Introduction:
Electrical storm (ES), commonly defined as the occurrence of three or
more ventricular arrhythmia or appropriate shocks from an implantable
cardioverter-defibrillator within 24 hours, poses a significant risk of
morbidity and mortality [1][2]. The MADIT-II
sub-study highlighted that post-myocardial infarction (MI) patients with
reduced LVEF developing ES experience heightened mortality risks, which
persist for several months after initial storm events[3]. ES serves as an independent marker for
subsequent death among ICD recipients, as highlighted by the AVID trial[4]. Common triggers of ES include myocardial
ischemia, acute decompensation of heart failure, metabolic/electrolyte
disorders, drug side effects, and increased sympathetic tone[5]. Managing ES demands a multidisciplinary,
multimodality approach that may include antiarrhythmics and adrenergic
blockade, sedation, anxiolysis, hemodynamic support, ICD reprogramming
and, in selected cases, temporary mechanical circulatory support
devices, and catheter ablation [6]. While
antiarrhythmic drugs are crucial for the acute termination of ES, their
efficacy in suppressing future arrhythmias is limited[5]. Post-MI patients with reduced LVEF commonly
receive beta-blockers, lidocaine, and amiodarone. Mexiletine, a class IB
antiarrhythmic, is considered for those refractory to high-dose
amiodarone or intolerant to lidocaine due to neurological toxicity[7,8]. Stellate ganglion block has shown efficacy
when standard measures fail [9]. In refractory
cases, bilateral sympathetic ganglionectomy emerges as a viable option,
demonstrating a high complete response rate (66.7%) and reduced ICD
shocks in the year following surgery [10, 11]. We
present a post-MI patient after CABG revascularization with reduced LVEF
experiencing refractory ES despite multiple interventions. Conventional
measures, including amiodarone, mexiletine, sedation, anxiolysis, and
stellate ganglion block, proved insufficient. Mechanical support with
Impella was initiated, and the patient underwent successful bilateral
sympathetic ganglionectomy. This case highlights bilateral sympathetic
ganglionectomy’s role in the management of refractory ES, showcasing its
potential efficacy when conventional interventions fail.