Impact of single versus dual local anaesthetic regimen on the efficacy and safety of percutaneous stellate ganglion block for electrical storm: new insights from the STAR study

Aims: Percutaneous stellate ganglion block (PSGB) is a promising treatment for refractory electrical storm (ES). However, there is a lack of solid indications regarding the optimal pharmacological regimens and combination of local anaesthetics (LAs). This study, from the multicentre STAR registry, aimed to evaluate the impact of single versus dual LA regimen on the efficacy and safety of PSGB. Methods and results: We analysed 422 PSGB procedures from 298 patients (30% single LA, 70% dual LAs). Both regimens significantly reduced the number of treated ventricular arrhythmias (VAs) in the 12 hours post-PSGB. Crucially, the combination of two LAs-typically pairing a fast-acting with a long-acting agent-resulted in a significantly higher rate of complete VA suppression at 1 hour (85% vs 70%, p<0.01) and 3 hours (78% vs 67%, p=0.02) compared with the single LA regimen. This superior early efficacy was confirmed after propensity score matching and multivariable analysis. The total complication rate, driven by minor ones, was higher with two LAs (8% vs 2%, p= 0.02), but this association was no longer significant after adjusting for the procedural approach (lateral vs. anterior). Conclusion: The combination of two local anaesthetics for PSGB is significantly associated with a greater likelihood of early and complete ventricular arrhythmia suppression in patients with electrical storm. Despite the need for randomized ad-hoc trials, the dual-LA regimen represents an optimization strategy for PSGB, offering enhanced efficacy without an increased risk of major complications.