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Al-Khatib SM. Cardiac Sympathetic Denervation for Ventricular Arrhythmias and Nonischemic Cardiomyopathy: The End of the Beginning. JACC Clin Electrophysiol 2024; 10:40-42. [PMID: 38069972 DOI: 10.1016/j.jacep.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Sana M Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.
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Joshi P, Estes S, DeMazumder D, Knollmann BC, Dey S. Ryanodine receptor 2 inhibition reduces dispersion of cardiac repolarization, improves contractile function, and prevents sudden arrhythmic death in failing hearts. eLife 2023; 12:RP88638. [PMID: 38078905 PMCID: PMC10712946 DOI: 10.7554/elife.88638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Sudden cardiac death (SCD) from ventricular tachycardia/fibrillation (VT/VF) is a leading cause of death, but current therapies are limited. Despite extensive research on drugs targeting sarcolemmal ion channels, none have proven sufficiently effective for preventing SCD. Sarcoplasmic ryanodine receptor 2 (RyR2) Ca2+ release channels, the downstream effectors of sarcolemmal ion channels, are underexplored in this context. Recent evidence implicates reactive oxygen species (ROS)-mediated oxidation and hyperactivity of RyR2s in the pathophysiology of SCD. We tested the hypothesis that RyR2 inhibition of failing arrhythmogenic hearts reduces sarcoplasmic Ca2+ leak and repolarization lability, mitigates VT/VF/SCD and improves contractile function. We used a guinea pig model that replicates key clinical aspects of human nonischemic HF, such as a prolonged QT interval, a high prevalence of spontaneous arrhythmic SCD, and profound Ca2+ leak via a hyperactive RyR2. HF animals were randomized to receive dantrolene (DS) or placebo in early or chronic HF. We assessed the incidence of VT/VF and SCD (primary outcome), ECG heart rate and QT variability, echocardiographic left ventricular (LV) structure and function, immunohistochemical LV fibrosis, and sarcoplasmic RyR2 oxidation. DS treatment prevented VT/VF and SCD by decreasing dispersion of repolarization and ventricular arrhythmias. Compared to placebo, DS lowered resting heart rate, preserved chronotropic competency during transient β-adrenergic challenge, and improved heart rate variability and cardiac function. Inhibition of RyR2 hyperactivity with dantrolene mitigates the vicious cycle of sarcoplasmic Ca2+ leak-induced increases in diastolic Ca2+ and ROS-mediated RyR2 oxidation, thereby reducing repolarization lability and protecting against VT/VF/SCD. Moreover, the consequent increase in sarcoplasmic Ca2+ load improves contractile function. These potentially life-saving effects of RyR2 inhibition warrant further investigation, such as clinical studies of repurposing dantrolene as a potential new therapy for heart failure and/or SCD.
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Affiliation(s)
- Pooja Joshi
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical CenterNashvilleUnited States
| | - Shanea Estes
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical CenterNashvilleUnited States
| | - Deeptankar DeMazumder
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Internal Medicine, Veterans Affairs Pittsburgh Health SystemPittsburghUnited States
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Internal Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical CenterPittsburghUnited States
- Department of Surgery, University of Pittsburgh School of MedicinePittsburghUnited States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh School of MedicinePittsburghUnited States
| | - Bjorn C Knollmann
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical CenterNashvilleUnited States
| | - Swati Dey
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical CenterNashvilleUnited States
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Dey S, Joshi P, O'Rourke B, Estes S, DeMazumder D. Cardiac sympathetic denervation prevents sudden cardiac arrest and improves cardiac function by enhancing mitochondrial-antioxidant capacity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.29.526082. [PMID: 36778270 PMCID: PMC9915471 DOI: 10.1101/2023.01.29.526082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
RATIONALE Sudden cardiac arrest (SCA) and heart failure (HF) are leading causes of death. The underlying mechanisms are incompletely understood, limiting the design of new therapies. Whereas most autonomic modulation therapies have not shown clear benefit in HF patients, growing evidence indicates cardiac sympathetic denervation (CSD) exerts cardioprotective effects. The underlying molecular and cellular mechanisms remain unexplored. OBJECTIVE Based on the hypothesis that mitochondrial reactive oxygen species (mROS) drive the pathogenesis of HF and SCA, we investigated whether CSD prevents SCA and HF by improving mitochondrial antioxidant capacity and redox balance, to correct impaired Ca2+ handling and repolarization reserve. METHODS AND RESULTS We interrogated CSD-specific responses in pressure-overload HF models with spontaneous SCA using in vivo echocardiographic and electrocardiographic studies and in vitro biochemical and functional studies including ratiometric measures of mROS, Ca2+ and sarcomere dynamics in left ventricular myocytes. Pressure-overloaded HF reduced mitochondrial antioxidant capacity and increased mROS, which impaired β-adrenergic signaling and caused SR Ca2+ leak, reducing SR Ca2+ and increasing diastolic Ca2+, impaired myofilament contraction and further increased the sympathetic stress response. CSD improved contractile function and mitigated mROS-mediated diastolic Ca2+ overload, dispersion of repolarization, triggered activity and SCA by upregulating mitochondrial antioxidant and NADPH-producing enzymes. CONCLUSIONS Our findings support a fundamental role of sympathetic stress-induced downregulation of mROS scavenging enzymes and RyR-leak mediated diastolic Ca2+ overload in HF and SCA pathogenesis that are mitigated by CSD. This first report on the molecular and cellular mechanisms of CSD supports its evaluation in additional high-risk patient groups.
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Bhattacharya D, Namboodiri N, Sreelekshmi MP, Prabhu MA, Sreevilasam Pushpangadhan A, Menon S, Dharan BS, Valaparambil A. Left cardiac sympathetic denervation in children with Jervell Lange-Nielsen syndrome and drug refractory torsades - A case series. Pacing Clin Electrophysiol 2023; 46:1197-1202. [PMID: 37728293 DOI: 10.1111/pace.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Long QT syndrome is an inherited malignant channelopathy which leads to life-threatening arrhythmia, with multiple genotypes. Jervell and Lange-Nielsen syndrome (JLNS) is an autosomal recessive subtype of this disease, characterized by congenital sensorineural deafness and a high incidence of sudden cardiac death (SCD). METHODOLOGY We prospectively followed up six children who underwent left cardiac sympathetic denervation (LCSD) for JLNS in view of high-risk features despite being on maximally tolerated doses of oral propranolol. RESULTS Mean age at diagnosis was 2.75 ± 0.39 years, with a significant delay between onset of symptoms and diagnosis (mean 7.2 ± 3.5 months). All had sensorineural hearing loss, conforming to the JLNS phenotype. Mean QTc interval was 603 ± 93 ms, with T wave alternans (TWA) seen in all cases. All were started on propranolol and subsequently subjected to LCSD, and 3 underwent AAI permanent pacemaker implantation. Over a mean follow-up of 20 months, there was a significant reduction in QTc (603 ± 93 ms to 501 ± 33 ms, p = .04), which was persistent on follow-up (525 ± 41 ms) and only two out of six had persistent T wave alternans on ECG (p < .01). None of these children had presyncope, syncope, seizures, torsades de pointes, cardiac arrest or death on follow up following LCSD. CONCLUSION Jervell Lange-Nielsen syndrome is a subtype of LQTS with high-risk features. LCSD, an effective therapeutic option for those having symptoms despite being on propranolol, results in significant reduction of QTc interval and amelioration of symptoms.
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Affiliation(s)
- Deepanjan Bhattacharya
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Narayanan Namboodiri
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | - Mukund A Prabhu
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | | | - Sabarinath Menon
- Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Baiju S Dharan
- Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Ajitkumar Valaparambil
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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Joshi P, Estes S, DeMazumder D, Knollmann BC, Dey S. Ryanodine receptor 2 inhibition reduces dispersion of cardiac repolarization, improves contractile function and prevents sudden arrhythmic death in failing hearts. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.29.526151. [PMID: 37662391 PMCID: PMC10473608 DOI: 10.1101/2023.01.29.526151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Introduction Sudden cardiac death (SCD) from ventricular tachycardia/fibrillation (VT/VF) are a leading cause of death, but current therapies are limited. Despite extensive research on drugs targeting sarcolemmal ion channels, none have proven sufficiently effective for preventing SCD. Sarcoplasmic ryanodine receptor 2 (RyR2) Ca 2+ release channels, the downstream effectors of sarcolemmal ion channels, are underexplored in this context. Recent evidence implicates reactive oxygen species (ROS)- mediated oxidation and hyperactivity of RyR2s in the pathophysiology of SCD. Objective To test the hypothesis that RyR2 inhibition of failing arrhythmogenic hearts reduces sarcoplasmic Ca 2+ leak and repolarization lability, mitigates VT/VF/SCD and improves contractile function. Methods We used a guinea pig model that replicates key clinical aspects of human nonischemic HF, such as a prolonged QT interval, a high prevalence of spontaneous arrhythmic SCD, and profound Ca 2+ leak via a hyperactive RyR2. HF animals were randomized to receive dantrolene (DS) or placebo in early or chronic HF. We assessed the incidence of VT/VF and SCD (primary outcome), ECG heart rate and QT variability, echocardiographic left ventricular (LV) structure and function, immunohistochemical LV fibrosis, and sarcoplasmic RyR2 oxidation. Results DS treatment prevented VT/VF and SCD by decreasing dispersion of repolarization and ventricular arrhythmias. Compared to placebo, DS lowered resting heart rate, preserved chronotropic competency during transient β-adrenergic challenge, and improved heart rate variability and cardiac function. Conclusion Inhibition of RyR2 hyperactivity with dantrolene mitigates the vicious cycle of sarcoplasmic Ca 2+ leak-induced increases in diastolic Ca 2+ and ROS-mediated RyR2 oxidation, thereby increasing repolarization lability and protecting against VT/VF/SCD. Moreover, the consequent increase in sarcoplasmic Ca 2+ load improves contractile function. These potentially life-saving effects of RyR2 inhibition warrant further investigation, such as clinical studies of repurposing dantrolene as a potential new therapy for heart failure and/or SCD.
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Chung WH, Lin YN, Wu MY, Chang KC. Sympathetic Modulation in Cardiac Arrhythmias: Where We Stand and Where We Go. J Pers Med 2023; 13:jpm13050786. [PMID: 37240956 DOI: 10.3390/jpm13050786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
The nuance of autonomic cardiac control has been studied for more than 400 years, yet little is understood. This review aimed to provide a comprehensive overview of the current understanding, clinical implications, and ongoing studies of cardiac sympathetic modulation and its anti-ventricular arrhythmias' therapeutic potential. Molecular-level studies and clinical studies were reviewed to elucidate the gaps in knowledge and the possible future directions for these strategies to be translated into the clinical setting. Imbalanced sympathoexcitation and parasympathetic withdrawal destabilize cardiac electrophysiology and confer the development of ventricular arrhythmias. Therefore, the current strategy for rebalancing the autonomic system includes attenuating sympathoexcitation and increasing vagal tone. Multilevel targets of the cardiac neuraxis exist, and some have emerged as promising antiarrhythmic strategies. These interventions include pharmacological blockade, permanent cardiac sympathetic denervation, temporal cardiac sympathetic denervation, etc. The gold standard approach, however, has not been known. Although neuromodulatory strategies have been shown to be highly effective in several acute animal studies with very promising results, the individual and interspecies variation between human autonomic systems limits the progress in this young field. There is, however, still much room to refine the current neuromodulation therapy to meet the unmet need for life-threatening ventricular arrhythmias.
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Affiliation(s)
- Wei-Hsin Chung
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90024, USA
| | - Yen-Nien Lin
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - Mei-Yao Wu
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung 404333, Taiwan
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
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Cardiac Sympathetic Denervation for the Management of Ventricular Arrhythmias. J Interv Card Electrophysiol 2022; 65:813-826. [PMID: 35397706 DOI: 10.1007/s10840-022-01211-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The autonomic nervous system contributes to the pathogenesis of ventricular arrhythmias (VA). Though anti-arrhythmic drug therapy and catheter ablation are the mainstay of management of VAs, success may be limited in patients with more refractory arrhythmias. Sympathetic modulation is increasingly recognized as a valuable adjunct tool for managing VAs in patients with structural heart disease and inherited arrhythmias. RESULTS In this review, we explore the role of the sympathetic nervous system and rationale for cardiac sympathetic denervation (CSD) in VAs and provide a disease-focused review of the utility of CSD for patients both with and without structural heart disease. CONCLUSIONS We conclude that CSD is a reasonable therapeutic option for patients with VA, both with and without structural heart disease. Though not curative, many studies have demonstrated a significant reduction in the burden of VAs for the majority of patients undergoing the procedure. However, in patients with unilateral CSD and subsequent VA recurrence, complete bilateral CSD may provide long-lasting reprieve from VA.
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König S, Schröter T, Borger MA, Bertagnolli L, Nedios S, Darma A, Hindricks G, Arya A, Dinov B. Outcomes following cardiac sympathetic denervation in patients with structural heart disease and refractory ventricular arrhythmia. Europace 2022; 24:1800-1808. [DOI: 10.1093/europace/euac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
Cardiac sympathetic denervation (CSD) has been introduced as a bailout therapy in patients with structural heart disease and refractory ventricular arrhythmias (VAs), but available data are scarce. Purpose of this study was to estimate immediate results, complications, and mid-term outcomes of CSD following recurrent VA after catheter ablation.
Methods and results
Adult patients who underwent CSD in the Heart Center Leipzig from March 2017 to February 2021 were retrospectively analysed. Follow-up (FU) was executed via implantable cardioverter defibrillator (ICD) interrogation, telephone interviews, and reviewing medical records. Twenty-one patients (age 63.7 ± 14.4 years, all men, 71.4% non-ischaemic cardiomyopathy, left ventricular ejection fraction 31.6 ± 12.6%) received CSD via video-assisted thoracoscopic surgery (90.5% bilateral, 9.5% left-sided only). Indication for CSD was monomorphic ventricular tachycardia in 76.2% and ventricular fibrillation in 23.8 with 71.4% of patients presenting with electrical storm before index hospitalization. Procedure-related major complications occurred in 9.5% of patients. In-hospital adverse events not related to surgery were common (28.6%) and two patients died during the index hospital stay. During FU (mean duration 9.1 ± 6.5 months), five more patients died. Of the remaining patients, 38.5 and 76.9% were free from any VA or ICD shocks, respectively.
Conclusions
The CSD showed additional moderate efficacy to suppress VAs, when performed as a bailout therapy after previously unsuccessful catheter ablation. At 9 months, it was associated with freedom of ICD shocks in two-thirds of patients. In a population with many comorbidities, the rate of CSD-related complications was acceptable, although there was an overall high risk of procedure unrelated adverse events and death.
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Affiliation(s)
- Sebastian König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
- Leipzig Heart Institute , Leipzig , Germany
| | - Thomas Schröter
- Heart Center Leipzig at University of Leipzig, Department of Cardiac Surgery , Leipzig , Germany
| | - Michael A Borger
- Heart Center Leipzig at University of Leipzig, Department of Cardiac Surgery , Leipzig , Germany
| | - Livio Bertagnolli
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Sotirios Nedios
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Angeliki Darma
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
- Leipzig Heart Institute , Leipzig , Germany
| | - Arash Arya
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
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Brain-heart communication in health and diseases. Brain Res Bull 2022; 183:27-37. [PMID: 35217133 DOI: 10.1016/j.brainresbull.2022.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 12/19/2022]
Abstract
Tight connections between the brain and heart have attracted a considerable amount of attention. This review focuses on the anatomical (extrinsic cardiac autonomic nervous system and intrinsic cardiac autonomic nervous system) and functional (neuroendocrine-heart axis and neuroimmune-heart axis) connections between the brain and heart, the linkage between central nervous system diseases and cardiovascular diseases, the harm of sympathetic hyperactivity to the heart, and current neuromodulation therapies. Depression is a comorbidity of cardiovascular diseases, and the two are causally related. This review summarizes the mechanisms and treatment of depression and cardiovascular diseases, providing theoretical evidence for basic research and clinical studies to improve treatment options.
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Yalin K, Altinsoy M, Soysal A, Aksu T, Gopinathannair R, Braunstein E, Cheung J. Long-term Success of Partial Ganglionated Plexus Ablation in a Patient with Tachycardia-bradycardia Syndrome and Syncope: Whom and How? J Innov Card Rhythm Manag 2021; 12:4720-4725. [PMID: 34712507 PMCID: PMC8545434 DOI: 10.19102/icrm.2021.121006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Chihara RK, Chan EY, Meisenbach LM, Kim MP. Surgical Cardiac Sympathetic Denervation for Ventricular Arrhythmias: A Systematic Review. Methodist Debakey Cardiovasc J 2021; 17:24-35. [PMID: 34104317 DOI: 10.14797/qiqg9041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Ventricular arrhythmias are potentially life-threatening disorders that are commonly treated with medications, catheter ablation and implantable cardioverter defibrillator (ICD). Adult patients who continue to be symptomatic, with frequent ventricular arrhythmia cardiac events or defibrillation from ICD despite medical treatment, are a challenging subgroup to manage. Surgical cardiac sympathetic denervation has emerged as a possible treatment option for people refractory to less invasive medical options. Recent treatment guidelines have recommendedcardiac sympathectomy for ventricular tachycardia (VT) or VT/fibrillation storm refractory to antiarrhythmic medications, long QT syndrome, and catecholaminergic polymorphic VT, with much of the data pertaining to pediatric literature. However, for the adult population, the disease indications, complications, and risks of cardiac sympathectomy are less understood, as are the most effective surgical cardiac denervation techniques for this patient demographic. This systematic review navigates available literature evaluating surgical denervation disease state indications, techniques, and sympathectomy risks for medically refractory ventricular arrhythmia in the adult patient population.
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Affiliation(s)
- Ray K Chihara
- Houston Methodist Hospital, Houston, Texas.,Weill Cornell Medical College, New York, New York
| | - Edward Y Chan
- Houston Methodist Hospital, Houston, Texas.,Weill Cornell Medical College, New York, New York
| | | | - Min P Kim
- Houston Methodist Hospital, Houston, Texas.,Weill Cornell Medical College, New York, New York
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