Neuromodulation strategy implementation in a modern high-volume VT unit program

Background

Neuromodulation has recently emerged as a promising adjunctive therapy for refractory ventricular tachycardia (VT). Among available techniques, percutaneous stellate ganglion blockade (PSGB) has gained attention for acute arrhythmia control, while surgical cardiac sympathetic denervation (CSD) represents a durable option for selected patients with treatment-resistant VT.

Objective

To assess the integration and clinical impact of neuromodulation strategies within a tertiary referral program for VT ablation.

Methods

Patients undergoing VT ablation discontinued antiarrhythmic drugs before the procedure and, if sustained VT occurred, were stabilized with intravenous lidocaine or ultrasound-guided PSGB; in refractory or selected cases, surgical CSD was performed.

Results

A structured neuromodulation program was initiated in December 2022. Between December 2022 and June 2024, 196 patients were admitted for VT evaluation and ablation. During the waiting period for the scheduled ablation 115 patients experienced episodes of VT (Fig.1). 13 PSGB procedures were performed in 11 patients. After the procedure, all patients, except one, subsequently underwent VT ablation, with the timing of ablation varying depending on the clinical response to PSGB and the pharmacological stabilization therapy. Urgent ablation was required in only one patient, after an attempt to achieve stabilization with PSGB had been unsuccessful. In only two cases, PSGB was carried out to manage VT recurrence after ablation. One patient experienced a complication in the form of respiratory depression following the PSGB procedure, which occurred during the intravenous lidocaine infusion. The efficacy of PSGB was assessed by comparing the number of implantable cardioverter-defibrillator (ICD) therapies—anti-tachycardia pacing (ATP) and shocks—within 12 hours before and after the procedure. PSGB resulted in a significant reduction in both ATPs and shocks, indicating improved arrhythmic stability and enabling safe bridging to elective ablation (Fig.2).

In this cohort, 6 patients (3% of the total) underwent cardiac sympathetic denervation performed by our surgical team. This procedure was indicated after transcatheter VT ablation had failed in all but one patient who had a contraindication to transcatheter ablation.

At a median follow-up of 2 years (24 months), 64% of the patients who underwent cardiac sympathetic denervation (n=6) were free from ICD shocks, ATPs, or sustained VT episodes.

Conclusions

Temporary and permanent neuromodulation techniques can be readily incorporated into a modern VT program and serve as alternative options in challenging situations.PSGB is safe and effective. Its learning curve is fast and can be spread in the whole EP team. Its use as a bridge to ablation should be balanced precisely. CSD is effective and rapid. Its efficacy is well established but always considered as a bailout procedure in a tertiary referral centre.Figure 1Figure 2