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8 th Global Cardiologists and Echocardiography Annual Meeting July 18-20, 2016 Berlin, Germany

8 th Global Cardiologists and Echocardiography Annual Meeting July 18-20, 2016 Berlin, Germany. The role of the stellate ganglion block in heart diseases. Prof. Dr. med. Lorenz Fischer General internal medicine FMH Neural Therapy SANTH Interventional Pain Management SSIPM

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8 th Global Cardiologists and Echocardiography Annual Meeting July 18-20, 2016 Berlin, Germany

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  1. 8th Global Cardiologists and Echocardiography Annual MeetingJuly 18-20, 2016 Berlin, Germany The role of the stellate ganglion block in heart diseases Prof. Dr. med. Lorenz Fischer General internal medicine FMH Neural Therapy SANTH Interventional Pain Management SSIPM Chairholder Neural Therapy & Co-Director IKOM, University of Bern

  2. Agenda • The role of the autonomic nervous system in heart diseases • Pathomechanisms • The role of the stellate ganglion block in heart diseases

  3. Sympathetic nerve system (SNS) Parasympathetic nerve system (PNS) Autonomic nerve system (ANS) oftheheart Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  4. Autonomic nerve system • The balance of activity of SNS/PNS plays an important rolein the regulation of • Blood pressure • Heart rate • Myocardial contractility • Coronary perfusion Ref. see: Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  5. Autonomic nerve system • An imbalance of activity of SNS/PNS • can lead to disturbances in: • Blood pressure • Heart rate • Myocardial contractility • Coronary perfusion • and • can cause and maintain pain and inflammation. Ref. see: Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  6. Autonomic nerve system Several pathomechanisms are involved – and local anesthetics (LA) are gaining ground in the treatment of these disorders of the ANS. Ref. see: Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  7. Stellate ganglion block in heart diseases Various authors have demonstrated that the stellate ganglion block using LA has a beneficial effect on cardiac arrhythmias. Ref. see: Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  8. Stellate ganglion block in heart diseases • Case example • 67 years old female • supraventricular tachycardia for more than1 hour • Verapamilp.o. • Drinking ice water • Valsalva manoeuvre • Carotid sinus massage without success Supraventricular tachycardia (f 170/min) Fischer L, 1995

  9. Stellate ganglion block in heart diseases Case example: supraventricular tachycardia Supraventricular tachycardia (f 170/min) Normal sinusrhythmimmediately (1–2 min) after the SGB without success Stellate ganglion block (SGB) Fischer L, 1995

  10. Pathomechanisms LA have also a beneficial effect on pain an inflammation pharmacological effect stellate ganglion block (SGB) Ref. see: Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  11. Pathomechanisms Pathophysiology of the SNS and possible effects of LA/SGB in detail: Ref. see: Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  12. Pathomechanisms In pathological neuronal reflex arcs the SNS plays a key role: analogous the mathematical chaos theory these connections create a vicious circle (positive feedback, iteration) of pain and inflammation. Fischer L, 1998; Jänig W & Fischer L, 2011 Disruption by LA: The system gets the chance to a new organisation (self-organisation [cf. chaos theory]) Fischer L, 1998; Jänig W & Fischer L, 2011

  13. Pathomechanisms Recruitment of new spinal wide dynamic range (WDR) neurons with inter alia spontaneous activity Zieglgänsberger 2010 Reductionofthe (spontaneous) activity of the sympathetically activated WDR neurons by LA Roberts & Foglesang 1998 by temporarily disrupting (“resetting”) the positive neuronal feedback loopsJänig 2011, Mc Quay & Moore 1999, Rosenquist & Vrooman 2013

  14. Pathomechanisms Long-term potentiation in sympathetic ganglia (sympatheticplasticity) Alkadhi et al 2005 Indirectreductionofthelong-termpotentiationby LA Kansha et al 1999, Tan et al 1999

  15. Pathomechanisms „Sympatheticsprouting“, e.g. in dorsal root ganglia Price & Mudge1983, McLachlan et al 1993, andothers Reductionby LA Chung & Chung 2001, Zhang et al 2004, Xie et al 2007, andothers

  16. Pathomechanisms Sympathetic-afferent couplingJänig & Koltzenburg 1991, andothers Possibilityofregressionbyrepeatedapplicationof LA

  17. Pathomechanisms Ectopic generation of neuronal action potentials Reductionby LA Sukhotinsky et al 2004

  18. Pathomechanisms SNS: neurogenicinflammation (vasomotion, release of neuropeptides) Goadsby & Edvinson 1993, Cassuto et al 2006, andothers Regulation ofthevasomotionRicker 1924; reductionofthereleaseofneuropeptides (substance P) by LA Cassuto 2006

  19. Stellate ganglion block in heart diseases • Extensive studies are needed about the role of SGB in heart diseases! • Is SGB dangerous? • Does SGB affect hemodynamic variables and echocardiographic parameters?

  20. Stellate ganglion block in heart diseases SGB with a modified technique, small volume of LA (3mL of procaine 1%), and precision because of the low permeability of procaine compared to other LA. More than 1000 SGB without any complication.

  21. Stellate ganglion block in heart diseases

  22. Stellate ganglion block in heart diseases • Test persons and methods • 15 healthy volunteers • Another 15 healthy volunteers as a control group (sham injection of LA) • Systolic and diastolic blood pressure, heart rate and echocardiographic parameters were recorded before and after SGB • Results • After SGB only diastolic blood pressure significantly increased without clinical significanceNo changes in the control group • After SGB on the left significant reduction of the maximum velocity of myocardial contraction appeared Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  23. Stellate ganglion block in heart diseases Conclusions Even the precise SGB with a small volume of procaine cannot avoid a partial parasympathetic effect. The hemodynamic effects are negligible. THIS DOES NOT MEAN THOUGH THAT THE THERAPEUTIC EFFECTS FOLLOWING SGB ARE DIMINISHED, since the simultaneous anesthesia of parasympathetic fibers will not impair the beneficial antiarrhythmic, antiinflammatory and pain inhibiting effects of SGB. Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  24. Stellate ganglion block in heart diseases Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  25. Stellate ganglion block in heart diseases Conclusions SGB, performed in the above described way, is safe and has only minor hemodynamic effects. That’s why we propose a broader application of SGB and further studies about the applicability of SGB in heart diseases. Puente de la Vega Costa, K., Gomez Perez M, Roqueta C, Fischer L: Auton Neurosci 2016; 197: 46-55

  26. Thank you for your attention !

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