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López-Millán Infantes, C. Coca-Gamito, A. Cámara-Faraig, E. Díaz-Infante, J.C. García Rubira" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "López-Millán Infantes" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Coca-Gamito" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Cámara-Faraig" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Díaz-Infante" ] 4 => array:2 [ "nombre" => "J.C." 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Parra, Guillermina Fita, Manel Azqueta, Mauricio González, Fernando Aranda, M. Luz Maestre, Jorge Silva, Javier Hortal, Daniel Morales, Emiliano Bórquez, Fabián Adasme, María Isabel Real, Jordi Mercadal, Pamela Zelada, Gonzalo Riobó, Katia Galdames, Raúl J. Domenech" "autores" => array:17 [ 0 => array:2 [ "nombre" => "Víctor M." "apellidos" => "Parra" ] 1 => array:2 [ "nombre" => "Guillermina" "apellidos" => "Fita" ] 2 => array:2 [ "nombre" => "Manel" "apellidos" => "Azqueta" ] 3 => array:2 [ "nombre" => "Mauricio" "apellidos" => "González" ] 4 => array:2 [ "nombre" => "Fernando" "apellidos" => "Aranda" ] 5 => array:2 [ "nombre" => "M. Luz" "apellidos" => "Maestre" ] 6 => array:2 [ "nombre" => "Jorge" "apellidos" => "Silva" ] 7 => array:2 [ "nombre" => "Javier" "apellidos" => "Hortal" ] 8 => array:2 [ "nombre" => "Daniel" "apellidos" => "Morales" ] 9 => array:2 [ "nombre" => "Emiliano" "apellidos" => "Bórquez" ] 10 => array:2 [ "nombre" => "Fabián" "apellidos" => "Adasme" ] 11 => array:2 [ "nombre" => "María Isabel" "apellidos" => "Real" ] 12 => array:2 [ "nombre" => "Jordi" "apellidos" => "Mercadal" ] 13 => array:2 [ "nombre" => "Pamela" "apellidos" => "Zelada" ] 14 => array:2 [ "nombre" => "Gonzalo" "apellidos" => "Riobó" ] 15 => array:2 [ "nombre" => "Katia" "apellidos" => "Galdames" ] 16 => array:2 [ "nombre" => "Raúl J." "apellidos" => "Domenech" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923001622?idApp=UINPBA00004N" "url" => "/23411929/0000007100000001/v2_202403290730/S2341192923001622/v2_202403290730/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Stellate ganglion block for the management of electrical storm: An observational study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "7" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.M. López-Millán Infantes, C. Coca-Gamito, A. Cámara-Faraig, E. Díaz-Infante, J.C. García-Rubira" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "López-Millán Infantes" "email" => array:1 [ 0 => "joselopezmillan@us.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Coca-Gamito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Cámara-Faraig" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Díaz-Infante" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J.C." "apellidos" => "García-Rubira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anaesthesiology, Critical Care and Pain Medicine, Virgen Macarena University Hospital, Seville, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Cardiology, Arrhythmia Unit, Virgen Macarena University Hospital, Seville, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Cardiology, Coronary Unit, Virgen Macarena University Hospital, Seville, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo del ganglio estrellado para el tratamiento de la tormenta eléctrica: un estudio observacional" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0295" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0001"></elsevierMultimedia></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0035" class="elsevierStylePara elsevierViewall">Electrical storm (ES) is a life-threatening emergency defined as 3 or more episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or implantable cardioverter-defibrillator (ICD) discharges within 24 h.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has an incidence of 10%–20% in patients with secondary prevention ICDs and around 4% in patients with primary prevention ICDs,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and an overall mortality rate that ranges between 20% and 50%, depending on the series.</p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the SHIELD study, a reversible aetiology can only been identified in 13% of patients.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Some predictors of ES are advanced age, left ventricular systolic dysfunction, previous episodes of VT/VF, cardiac ischaemia, renal failure, and hyper or hypokalaemia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The importance of sympathetic hyperactivity is variable and depends on the type, aetiology, mechanism of the underlying arrhythmia, and clinical setting.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main goal of acute treatment is haemodynamic stabilization and prevention of recurrence through antiarrhythmic drug therapy, ICD reprogramming, sedation, and systemic adrenergic tone containment or ventricular assist. Catheter ablation is essential to ensure electrical stability, reduce recurrence, and improve survival.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">When the above measures are ineffective, open prospective studies <a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and single case reports<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> have shown that other therapies, such as continuous epidural anaesthesia, surgical thoracic sympathectomy by endoscopic thoracoscopy (ETS) or radiofrequency ablation of the stellate ganglion can reduce cardiac sympathetic activity and recurrence of ES for a variable period of time.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Stellate ganglion block (SGB) is known to be effective in the acute treatment of ES, although response varies depending on the technique used.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Outcomes can be affected by type of local anaesthetic used, the use of adjuvants, administration of unilateral or bilateral block, continuous or bolus block, block guided by ultrasound, fluoroscopy or anatomical landmarks, and the performance of pulsed or continuous radiofrequency (CRF) ablation of the ganglion.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0060" class="elsevierStylePara elsevierViewall">The objective of this study is to assess the effectiveness and safety of ultrasound-guided stellate ganglion block in the management of refractory electrical storm in a cohort of patients.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Method</span><p id="par0065" class="elsevierStylePara elsevierViewall">After approval by the Virgen Macarena-Virgen del Rocío Ethics Committee (no. 20191011115736), we selected patients admitted to the Coronary Unit of the Virgen Macarena University Hospital between January 2018 and December 2021 diagnosed with ES who met the criteria for SGB for compassionate use at the discretion of the Arrhythmia Unit, were over 18 years of age, and refractory to all treatment options (deep sedation, intravenous sympathetic blockade, anti-arrhythmic treatment including beta-blockade, electrical cardioversion and catheter ablation). SGB was performed as bridging therapy until surgical sympathectomy by video-assisted thoracoscopy, new catheter ablation of the arrhythmic substrate or transplant, or as definitive treatment. The patients had previously given their informed written consent.</p><p id="par0070" class="elsevierStylePara elsevierViewall">An ultrasound-guided unilateral left stellate ganglion block was performed at C6 using a BD Yale™ Quincke point 22 G 3<span class="elsevierStyleSup">1/2</span> needle inserted in-plane to administer a single shot of 7–10 ml of 0.25% bupivacaine without adrenaline together with corticosteroids (dexamethasone or betamethasone). Due to the potential deleterious effects of adrenaline in this type of patient, it was replaced by a non-particulate steroid for the purpose of prolonging the blockade.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We defined a positive result as resolution of the ES episode and sustained ventricular arrhythmia. If significant symptomatic relief was not obtained with the unilateral block, a right-sided block was performed.</p><p id="par0080" class="elsevierStylePara elsevierViewall">When complete or partial relapse of the arrhythmia that was refractory to other treatments occurred after initial resolution of the ES, we performed fluoroscopy-guided CRF ablation of the stellate ganglion using a unilateral anterior or bilateral approach under local anaesthesia to obtain prolonged, significant, symptomatic relief. A Boston Scientific CU-CUR™ 23 G 100 mm needle with a 5-millimeter active tip was used. Radiofrequency ablation (80 degrees for 90 s) was performed at 3 points at C7.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The following variables were collected: age, sex, cardiovascular risk factors, cardiac history, left ventricular ejection fraction (LVEF), date of first arrhythmia, cause of admission, type of arrhythmia and morphology, arrhythmia trigger, anti-arrhythmic medications used, cardioversion, other treatments received before and after the block (ICD, CRF, surgery, ablation), regional anaesthesia technique, complications and adverse effects, arrhythmia-free time after the block, patient discharge date, patient survival, and cause of death.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Data were analysed on Excel® for Windows XP® and SPSS® 24.0 using descriptive statistics. Wilcoxon's signed rank test for related samples was performed to assess the difference between the number of arrhythmic events before and after the stellate ganglion block; significance was set at 0.050. The null hypothesis was that the median difference between pre-SGB arrhythmias and post-SGB arrhythmias was equal to 0.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">Seven patients who met all the inclusion criteria were selected. Their characteristics and relevant clinical history are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Most (85.71%) patients were men. The average age (SD) was 67.8 years (8.01). All presented at least 1 cardiovascular risk factor, and 48.85% presented more than 3 cardiovascular risk factors.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Most (85.71%) patients had a history of heart disease, with dilated cardiomyopathy (85.71%) being the most common morbidity.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The patient with no cardiac history was admitted due to cardiac ischaemia (STEMI), this being the trigger for ES. All patients with a history of cardiac disease had received an ICD.</p><p id="par0115" class="elsevierStylePara elsevierViewall">All (100%) patients were sedated, treated with beta-blockers, received antiarrhythmic drugs, and were cardioverted before SGB.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Mean LVEF was 36.3% (14.65%). Only 1 patient presented preserved LVEF; in 2 patients LVEF was around 43%, and in 4 it was ≤25%.</p><p id="par0125" class="elsevierStylePara elsevierViewall">All patients underwent the same SGB technique. The dose of local anaesthetic varied slightly depending on its spread under ultrasound vision and the type of steroid used, which was based on availability. In 4 patients, the block was left unilateral and in 3 patients it was bilateral due to the persistence of symptoms. All (100%) patients experienced significant symptom relief with resolution of VT.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The only block-related adverse effect was Horner's syndrome on the blocked side in all patients. The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The antiarrhythmic effect of SGB in all cases lasted beyond the estimated half-life of the local anaesthetic, and all patients remained symptom free for 4 days, giving the treating team time to perform ICD implantation in 1 patient, and catheter ablation as definitive treatment for the arrhythmia in 6 patients. One of the patients with unilateral SGB did not require cardiac ablation but underwent scheduled bilateral surgical thoracic sympathectomy 4 months after discharge, and has presented no arrhythmic events since then.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Three patients underwent CRF ablation of the stellate ganglion on the side where they had previously received successful SGB. In 1 case treatment was unilateral, 3 months after the block, during a second admission in which the patient underwent follow-up cardiac ablation. That patient was discharged 11 days later, and presented an isolated episode of monomorphic ventricular tachycardia (MVT) at 3 months, but has remained asymptomatic for 2 years. Radio frequency ablation was bilateral in 2 patients, 1 of which had undergone cardiac ablation between the SGB and the CRF ablation. Subsequently, 2 patients underwent bilateral sympathectomy by video-assisted thoracoscopy - 1 scheduled and the other due to recurrence of the arrhythmia.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In all patients, episodes of ventricular arrhythmia and the number of external electrical discharges or ICD discharges per day decreased, and none presented complications at this phase of the interventional treatment.</p><p id="par0150" class="elsevierStylePara elsevierViewall">One patient (14.29%) died in hospital, and 2 patients died during follow-up - 1 of refractory heart failure and the other of nosocomial pneumonia; none presented new arrhythmia events.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Three of the 4 surviving patients underwent cardiac ablation. The patient who was not ablated received bilateral sympathectomy. Two patients underwent CRF ablation - 1 delayed unilateral RF and the other bilateral. The only patient with ischaemic aetiology that received bilateral SGB underwent cardiac rehabilitation with the support of a ventricular assist device. This patient had more than 30 external cardioversions before the SBG, but has not presented any further arrhythmia events since ablation.</p><p id="par0160" class="elsevierStylePara elsevierViewall">At the end of follow-up, only 1 patient presented an episode of VT that required admission, and the other 3 have remained arrhythmia-free for more than 2 years.</p><p id="par0165" class="elsevierStylePara elsevierViewall">According to the statistical analysis, the difference between the number of arrhythmic events before and after performing stellate ganglion block is statistically significant. Wilcoxon's signed rank test was performed for related samples with a significance level of 0.050. The null hypothesis was that the median difference between pre-SGB and post-SGB arrhythmias was equal to 0. This hypothesis was rejected with <span class="elsevierStyleItalic">p</span> = 0.018. However, the same analysis revealed that improvement after radiofrequency is not statistically significant (<span class="elsevierStyleItalic">p</span> 0.414).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">The objective of this study was to assess the effectiveness and safety of SGB for the treatment of refractory ES. Our results, despite the study’s limitations, have shown that ultrasound-guided single-shot SGB with bupivacaine and steroids could be an effective and safe technique for the symptomatic control of patients with ES who do not respond to conventional cardiological treatment, since all our patients responded favourably, with no complications or significant adverse events.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The stellate ganglion is a structure located on both sides of the neck at the level of the union of the transverse process with the vertebral body of C7 medial to the scalene muscles and lateral to the longus colli muscle. The ganglion is anterior to the lower third of the brachial plexus and superior to the subclavian artery and the origin of the vertebral artery. It is the result of the fusion of the lower cervical ganglion with the first thoracic ganglion in 80% of individuals.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The stellate ganglion provides sympathetic output to the myocardium, upper extremity, neck, and face, and mediates multiple cardiovascular effects, including upper extremity and facial vasodilatation, anhidrosis,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and reduced inotropy and chronotropy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However, the right and left stellate ganglia have different sympathetic effects on the myocardium, insofar as the left ganglion has the most impact on myocardial sympathetic tone. In a porcine model of myocardial infarction, an induced myocardial injury produced morphological and neurochemical changes in both stellate ganglia about 5 weeks after the event. There was an increase in neuronal size and synaptic density in both stellate ganglia, with a measurable increase in neuronal firing over 8 weeks.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In the few studies that have investigated the role of SGB in the treatment of ES, both the technique used and the characteristics of the patients treated varied considerably.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our study, we standardized the technique to reduce variability and developed a protocol for administering SGB based cardiological criteria. All the patients included presented ES and had failed conventional measures. All received acute unilateral SGB, followed by bilateral SGB when ES did not cease, and ultimately CRF if SGB was initially successful but the patient relapsed.</p><p id="par0185" class="elsevierStylePara elsevierViewall">SGB is a simple point-of-care technique that has potential side effects such as hoarseness or Horner Syndrome, and complications such as haematoma, brachial plexopathy, phrenic nerve block, pneumothorax, intrathecal or epidural block and intravascular injection.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Although the technique is short-lived, it stabilizes the patient long enough to perform other definitive cardiological treatments.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The duration of SGB is variable, although it is longer than the estimated half-life of the local anaesthetic used, possibly due to the plasticity of neural processing, the distance between the puncture and the node, or the thickness of the nodal sheath.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The volume of local anaesthetic used in our study ranges from 7–10 ml, depending on the spread observed under ultrasound. The administration of low-dose perineural steroids extends the effect of the local anaesthetic, although it can delay onset of the blockade. We decided to use bupivacaine due to its duration of action and ability to combine with steroids, unlike ropivacaine; levobupivacaine is not available in our centre. Although we prefer to use the non-particulate steroid dexamethasone for this technique, other steroids could also be considered. The recommended steroid dose is controversial, so the benefits will need to be weighed up against the side effects.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Careful consideration of these factors could obviate the need for continuous epidural catheter blockade of the stellate ganglion or the thoracic sympathetic nervous system while awaiting definitive cardiological treatment.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The long-term effect of sympathetic blockade on arrhythmia has not been studied. CFR ablation of the stellate ganglion to treat chronic sympathetic nervous system pain has a low level of evidence in the literature.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, it is widely used in clinical practice to prolong the duration of sympathetic blockade, and in our patients we used it to prolong the antiarrhythmic effect in the event of arrhythmia recurrence.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Fluoroscopy-guided ablation using an anterior approach permits more extensive lymph node ablation. Trejo Velasco et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> pioneered the use of non-ablative ultrasound-guided pulsed radiofrequency stellate ganglion treatment at the level of C6, and showed that the technique was safe and gave good long-term results, although the patient underwent cardiac ablation for definitive treatment of arrhythmia. Similar procedures have been described in other case reports, although it is impossible to determine the long-term effect of the technique because it was performed in combination with other treatments.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Although fluoroscopy-guided CRF ablation is safe, it must be performed in the operating room, and does not provide dynamic visualisation. However, it identifies bony landmarks that can be useful in static procedures such as radiofrequency ablation, where it is not necessary to observe the spread of an injectate such as a local anaesthetic, and fluoroscopy images can be enhanced by injecting a radiopaque contrast medium. Using the anterior approach, the needle is positioned parallel to the lymph node, thereby increasing the contact surface and generating a larger lesion. However, experts recommend performing CRF in clusters of 3 at the junction of the vertebral body with the transverse process of C7.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Usmani et al. reported better results in the neuromodulation of ganglion impar using CRF compared with pulsed radiofrequency.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Bilateral SGB for effective arrhythmia control, which is controversial in the literature, was required in less than half of our patients. While some authors perform left cervicothoracic sympathetic blockade,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> others prefer right SGB.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In the series of cases published by García-Moran et al.,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> the authors performed continuous blockade of the left stellate ganglion, and in 2 recurrent cases they performed bilateral sympathetic blockade using thoracic epidural anaesthesia with a catheter. Although the left stellate ganglion supplies most of the sympathetic innervation of the heart, the right stellate ganglion also contributes, and the degree of involvement of each ganglion could determine the type of arrhythmia, its aetiology, and the functional anatomy of the patient. Some studies mention that innervation of the sinus node depends mainly on the right stellate ganglion.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Differences in patient response to cardiac sympathetic blockade are likely due to the presence of other mechanisms that mediate or generate ventricular arrhythmias. Likewise, direct thoracic nerve fibres that do not synapse in the stellate ganglion (thoracic segments T1 to T5) participate in the formation of the cardiac plexus, so sympathetic blockade obtained by this route could be necessary but insufficient in the treatment of ES.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The benefit of sympathectomy varies, and there is no consensus beyond considering it a complement to definitive cardiological treatment, albeit with the added morbidity of any surgical technique under general anaesthesia in patients with high anaesthetic risk.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our study, 2 patients underwent surgical treatment: 1 received unilateral SGB followed by cardiac ablation due to recurrence of ventricular arrhythmias, and died of non-arrhythmic causes at 13 months; and the other received unilateral SGB without cardiac ablation and underwent preventive surgery 4 months after discharge, remaining asymptomatic at 31 months of follow-up. It is impossible to know what the outcome would have been if these patients had not undergone surgical sympathectomy or if we had performed CRF ablation.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The low rate of in-hospital mortality (14.27%) in our study compared to that reported by García-Morán, et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> is striking, and could be due to our standardized, multidisciplinary strategy coordinated with the Arrhythmia Unit and the Coronary Unit in the acute phase.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Three of the 4 patients currently in follow-up underwent cardiac ablation. The patient who was not ablated underwent bilateral sympathectomy. Two patients received CRF ablation - 1 delayed unilateral and the other bilateral. The patient with ischaemic aetiology received bilateral SGB and underwent cardiac rehabilitation. This patient has had no further arrhythmic events, and has not been readmitted to hospital.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Three of the 4 patients have been followed up for over 2 years, during which time they have not required hospitalisation for arrhythmia. The other patient, who was admitted for arrhythmia after discharge, has now been arrhythmia-free for 5 months and is awaiting a heart transplant.</p><p id="par0240" class="elsevierStylePara elsevierViewall">In the retrospective series of eight patients reported by García-Morán et al.,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> mortality was 50%, and only 1 patient was followed up for more than 1 year. In general, follow-up in published cases is short – 4 months in the case of Trejo-Velasco et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> – even after performing radiofrequency ablation, and in some it is not mentioned at all, as in the case of Mata et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> who focussed their report on in-hospital outcomes during the acute phase of ES.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The treatment of ES is complex and usually requires a combination of therapies to achieve a good outcome, so a multidisciplinary approach is recommended.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Despite the proven safety of stellate ganglion block compared with other interventional alternatives,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> reducing the volume of local anaesthetic used in our patients would not have affected the quality of the block but would have reduced the risk of side effects.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Our study has the methodological limitations inherent to an observational study with a very small cohort of patients and no sample size calculation. However, few of our patients died in hospital, and after prolonged follow-up 75% are still active.</p><p id="par0255" class="elsevierStylePara elsevierViewall">The positive results obtained support the benefit of SGB as a bridging therapy or as a complement to definitive cardiological treatment in patients with acute ES.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0260" class="elsevierStylePara elsevierViewall">Ultrasound-guided stellate ganglion block may be an effective and safe complement or bridging therapy to definitive cardiological treatment of arrhythmia in patients with acute refractory electrical storm.</p><p id="par0265" class="elsevierStylePara elsevierViewall">The long-term role of RF stellate ganglion ablation remains to be determined. Larger studies of higher methodological quality are still needed.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Author’s contributions</span><p id="par0270" class="elsevierStylePara elsevierViewall">LMJM and CGC performed analgesia techniques. DIE performed cardiac ablation techniques. GRJC performed non-interventional treatment. All authors participated in the design and implementation of the study. CFA collected data as an independent investigator. LMJM, CGC, DIE, GRJC and CFA provided input on writing and reviewing the final version of this manuscript. All authors meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors have approved the manuscript.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0275" class="elsevierStylePara elsevierViewall">No conflicts of interest have been declared by the authors.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding statement</span><p id="par0280" class="elsevierStylePara elsevierViewall">This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres2115100" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1801973" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2115101" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1801974" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Method" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Author’s contributions" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding statement" ] 13 => array:2 [ "identificador" => "xack736464" "titulo" => "Acknowledgments" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-10-02" "fechaAceptado" => "2023-01-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1801973" "palabras" => array:4 [ 0 => "Electrical storm" 1 => "Treatment" 2 => "Stellate ganglion block" 3 => "Ventricular tachycardia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1801974" "palabras" => array:4 [ 0 => "Tormenta arrítmica" 1 => "Tratamiento" 2 => "Bloqueo del ganglio estrellado" 3 => "Taquicardia ventricular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Electrical storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, stellate ganglion block can help control arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of this study is to assess the effectiveness and safety of stellate ganglion block in the management of refractory arrhythmic storm.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Follow-up of a cohort of patients with refractory electrical storm that met the criteria for performing stellate ganglion block. The block was ultrasound-guided at C6 using local anaesthetic and a steroid – left unilateral first, bilateral if no response, followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Seven patients were included. The in-hospital mortality rate was 14.29%. Four patients received unilateral and 3 bilateral stellate ganglion block. Six were ablated and 1 received an implantable cardioverter-defibrillator. Electrical storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three patients underwent radiofrequency ablation and 2 underwent surgical thoracic sympathectomy. The only side effect was Horner’s syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two patients died after discharge and 4 are alive at the time of writing, 3 of them have not been re-admitted for ventricular events for more than 2 years.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ultrasound-guided stellate ganglion block is an effective and safe complement to standard cardiological treatment of refractory electrical storm.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La tormenta arrítmica es una urgencia vital. Cuando el tratamiento agudo convencional no es efectivo, el bloqueo del ganglio estrellado puede contribuir al control de la arritmia al proporcionar un bloqueo simpático visceral cervicotorácico. El objetivo de este estudio es valorar la efectividad y seguridad del bloqueo ecoguiado del ganglio estrellado para el tratamiento de la tormenta arrítmica refractaria.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Seguimiento de una cohorte de pacientes con tormenta arrítmica que cumplen criterios para el bloqueo del ganglio estrellado.El bloqueo fue realizado guiado con ecografía a nivel C6 utilizando anestésico local y esteroide, primero en lado izquierdo y, si no respuesta, seguidamente en el lado derecho bilateralmente, y seguido de radiofrecuencia convencional guiada mediante fluoroscopia a nivel C7 si la respuesta al bloqueo fue faroable de forma transitoria con reaparición posterior de la arrítmia.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se incluyó a siete pacientes, con una mortalidad durante el ingreso del 14.29%. Cuatro pacientes recibieron bloqueo unilateral y tres bloqueo bilateral del ganglio estrellado. Seis recibieron ablación cardíaca y a uno de ellos se implantó un desfibrilador cardíaco automático. La tormenta arrítmica fue controlada termporalmente en todos los casos más allá de la duración del efecto anestésico local. Tres pacientes se sometieron a ablación por radiofrecuencia del ganglio estrellado y dos a simpatectomía torácica endoscópica del ganglio estrellado. El único efecto adverso observado durante el estudio fue el síndrome de Horner después del bloqueo anestésico del ganglio estrellado. Dos pacientes fallecieron antes del alta y cuatro continúan de alta; tres de ellos sin reingreso posterior debido a eventos ventriculares desde hace más de dos años.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El bloqueo ecoguiado del ganglio estrellado es una técnica efectiva y segura para el tratamiento de la tormenta arrítmica refractaria como complemento al tratamiento cardiológico habitual.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AC: alcohol consumption; AF: atrial fibrillation; DLP: dyslipidaemia; Dilated M: dilated myocardiopathy DM: diabetes mellitus; HOCM: hypertrophic obstructive cardiomyopathy; ICD: implantable cardioverter-defibrillator; LVEF: left ventricular ejection fraction; MI: myocardial infarction; PCI: percutaneous coronary intervention.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ID \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AHT \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">DLP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Smoking \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AC \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">DM \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LVEF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cardiological history \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ICD \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MI + PCI + Dilated M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2008 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dilated M + VF + Atrial flutter + PCI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AMI + Dilated M + MI + PHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2014 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HOCM + AF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2011 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AF + Dilated M + PCI + ICD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2013 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dilated M + ICD + PCI + AF + iatrogenic tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2014 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3497672.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ID \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drugs \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Side \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Relief (days) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ablation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">STS \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Final Resolution (months) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exitus \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 8 ml + DXM 4mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 7 ml + BMT 6mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unilateral left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, two \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 8 ml + DXM 4mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unilateral left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T1-T5bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 10 ml + DXM 4mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unilateral left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 10 ml + BMT 6mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unilateral left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T2-T4bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 8 ml + DXM 4mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, two \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bupivacaine 0.25% 10 ml + DXM 4mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Notab \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3497671.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Intervention on the stellate ganglion and results. BMT: betamethasone; DXM: dexamethasone; RF: radiofrequency; STS: surgical thoracic sympathectomy.</p>" ] ] 2 => array:5 [ "identificador" => "tb0001" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0081" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0011">What is already known?</span><p id="par0010" class="elsevierStylePara elsevierViewall">There is evidence of the benefit of stellate ganglion block in the acute treatment of electrical storm, although response varies depending on the technique used.</p></span><span id="sec0082" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0012">What this study adds?</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study evaluates the effectiveness and safety of ultrasound-guided stellate ganglion block in the management of refractory electrical storm in a cohort of patients using a standardized technique, a multidisciplinary approach, and long-term follow-up.</p></span><span id="sec0083" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0013">How this study might affect research, practice or policy?</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ultrasound-guided stellate ganglion block is an effective and safe complement or bridging therapy to definitive cardiological treatment of arrhythmia in patients with acute refractory electrical storm. The long-term role of RF stellate ganglion ablation remains to be determined.</p></span></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "American College of Cardiology; American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.P. Zipes" 1 => "A.J. Camm" 2 => "M. Borggrefe" 3 => "A.E. Buxton" 4 => "B. Chaitman" 5 => "M. 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