Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 23 , ISSUE 11 ( November, 2019 ) > List of Articles


Thoracic Epidural Blockade for Ventricular Tachycardia Storm in Patient with Takotsubo Cardiomyopathy

Jahagirdar Ashwini, Makwana Durgesh, Date Girish

Keywords : Epidural anesthesia, Takotsubo cardiomyopathy, Ventricular tachycardia

Citation Information : Ashwini J, Durgesh M, Girish D. Thoracic Epidural Blockade for Ventricular Tachycardia Storm in Patient with Takotsubo Cardiomyopathy. Indian J Crit Care Med 2019; 23 (11):529-532.

DOI: 10.5005/jp-journals-10071-23282

License: CC BY-NC 4.0

Published Online: 01-11-2019

Copyright Statement:  Copyright © 2019; The Author(s).


Introduction: Takotsubo cardiomyopathy is acute nonischemic myocardial dysfunction of the left and/or right ventricle which usually recovers completely within several days to weeks. We report a case where thoracic epidural analgesia was used to manage sympathetic storm in Takotsubo cardiomyopathy. Case description: A 58-year-old diabetic female who was being treated for urinary tract infection and diabetic ketoacidosis for the past 2 days sustained an episode of pulseless ventricular tachycardia which was treated as per ACLS protocol. Troponin levels were raised, and 2D echocardiography was showing “Takotsubo cardiomyopathy” with typical apical ballooning of the left ventricle at the time of admission, and she was mechanically ventilated and receiving vasopressors. She continued to get episodes of ill-sustained ventricular tachycardia. In spite of conventional management, episodes of ill-sustained ventricular tachycardia continued, and hence, sympathetic blockade with thoracic epidural catheter was administered to control the ventricular tachycardia storm. Conclusion: Sympathetic blockade to treat ventricular tachycardia is a promising approach which needs to be validated with more evidence.

PDF Share
  1. Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA 2011;306(3):277–286. DOI: 10.1001/jama.2011.992.
  2. Lyon AR, Bossone E, Schneider B, Sechtem U, Citro R, Underwood SR, et al. Current state of knowledge on Takotsubo syndrome: a position statement from the taskforce on Takotsubo syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2016;18(1):8–27. DOI: 10.1002/ejhf.424.
  3. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Takotsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008;155(3):408–417. DOI: 10.1016/j.ahj.2007. 11.008.
  4. Abraham J, Mudd JO, Kapur NK, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol 2009;53(15):1320–1325. DOI: 10.1016/j.jacc.2009.02.020.
  5. Paur H, Wright PT, Sikkel MB, Tranter MH, Mansfield C, O'Gara P, et al. High levels of circulating epinephrine trigger apical cardiodepression in a beta2-adrenergic receptor/Gi-dependent manner: a new model of Takotsubo cardiomyopathy. Circulation 2012;126(6):697–706. DOI: 10.1161/CIRCULATIONAHA.112.111591.
  6. Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352(6):539–548. DOI: 10.1056/NEJMoa043046.
  7. Stiermaier T, Eitel C, Denef S, Desch S, Schuler G, Thiele H, et al. Prevalence and clinical significance of life-threatening arrhythmias in Takotsubo cardiomyopathy. J Am Coll Cardiol 2015;65(19):2148–2150. DOI: 10.1016/j.jacc.2015.02.062.
  8. Stiermaier T, Moeller C, Oehler K, Desch S, Graf T, Eitel C, et al. Long-term excess mortality in Takotsubo cardiomyopathy: predictors, causes and clinical consequences. Eur J Heart Fail 2016;18(6):650–656. DOI: 10.1002/ejhf.494.
  9. Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med 2015;373(10):929–938. DOI: 10.1056/NEJMoa1406761.
  10. Meissner A, Eckardt L, Kirchhof P, Weber T, Rolf N, Breithardt G, et al. Effects of thoracic epidural anesthesia with and without autonomic nervous system blockade on cardiac monophasic action potentials and effective refractoriness in awake dogs. Anesthesiology 2001;95(1):132–138. DOI: 10.1097/00000542-200107000- 00023.
  11. Howard-Quijano K, Takamiya T, Dale EA, Yamakawa K, Zhou W, Buckley U, et al. Effect of thoracic epidural anesthesia on ventricular excitability in a porcine model. Anesthesiology 2017;126(6): 1096–1106. DOI: 10.1097/ALN.0000000000001613.
  12. Bourke T, Vaseghi M, Michowitz Y, Sankhla V, Shah M, Swapna N, et al. Neuraxial modulation for refractory ventricular arrhythmias value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation 2010;121(21):2255–2262. DOI: 10.1161/CIRCULATIONAHA.109.929703.
  13. Eitel I, Stiermaier T, Graf T, Möller C, Rommel KP, Eitel C, et al. Optical coherence tomography to evaluate plaque burden and morphology in patients with Takotsubo syndrome. J Am Heart Assoc 2016;5(12):e004474. DOI: 10.1161/JAHA.116.004474.
  14. Stiermaier T, Moller C, Graf T, Eitel C, Desch S, Thiele H, et al. Prognostic usefulness of the ballooning pattern in patients with Takotsubo cardiomyopathy. Am J Cardiol 2016;118(11):1737–1741. DOI: 10.1016/j.amjcard.2016.08.055.
  15. Sato HTHUT. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. Clinical aspects of myocardial injury: from ischemia to heart failure. 1990. pp. 56–64.
  16. Citro R, Bossone E, Parodi G, Carerj S, Ciampi Q, Provenza G, et al. Clinical profile and in-hospital outcome of Caucasian patients with Takotsubo syndrome and right ventricular involvement. Int J Cardiol 2016;219:455–461. DOI: 10.1016/j.ijcard.2016.06.039.
  17. Do DH, Bradfield J, Ajijola OA, Vaseghi M, Le J, Rahman S, et al. Thoracic epidural anesthesia can be effective for the short-term management of ventricular tachycardia storm. J Am Heart Assoc 2017;6(11):e007080. DOI: 10.1161/JAHA.117.007080.
  18. Estes EH, Izlar H. Recurrent ventricular tachycardia: a case successfully treated by bilateral cardiac sympathectomy. Am J Med 1961;31: 493–497. DOI: 10.1016/0002-9343(61)90132-2.
  19. Vaseghi M, Gima J, Kanaan C, Ajijola OA, Marmureanu A, Mahajan A, et al. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm 2014;11(3):360–366. DOI: 10.1016/j.hrthm.2013.11.028.
  20. Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan A, et al. Bilateral cardiac sympathetic denervation for the management of electrical storm. J Am Coll Cardiol 2012;59(1):91–92. DOI: 10.1016/j.jacc.2011.09.043.
  21. Pedersen CT, Kay GN, Kalman J, Borggrefe M, Della-Bella P, Dickfeld T, et al. EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace 2014;16(9):1257–1283. DOI: 10.1093/europace/euu194.
  22. Vaseghi M, Barwad P, Malavassi Corrales FJ, Tandri H, Mathuria N, Shah R, et al. Cardiac sympathetic denervation for refractory ventricular arrhythmias. J Am Coll Cardiol 2017;69(25):1359–1362,. DOI: 10.1016/j.jacc.2017.04.035.
  23. Mahajan A, Moore J, Cesario DA, Shivkumar K. Use of thoracic epidural anesthesia for management of electrical storm: a case report. Heart Rhythm 2005;2(12):1359–1362. DOI: 10.1016/j.hrthm.2005.09.004.
  24. Irie T, Yamakawa K, Hamon D, Nakamura K, Shivkumar K, Vaseghi M. Cardiac sympathetic innervation via middle cervical and stellate ganglia and antiarrhythmic mechanism of bilateral stellectomy. Am J Physiol Heart Circ Physiol 2017;312(3):H392–H405. DOI: 10.1152/ajpheart.00644.2016.
  25. Schwartz PJ, Stone HL. Left stellectomy in the prevention of ventricular fibrillation caused by acute myocardial ischemia in conscious dogs with anterior myocardial infarction. Circulation 1980;62(6):1256–1265. DOI: 10.1161/01.cir.62.6.1256.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.