Ultrasound-guided stellate ganglion block as a rescue sympathetic modulation strategy in refractory ventricular tachycardia

Dear Editor, First described in 1936[1] and long established in pain medicine (complex regional syndrome and upper limb vascular syndromes), the stellate ganglion block (SGB) is now re-emerging in perioperative and critical care practice—not primarily as an analgesic intervention, but as a tool for modulating sympathetic physiology. A recent comprehensive narrative review examines its ability to influence autonomic outflow, inflammation, perfusion, and electrophysiologic stability. Sympathetic modulation through SGB may influence cardiac electrical stability, neuroinflammatory pathways, pulmonary mechanics, and microcirculatory flow.[2] Unlike traditional regional anesthesia techniques that aim to interrupt nociceptive transmission, SGB targets the cervicothoracic sympathetic chain, producing also systemic downstream effects. The strongest and most consistent evidence to date supports the use of SGB in refractory ventricular arrhythmias and electrical storm, where it can rapidly suppress sympathetic-driven myocardial instability, even in anticoagulated or critically ill patients.[3] Here, we describe the case of a patient with severe post-ischemic dilated cardiomyopathy, ventricular thrombosis and refractory ventricular tachycardia, in whom ultrasound-guided SGB enabled rhythm stabilization and successful cardioversion. Written informed consent for publication of this case, and accompanying images was obtained from the patient. A 58-year-old man, 175 cm height, and 73 kg weight (Body Mass Index, BMI 24 kg.m2), with post-ischemic dilated cardiomyopathy was admitted with persistent ventricular tachycardia. His medical history included implantation of an automatic implantable cardioverter-defibrillator, two previously failed catheter ablations, and 4 months earlier an episode of sustained ventricular arrhythmia complicated by left ventricular endocavitary thrombosis. Transthoracic echocardiography demonstrated severe left ventricular systolic dysfunction with an ejection fraction of 20%. Because of the ventricular thrombosis, further catheter ablation was contraindicated. Despite continuous intravenous infusions of lidocaine and amiodarone, the patient remained in slow VT. The cardiology team requested anesthesiologist support for a sympathetic neuromodulation through US-SGB. The patient was assessed as American Society of Anesthesiologists (ASA) physical status III. After written informed consent, the procedure was performed in a monitored setting (Coronary Care Unit). Sedation was provided with intravenous midazolam 4 mg. Under full aseptic conditions, a left-sided ultrasound-guided SGB was performed at C6 level. A 22-gauge, 50-mm needle was advanced in-plane from lateral to medial toward the prevertebral fascia located over the longus colli muscle, and below the carotid artery, through continuous visualization of the carotid artery, internal jugular vein, and thyroid gland [Figure 1]. After negative aspiration, 10 mL of 2% mepivacaine was injected. Potential risky structures as vertebral artery, oesophagus, trachea, and brachial plexus were identified. The procedure was uneventful with the real-time view of the needle and spread of the injectate over the longus colli muscle. Vital parameters were not modified. Two hours later, sinus rhythm returned spontaneously. The patient reported prompt relief of palpitations and did not experience any discomfort or adverse effects related to the block (such as ptosis, miosis, blurred vision, enophthalmos, anhydrosis, upper extremity numbness or weakness, dyspnea, dysphagia, or a lump in throat). Intravenous lidocaine was discontinued, while amiodarone was continued. The patient remained hemodynamically stable with no recurrence of VT and no neurological, vascular, or other complications related to the block. He was discharged after 2 days in stable sinus rhythm.Figure 1: The sonoanatomy of stellate ganglion block. Ultrasound-guided stellate ganglion block. US image at level of the sixth cervical (C6) transverse process (TP). Illustrated in-plane lateral to medial needle trajectory. Local anesthetic is deposited under the carotid artery (CA) above the longus colli (LC) muscle. To be noted the relevant nearby structures: prevert, prevertebral (fascia); SclM, sternocleidomastoid muscle; IJV, internal jugular vein; Th, thyroid; Oes, oesophagus; C5 and C6, brachial plexus rootsThis case demonstrates the value of SGB as a rescue in refractory ventricular tachycardia when pharmacological therapy had failed, and catheter ablation was contraindicated because of ventricular thrombosis. SGB provided a temporary but critical autonomic reset, allowing spontaneous cardioversion to succeed and remain stable. As ultrasound-guided techniques have improved safety, reproducibility, and accessibility, SGB is increasingly feasible outside specialized pain clinics. Its current appeal lies in being less invasive, rapidly acting, and physiologically targeted—qualities that align also with contemporary perioperative medicine, where modulation of stress responses, inflammation, and organ protection are increasingly prioritized. Additional signals have emerged in cardio-thoracic surgery, abdominal surgery complicated by stress-mediated ileus, and neurocritical care contexts such as subarachnoid hemorrhage and cerebral vasospasm. Randomized trials also suggest reductions in anesthetic requirements and improvements in quality-of-recovery metrics, suggesting a significant role in perioperative medicine, including prevention and treatment of perioperative arrhytmias.[4] Further data are still needed to define all its true clinical value. Author contributions All authors contributed equally to the manuscript and read and approved the final version of the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.