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.