Stellate ganglion radiofrequency – beyond chronic pain management 

Background
	The stellate ganglion is a neuronal structure formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. It is a structure with sympathetic functions.
The Electrical Storm (ES) is a life-threatening syndrome, characterized by recurrent ventricular fibrillation (VF) and ventricular tachycardia (VT). Many times unresponsive to antiarrhythmic drugs, it presents a major clinical challenge.

Case Report
A 70-year-old male, with history of myocardial infarction with elevated ST in 2003, 2014 and 2015, with a depressed myocardic function and an Implantable Cardioverter Defribillator (ICD) since July 2015, admitted at the Coronary Unit with an ES in June 2016. This episode was managed with lidocaine perfusion and phenytoin.
On 24th August the patient was readmitted with another ES. Perfusions of lidocaine and esmolol were used to control the ES. Ablation treatment was performed by Cardiology without success. On the 8th October the patient returned to the ES, with various ICD discharges.
On the 11th October a Pulsated Radiofrequency (PLR) of the left stellate ganglion was performed.
The patient was positioned in dorsal decubitus, the stellate ganglion identified with ecographic control and PLR was performed. The procedure was uneventful. 
The patient had one episode of VF in the day after the procedure, successfully treated with the ICD and a lidocaine. Three days after the procedure the patient was discharged to the cardiology ward. The follow-up remain uneventful. 

Discussion
The use of ultrasound in critical care suffered a huge technical advance in recent years. Since we do not have to transport the patient and we have a direct view of the structures safety is improved.
Ventricular arrhythmias management requires a multimodal approach. Sympathetic cardiac neural modulation is one of the treatments used in this situations. 
Management of ES with PRF has been previously reported. 1
To our knowledge, this is the first case report of an ultrasound guided technique.



References
	Hayase J, et al. Comparative efficacy of stellate ganglion block with bupivacaine vs pulsed radiofrequency in a patient with refractory ventricular arrhythmias. Journal of Clinical Anesthesia 2016; 31: 162-165