A Randomized Controled Trial of Transcutaneous Magnetic Stimulation of the Stellate Ganglion to Treat Ventricular Tachycardia Storm
Phase: NA
Conditions: Ventricular Tachycardia
Sponsor: University of Pennsylvania

Title 
A Randomized Controlled Trial for 
Transcutaneous Magnetic Stimulation of 
the Stellate Ganglion to Treat Ventricular 
Tachycardia Storm 
Date 
06/04/2022 
NCT Number 
04043312 
Short Title 
Magnetic Stimulation for Electrical Storm 
Phase 
Randomized Controlled Trial 
Methodology 
Two arm, randomized sham controlled trial to assess the efficacy of 
transcutaneous magnetic stimulation of the left stellate ganglion to treat 
patients with ES. 
Study Center(s) 
Single-center 
Number of Subjects Twenty-six (26) subjects are expected to be enrolled 
Inclusion and 
Exclusion Criteria 
Inclusion Criteria: Age >18 years, ≥ 3 episodes of VT in 24 hours 
 
Exclusion Criteria: Pregnancy, planned ablation with in 24 hours, 
implanted ventricular assist device, metal implanted in head or neck 
(except the mouth), implanted medication pumps, cochlear implant, 
implanted brain stimulator, ocular implant, history of malignancy in 
neck (region of stimulation) 
 
 
 
 
 
 
 
 
 
 

 
 
 
This study will be conducted in full accordance all applicable University of Pennsylvania Research 
Policies and Procedures and all applicable Federal and state laws and regulations including the 
following regulations as they apply 45 CFR 46, 21 CFR Parts 50, 54, 56,and 812. All episodes of 
noncompliance will be documented. 
Introduction 
1.1 
Background and Relevant Literature  
Cardiac electrical storm (ES) is a medical emergency characterized by three or more episodes of 
ventricular arrhythmia within 24 hours and associated with a significantly increased mortality and 
massive health resource utilization.  While the mechanism of ES is variable, it is likely induced by 
a complex interplay of triggers (e.g. electrolyte abnormalities), autonomic dysfunction, and an 
abnormal electrophysiological substrate. Several therapies are utilized including sympathetic 
blockade (through deep sedation and beta blockers), antiarrhythmic drugs, implantable 
cardioverter defibrillator (ICD) reprograming where applicable, and catheter ablation. Despite 
standard intervention, mortality rates remain high and additional therapeutic options are actively 
being investigated.  
 
Numerous lines of evidence have suggested the therapeutic benefit of autonomic modulation for 
the treatment of ventricular arrhythmias. In 1916, Thomas Jonnesco first performed a left 
sympathetic denervation for incapacity angina and life-threatening cardiac arrhythmias (1).  Since 
that time, cardiac sympathetic denervation (CSD) has been used to successful treat patients at high 
risk for sudden death due to congenital long QT syndrome, catecholaminergic polymorphic 
ventricular tachycardia, or post-myocardial infarction (2, 3). Given the dominance of left sided 
sympathetic nerves innervating the ventricle, left CSD has been utilized more commonly, although 
bilateral CSD is also used (4). The number of indications with evidence of benefit continues to 
grow 
and 
includes 
hypertrophic 
cardiomyopathy, 
arrhythmogenic 
right 
ventricular 
cardiomyopathy, and ES (5-7).  
 
More recently, the surgical technique for CSD has improved with a minimally invasive thorascopic 
approach and non-surgical strategies for sympathetic denervation have also been employed (8-10).  
Although large prospective trials have not yet been conducted, there is growing evidence that 
stellate ganglion blockade (SGB) is an effective therapy for ES.  This procedure is performed by 
injecting local anesthetic agents percutaneously into the stellate ganglion generally via anatomic, 
ultrasound, or fluoroscopic guidance. The goal, similar to CSD is to reduce cardiac sympathetic 
tone to improve short-term control of ventricular arrhythmias and the need for defibrillation. While 
the anesthetic agents would be expected to have a short duration of effect based on their half-life, 
patients seem to experience an extended duration free of arrhythmia, possibly secondary to 
favorable remodeling of the highly plastic nature of the autonomic nervous system (10-12).  A 
non-invasive approach to block the autonomic input from the stellate ganglion could, therefore, be 
a valuable option to treat ES. 
 

1.2 
Name and Description of the Investigational Product  
The investigational device used will be transcutaneous magnetic stimulator produced by Magstim 
Company Limited (Magstim SuperRapid). The device utilizes current to produce an 
electromagnetic pulse that is delivered at low frequency to the stellate ganglion as described below. 
This system is FDA 510(k) approved for the stimulation of peripheral nerves.  rTMS systems are 
considered by the FDA to be Class II medical devices.  Given the clinical data described below, 
low frequency cervical magnetic stimulation does not pose significant health risks.  
1.2.1 Nonclinical Data 
There is relevant animal model data on the impact of sympathetic magnetic stimulation on atrial 
fibrillation and ventricular arrhythmias. In 2004, Scherlag et al. applied high frequency (2kHz) 
magnetic stimulation to canine vagosympathetic trunks, demonstrating the ability to induce atrial 
fibrillation (AF). They additionally applied low frequency (0.04 Hz) magnetic stimulation across 
canine chest, inducing 2:1 AV block and making AF non-inducible for several hours (13). This 
result was re-demonstrated recently, with low frequency (0.952 Hz) and extremely low intensity 
(3.4x10-12 Tesla) magnetic stimulation to canine cervical vagal trunks and across chest walls 
inhibiting AF inducibility for hours (14).  These animal studies fit with a growing body of evidence 
that autonomic modulation can be used to treat AF. This includes ganglion plexus ablation or 
botulinum toxin injection, spinal cord stimulation, and renal artery denervation (15-18).  Low-
level electrical vagal nerve stimulation has proven especially promising in animal studies, reducing 
inducibility of AF, preventing AF development in obstructive sleep apnea rabbit models, and even 
reversing atrial remodeling (19, 20).  A canine study of low-frequency (1 Hz) magnetic stimulation 
applied over the left stellate ganglion at 90% of the local motor threshold recently showed the 
ability to prevent ventricular arrhythmias in the setting of acute myocardial infarction (21). These 
results suggest that the beneficial effects of sympathetic modulation via CSD or SGB may be 
reproducible with non-invasive and painless magnetic stimulation.   
 
1.2.2 Clinical Data to Date 
To date, there is no clinical data on magnetic stimulation for the treatment of arrhythmias, 
including ventricular tachycardia or ES.  There is, however, extensive clinical data on the safety 
and efficacy of TMS for neurological and psychiatric disease as well as percutanesous cervical 
magnetic stimulation for phrenic nerve stimulation and promotion of bone growth following spine 
surgery.  
 
The majority of safety data comes from the TMS literature, which has been referenced in the use 
of peripheral stimulation as well given the similar physical properties. The primary concern of 
TMS systems has been heating, which is an unavoidable consequence of the generation of current. 
Air or oil coiling systems can be put in place were necessary to avoid excessive heating of the coil 
and commercially available coils have heat sensors and automatic shut-off systems in place (22). 
Excessive heating is of less of a concern with the use of exclusively low-frequency stimulation. 
Attractive force and heating of ferromagnetic objects is also a theoretical concern. This includes 
aneurysm clips in the brain, which do not appear to be significantly affected by TMS, as well as 
cochlear implants and deep brain stimulations, which are considered contraindications to TMS 
(22).  
 

For magnetic therapy of cardiac arrhythmias, implanted cardiac devices pose a potential concern. 
TMS is considered safe in the presence of implanted cardiac devices, along with vagal nerve 
stimulators and spinal cord stimulators as long as the TMS is not activated over the components 
in the chest. There is literature on the safe use of TMS in patients with implanted cardiac devices 
- no effect on device function has been noted (23, 24). Furthermore, according to the 
recent safety consensus statement, TMS is considered safe in individuals with cardiac pacemakers 
(22). Peripheral magnetic stimulation generally produces the same approximate magnetic intensity 
of a 1.5-Tesla MRI scanner and often substantially less (13, 22). Notably, in our feasibility study 
discussed below, no subject received more than 35% of the maximal device capacity (1.2 T) during 
the stimulation protocol. Patients with implanted cardiac devices are able to safely have 1.5 Tesla 
MRIs performed when the magnetic stimulation is directed directly over the device in the case of 
chest MRI (25). As we will not be stimulating over any device components (which are located in 
the chest, not the neck) we feel that our protocol can also be safely performed in this patient 
population just as it is for TMS.  
 
Nevertheless, additional precautions will be taken as described in our protocol. For enhanced 
safety, patients with implanted cardiac devices in our study will undergo reprogramming and 
monitoring of the ICD as previously validated for magnetic resonance imaging studies where the 
device is exposed to magnetic fields.  Prior to stimulation, the device will be interrogated to 
determine normal function and parameters as well as underlying heart rhythm and possible 
dependence on pacemaker function. Any patients with abnormally functioning devices at baseline 
will be excluded. All tachycardia therapies will be turned off during the protocol to prevent 
inappropriate delivery of therapy. In the event of pacemaker dependence, the device will be set to 
an asynchronous pacing mode to prevent the magnetic stimulation from inappropriate inhibiting 
necessary pacing. Following the procedure, during which an Advanced Cardiac Life Support 
(ACLS) trained provider will monitor the patient closely as per our initial protocol design, the 
device will be re-interrogated to determine any change in function or parameters. Tachycardia 
therapies will be turned back on as appropriate after completion of the protocol (25, 26).  
 
It is also important to note that TMS has not been studied in pregnant patients.  
 
Relevant safety data from peripheral magnetic stimulation comes largely from phrenic nerve 
stimulation, which it is used for respiratory muscle weakness. Cervical magnetic stimulation has 
been performed to stimulation the phrenic nerve for decades using 1.5 T magnets without 
significant adverse effects and is reportedly painless (27-29).  It has also been used in intubated 
patients (30). Phrenic nerve magnetic stimulation has also been safely performed with application 
directly over the upper sternum (30).  Interesting, a CervicalStim device is a commercially 
available device used to aid in bone healing after cervical-spine fusion. This device has been shown 
to safely deliver high frequency (3.85 kHz), low intensity (1.19 x 10-6 Telsa) to the posterior 
cervical spine (31, 32). The presence of implanted cardiac devices is considered a warning but not 
a contraindication to its use.  
 

2 
Study Administration, Data Handling and Record Keeping 
2.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those 
regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts should 
be made to obtain permission to collect at least vital status (i.e. that the subject is alive) at the end 
of their scheduled study period. 
2.2 
Data Collection and Management  
Study data will be imported in to MS Excel following each enrollment. The PI and co-investigator 
will have access to this data. To retain confidentiality, the data will be stored on an encrypted flash-
drive. Within 6-months of study completion, the data will de-identified to retain confidentiality 
going forward. The data will be stored, de-identified, for up to 5 years.  
Signed consent forms will be retained in a locked file cabinet.  
 
2.3 
Records Retention  
Records, including signed consent forms will be retained for at least 3 years following the 
completion of the study. After three years, the signed consent forms will be effectively destroyed. 
 
3 
Study Monitoring, Auditing, and Inspecting 
3.1 
Study Monitoring Plan 
This study will be monitored according to the monitoring plan described above. The investigator 
will allocate adequate time for such monitoring activities.  The investigator will also ensure that 
the monitor or other compliance or quality assurance reviewer is given access to all the above 
noted study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.), and has adequate space to conduct the monitoring visit. 
3.2 
Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, the 
sponsor, government regulatory bodies, and University compliance and quality assurance groups 
of all study related documents (e.g. source documents, regulatory documents, data collection 
instruments, study data etc.).  The investigator will ensure the capability for inspections of 
applicable study-related facilities. 
 

4 
Ethical Considerations 
This study is to be conducted in accordance with applicable US government regulations and 
international standards of Good Clinical Practice, and applicable institutional research policies and 
procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent Ethics 
Committee (EC) or Institutional Review Board (IRB), in agreement with local legal prescriptions, 
for formal approval of the study conduct.  The decision of the EC/IRB concerning the conduct of 
the study will be made in writing to the investigator and a copy of this decision will be provided 
to the sponsor before commencement of this study.  
4.1 
Risks 
The risks of the magnetic stimulation protocol include change in blood pressure or heart rate, 
induced arrhythmias, and patient discomfort. None of these changes were apparent in the 5 patients 
enrolled in the feasibility study. Subjects will be monitored for each of these during the protocol 
and it will be terminated as described above. As cervical magnetic stimulation has been performed 
in other patient populations without the aforementioned adverse effects, we believe the risks posed 
will be minimal.   
 
Additionally, for subjects with implanted cardiac devices, the risks include device malfunction. 
Devices will be interrogated before and after the protocol to ensure normal functioning. Notably, 
the stimulation will not be directed at the devices, consistent with consensus statement guidelines 
for TMS.  Using the same protocol for interrogation and reprograming, magnetic resonance 
imaging can be safely performed and we believe the proposed magnetic stimulation protocol poses 
minimal risk in these subjects. 
4.2 
Benefits 
Direct Benefits: 
• Decreased burden of arrhythmias. 
 
Indirect Benefits: 
• Development of a novel treatment for cardiac arrhythmias, benefiting society as a 
whole. 
 
4.3 
Risk Benefit Assessment 
The risks of participating in the study are outweighed by the potential benefits of participating in 
the study.  
4.4 
Informed Consent Process / HIPAA Authorization  
• Primary or co-investigator will obtain informed consent with signature of the consent form. 
• The consent process will take place in the hospital or over the phone if patient is unable to 
consent and health care decision maker is not in the hospital. If the subject is able to provide 
verbal consent but unable to sign the consent form, a witness to verbal consent will sign the 
form. 

• During the consent process, subjects or health care decision maker will read-back all risks to 
ensure comprehension of the study. Where applicable, the legally authorized representative will 
be provided with the informed consent form to read and sign. 
• Prior to consent, subjects will be assured that there will be no change in the clinical care 
received if they decline to participate. 
• Subject’s privacy will be assured with all consent forms and clinical information securely 
maintained. 
• Consent will take place at the time of initial discussion regarding enrollment. 
 
5 
Safety and Adverse Events 
5.1 
Definitions 
5.1.1 Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in 
severity during the course of the study.  Intercurrent illnesses or injuries should be regarded as 
adverse events.  Abnormal results of diagnostic procedures are considered to be adverse events if 
the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
5.1.2 Serious Adverse Event 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that 
is:  
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly of 
major clinical significance.   They may jeopardize the subject, and may require intervention to 
prevent one of the other serious outcomes noted above.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-
serious adverse events.  
5.2 
Recording of Adverse Events 
At each contact with the subject, the investigator will seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events will 
be recorded immediately in the source document, and also in the appropriate adverse event module 

of the case report form (CRF).  All clearly related signs, symptoms, and abnormal diagnostic 
procedures results should recorded in the source document, though should be grouped under one 
diagnosis. 
 
All adverse events occurring during the study period will be recorded.  The clinical course of each 
event will be followed until resolution, stabilization, or until it has been determined that the study 
intervention or participation is not the cause.  Serious adverse events that are still ongoing at the 
end of the study period will be followed up to determine the final outcome.  Any serious adverse 
event that occurs after the study period and is considered to be possibly related to the study 
intervention or study participation will be recorded and reported immediately. 
5.3 
Relationship of AE to Study  
The primary investigator will determine the relationship of each adverse event to the study 
procedure. The relationship will be classified (definitely related, probably related, possibly related, 
unlikely, or unrelated). 
5.4 
Reporting of Adverse Events, Adverse Device Effects and Unanticipated Problems 
All reportable adverse events will be reported per the Penn IRB guidelines. All reports will include 
the following information:  
• Study identifier 
• Study Center 
• Subject number 
• A description of the event 
• Date of onset 
• Current status 
• Whether study intervention was discontinued 
• The reason why the event is classified as serious 
• Investigator assessment of the association 
between the event and study intervention 
 
 
Additionally all other events (unanticipated problems, adverse reactions, unanticipated adverse 
device effects and subject complaints will be recorded and reported with respect to institutional 
and federal policies as described in the Penn Manual and below.  
 
5.4.1 Follow-up report 
If an SAE has not resolved at the time of the initial report and new information arises that changes 
the investigator’s assessment of the event, a follow-up report including all relevant new or 
reassessed information (e.g., concomitant medication, medical history) should be submitted to the 
IRB. The investigator is responsible for ensuring that all SAE are followed until either resolved or 
stable.  
5.4.2 Investigator Reporting: Notifying the Penn IRB  
Reportable events will include any adverse event or incident that has the potential to be classified 
by the IRB as an unanticipated problem posing risks to participants or others. This includes 
incidents events that are both unexpected in nature or severity and probably or definitively related 
to participation in the research study, which will be determined by the primary investigator.  All 
such events will be reported to the IRB within 10 business days of discovery. If the event involved 
a death and indicates that others are at increased risk of harm, the report will be filled within 3 
days.  Notification will occur using a Reportable Event Form.  

5.5 
Stopping Rules  
If sustained ventricular arrhythmia or hemodynamic compromise (defined as a drop in systolic 
blood pressure >20 mmHg or need for additional inotropic support) occurs during the protocol, it 
will be terminated.  Additionally, if the subject requests the protocol be discontinued for any 
reason, it will be terminated.  
 
If any protocol is terminated before completion, further enrollment will cease until the primary 
investigator can evaluate the event in order to determine whether a significant safety risk was 
posed. If the intervention is felt to be probably or definitively associated with a significant safety 
risk, the IRB will be contact prior to continuing enrollment.  
 

Investigational 
Plan 
 
Subjects will be screened using intensive and cardiac care unit census 
lists in the EMR to identify patients meeting inclusion and exclusion 
criteria. Potential subjects will be discussed with primary clinical team 
prior to approaching. If the primary team feels enrollment is appropriate, 
subjects or their decision maker will be approached for consent. Written 
(or telephone consent when necessary) will be obtained before beginning 
the study protocol.  
 
Once screening and consent are complete, the subject will be 
randomized to the intervention or sham-control arm. Following 
randomization, intervention phase will begin. A 12-lead ECG will be 
performed and continuous telemetry monitoring will be activated prior 
to positioning the rTMS coil at the base of the left neck directed in 
approximation of the left stellate ganglion.  
 
For subjects randomized to the intervention arm, the rTMS system will 
then be activated at the maximal device intensity. If local muscle 
contraction is noted, the intensity will be decreased in 10% increments 
until contraction is no longer present. Once the motor threshold is 
determined, the intensity will be set to 80% of this threshold. If local 
muscle contraction is not noted at the maximal intensity, the setting will 
be set to 80% of the maximal intensity. Stimulation will then continue at 
a frequency of 0.9 Hz for 60 minutes. Blood pressure and perfusion 
index will be assessed every 5 minutes during stimulation. Following 
stimulation, a repeat 12 lead ECG will be performed. If applicable, 
patients will be asked whether they experience discomfort during the 
stimulation. 
 
For subjects randomized to the sham-control arm, the rTMS coil will be 
positioned with the back of the coil housing in contact with the subject 
– under this condition there will be an auditory artifact but no 
stimulation. To mimic the threshold determination, ten (10) individual 
pulses will be delivered at varying intensities by the machine prior to 
beginning 60 minutes of pulses at 0.9 Hz delivered at the minimal 
intensity of the system.  
 
Subjects, their primary clinical team, and the physician assessing 
arrhythmic outcomes will be blinded to their treatment arm for the 
duration of the study period.  
 
Telemetry monitoring for arrhythmias will be performed daily for either 
72 hours after the intervention phase or until hospital discharge if that 
occurs earlier.  
 
 
 

 
Primary Study Endpoints 
The primary endpoint will be freedom from VT in the 24-hours following 
randomization.  
Secondary Study Endpoints 
• Number of episodes of VT or NSVT in the 72-hours following 
randomization. 
• Change in ICD/pacemaker parameters 
• Change in blood pressure, heart rate, perfusion index, palm 
temperature during the stimulation protocol 
• Change in PR, QRS, and QTc interval from pre- and post-intervention 
ECGs 
• Presence of local skin irritation at the site of stimulation 
• Subjective reported discomfort from stimulation (when applicable – 
i.e. non-sedated patient) assessed post-intervention with scale 0-10. 
• Mortality, duration of ICU hospitalization, antiarrhythmic drugs used, 
and ablation procedures performed  
 
 
Safety Evaluations 
During the stimulation protocol, heart rate will be monitored by 
continuous telemetry and blood pressure will be checked every 5 
minutes by automatic cuff or arterial line when present. Following 
completion of the protocol, subject discomfort will be assessed as 
above when possible. In patients with an implantable cardiac device, 
interrogation and re-programming will be performed before and after 
the protocol as above.  
 
If sustained ventricular arrhythmia or hemodynamic compromise 
(defined as a drop in systolic blood pressure >20 mmHg or need for 
additional inotropic support) occurs during the protocol, it will be 
terminated.  Additionally, if the subject requests the protocol be 
discontinued for any reason, it will be terminated. 
 
Duration of 
administration (if 
applicable) 
Each subject will receive a single 60-minute session of magnetic 
stimulation or sham magnetic stimulation based on their randomly 
assigned treatment arm.  

Reference therapy 
Standard therapy for ES is variable but often includes antiarrhythmic 
drugs, sedation, and catheter ablation. rTMS will be provided in 
addition to standard appropriate therapy for patients randomized to the 
rTMS arm. In patients randomized to the control arm, standard therapy 
alone will be provided in addition to sham stimulation.  
Statistical 
Methodology 
 
 
Based on the results of our feasibility study and available literature, we 
anticipate 80% of patients in the control group and 20% of patients in 
the TcMS group will have VT in the 24 hour period following 
randomization. Assuming alpha 0.05, a hazard ratio of 0.40, and a 
sample size of 26 subjects, we estimate study power to be greater than 
80%.  
 
Differences in outcomes between arms will be compared using χ2-tests 
or fisher’s exact test for categorical variables and analysis of variance 
for continuous variables. Subject characteristics and outcomes will be 
described using mean and standard deviation. Non-parametric 
statistical hypothesis tests will be used when the data are not normally 
distributed. Poisson regression will be used to evaluate the burden of 
recurrent VT.  All statistical tests will be 2-sided, with p<0.05 
indicating statistical significance.  
 
6 
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