Stellate ganglion blockade for treatment of ventricular electrical storm: an updated meta-analysis

Ventricular electrical storm (ES) significantly increases the risks of heart failure-related morbidity, mortality, and the need for heart transplantation(1). Standard treatment options include antiarrhythmic drugs and catheter ablation. The autonomic nervous system plays a role in arrhythmogenesis, and autonomic modulation techniques, such as stellate ganglion blockade (SGB), have shown promise in drug-refractory ES.

This meta-analysis aims to evaluate the efficacy and safety of SGB in patients with drug-refractory ventricular arrhythmias or ES.

We conducted a systematic search of MEDLINE, CENTRAL, and Scopus databases to identify trials using SGB in ES patients, following PRISMA guidelines. The primary outcome was the percentage of patients fre from ventricular arrhythmias (VA) at 24 and 72 hours post-SGB; the secondary outcome was the incidence rate ratio (IRR) of VA episodes before and after SGB. A random-effects meta-analysis was performed using the "metaprop" and "metagen" packages in R.

Out of 932 screened articles, 9 studies with 418 patients met the inclusion criteria (2-10). Th

e mean age was 63.6 ± 12.3 years, 84.4% were male, with a mean left ventricular ejection fraction of 27.4 ± 11.3%, and 56.9% had ischemic cardiomyopathy. Pharmacological SGB was performed in 8 studies, with one study using transcutaneous magnetic stimulation. The pooled proportion of VA-free patients was 75% (95% CI 62% - 84%) at 24 hours and 59% (95% CI 45% - 72%) at 72 hours (Figure 1). The incidence of VA episodes decreased from 15.64 to 0.62 episodes per 24 hours, with an IRR of 0.067, indicating a 93.7% reduction in the incidence rate of VA episodes post-intervention (Figure 2). No serious adverse events were reported; in-hospital mortality was 27.3%.

SGB is an effective and safe intervention for stabilizing patients with drug-refractory VA, with substantial VA suppression at 72 hours and a 94% reduction in episodes. This minimally invasive, accessible technique may be considered after failure of antiarrhythmic treatment, ablation, or even mechanical circulatory support. Further randomized trials are warranted to confirm these findings.