therapy for the control of ES and its immediate causes. Refractory ES was diagnosed according to the judgment of the responsible physician, without prior specification of criteria for episode duration, number, or toleration. In all patients, TSB was first attempted by left stellate ganglion block (LSGB); patients with recurrent ES or poor initial control after LSGB were scheduled for bilateral block by thoracic epidural anesthesia. LSGB was performed by ultrasound-guided bolus injection of local anesthetic via the paratracheal route. The procedure was carried out at the patient's bedside in the coronary care unit by anesthesia unit staff. Ultrasound guidance was also used to place a soft catheter for continuous infusion of 0.2% ropivacaine. The mean infusion rate was 7 mL/h, with an initial rate of 6 mL/h and a maximum of 12 mL/h. The efficacy of TSB was evaluated by clinical observation: the efficacy indicators were clinical signs of Horner syndrome for LSGB and relief of anterior chest pain in patients given thoracic epidural anesthesia. In all patients, TSB was used as an addition to conventional antiarrhythmic therapy and in no instances replaced or required withdrawal of baseline pharmacologic treatment. In 2 patients, LSGB did not achieve sufficient …