The treatment of recurrent ventricular tachycardia with bilateral cervico-thoracic sympathetic-ganglionectomy. A report of two cases

Bilateral Cardiac Sympathetic Denervation for Treatment-Resistant Ventricular Arrhythmias in Heart Failure Patients with a Reduced Ejection Fraction

The sympathetic nervous system plays an important role in life-threatening ventricular arrhythmias (VAs). Bilateral cardiac sympathetic denervation (BCSD) is performed for refractory VAs. We sought to assess our institutional experience with BCSD in managing treatment-resistant monomorphic ventricular tachycardia (MMVT) in heart failure patients with a reduced ejection fraction (HFrEF).Four patients with HFrEF (EF 30.0 ± 8.2%, New York Heart Association [NYHA] class IV 1) underwent BCSD for MMVT (VT storm 3, repetitive VT requiring implantable cardioverter defibrillator [ICD] therapy 1) refractory to antiarrhythmic drugs, catheter ablation and ICD therapy. BCSD was effective for suppressing VT in 3 patients for whom deep sedation was effective for suppressing VT. One patient remained alive after 14 months of follow-up without episodes of VT. One patient died of acute myocardial infarction before discharge and 1 patient died from unknown cause at 3 days post-discharge. In contrast, BCSD was completely ineffective for suppressing VT in a patient with NYHA class IV for whom deep sedation and stellate ganglion block were ineffective. This patient died on the 10th post-CSD day, despite left ventricular assist device implantation. In all cases, BCSD was successfully performed without procedure-related complications.Despite the limited number of cases, our results showed that BCSD in patients with HFrEF suppressed refractory MMVT in acute-phase except for a patient with NYHA class IV; however, the prognoses were not good. BCSD may be a treatment option at an earlier stage of NYHA and a bridge to orthotopic heart transplantation, even if BCSD is effective for suppressing VAs.

Thoracic Epidural Anesthesia Can Be Effective for the Short-Term Management of Ventricular Tachycardia Storm

Background

Novel therapies aimed at modulating the autonomic nervous system, including thoracic epidural anesthesia (TEA), have been shown in small case series to be beneficial in treating medically refractory ventricular tachycardia (VT) storm. However, it is not clear when these options should be considered. We reviewed a multicenter experience with TEA in the management of VT storm to determine its optimal therapeutic use.

Methods and Results

Data for 11 patients in whom TEA was instituted for VT storm between July 2005 and March 2016 were reviewed to determine the clinical characteristics, outcomes, and role in management. The clinical presentation was incessant VT in 7 (64%), with polymorphic VT in 3 (27%) and monomorphic VT in 8 (73%). The underlying conditions were nonischemic cardiomyopathy in 5 (45%), ischemic cardiomyopathy in 3 (27%), and hypertrophic cardiomyopathy, Brugada syndrome, and cardiac lipoma in 1 (9%) each. Five (45%) had a complete and 1 (9%) had a partial response to TEA; 4 of the complete responders had incessant VT. All 4 patients with a documented response to deep sedation demonstrated a complete response to TEA.

Conclusions

More than half of the patients with VT storm in our series responded to TEA. TEA may be effective and should be considered as a therapeutic option in patients with VT storm, especially incessant VT, who are refractory to initial management. Improvement in VT burden with deep sedation may suggest that sympathoexcitation plays a key role in perpetuating VT and predict a positive response to TEA.

Stellate ganglion blockade for the treatment of refractory ventricular arrhythmias: A systematic review and meta-analysis

INTRODUCTION

Treatment refractory ventricular arrhythmias (VAs) are often driven and exacerbated by heightened sympathetic tone. We aim to conduct a systematic review and meta-analysis of published studies of a temporary percutaneous stellate ganglion block (SGB) on VA burden and defibrillation episodes in patients with treatment refractory VAs.

METHODS

Relevant studies from January 1960 through May 2017 were identified in PubMed and Google Scholar. We performed a patient-level analysis using Student's t-test to compare outcomes before and after SGB.

RESULTS

We identified 22 unique case series with a total of 35 patients. Patients were 57 ± 17 years old and 69% were males with a high burden of VA. A unilateral (left)-sided SGB was used in 85.7% (30 of 35) of cases and the remaining were bilateral SGB. The use of a unilateral or bilateral SGB resulted in a significant reduction of VA episodes (24-hours pre: mean 16.5 [CI 9.7-23.1] events vs. post: mean 1.4 [CI 0.85-2.01] events; P = 0.0002) and need for defibrillation (24-hours pre: mean 14.2 [CI 6.8-21.6] vs. post: mean 0.6 [CI 0.3-0.9]; P = 0.0026). Furthermore, SGB was significantly associated with a reduction of VA burden regardless of etiology of cardiomyopathy, type of ventricular rhythm, and degree of contractile dysfunction. SGB was followed by surgical sympathectomy in 21% of cases.

CONCLUSIONS

Early experience suggests that SGB is associated with an acute reduction in the VA burden and offers potential promise for a broader use in high-risk populations. Randomized controlled studies are needed to confirm the safety and efficacy of this therapy.

Clinical neurocardiology defining the value of neuroscience-based cardiovascular therapeutics

The autonomic nervous system regulates all aspects of normal cardiac function, and is recognized to play a critical role in the pathophysiology of many cardiovascular diseases. As such, the value of neuroscience-based cardiovascular therapeutics is increasingly evident. This White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology, pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases.

Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up

BACKGROUND

Left and bilateral cardiac sympathetic denervation (CSD) have been shown to reduce burden of ventricular arrhythmias acutely in a small number of patients with ventricular tachyarrhythmia (VT) storm. The effects of this procedure beyond the acute setting are unknown.

OBJECTIVE

The purpose of this study was to evaluate the intermediate and long-term effects of left and bilateral CSD in patients with cardiomyopathy and refractory VT or VT storm.

METHODS

Retrospective analysis of medical records for patients who underwent either left or bilateral CSD for VT storm or refractory VT between April 2009 and December 2012 was performed.

RESULTS

Forty-one patients underwent CSD (14 left CSD, 27 bilateral CSD). There was a significant reduction in the burden of implantable cardioverter-defibrillator (ICD) shocks during follow-up compared to the 12 months before the procedure. The number of ICD shocks was reduced from a mean of 19.6 ± 19 preprocedure to 2.3 ± 2.9 postprocedure (P < .001), with 90% of patients experiencing a reduction in ICD shocks. At mean follow-up of 367 ± 251 days postprocedure, survival free of ICD shock was 30% in the left CSD group and 48% in the bilateral CSD group. Shock-free survival was greater in the bilateral group than in the left CSD group (P = .04).

CONCLUSION

In patients with VT storm, bilateral CSD is more beneficial than left CSD. The beneficial effects of bilateral CSD extend beyond the acute postsympathectomy period, with continued freedom from ICD shocks in 48% of patients and a significant reduction in ICD shocks in 90% of patients.

Left thorascopic sympathectomy for refractory long QT syndrome in children

Congenital long QT syndrome (LQTS) is a rare genetic ion transmembrane disorder that has been associated with multiple various genetic mutations including life-threatening cardiac arrhythmias and sudden death. Left thorascopic sympathectomy is an effective treatment for patients who are refractory to medical therapy or who need frequent epicardial internal cardiodefibrillator intervention. Although there is substantial literature about this therapy in adults, few reports detail the outcomes in children who undergo left thorascopic sympathectomies to treat LQTS. The authors report the successful use of a left thoracic sympathectomy for the treatment of an 11-year-old girl who had persistently symptomatic LQTS, even after implantation of an automatic cardioverter-defibrillator. The patient remained clinically stable without arrhythmias through 6 months' of follow-up. The authors also reviewed the relevant literature and found that it suggests that 77% of patients will have immediate resolution of their symptoms/arrhythmias after the procedure. When the outcome definition was broadened to include patients who had only 1 or 2 cardiac episodes in the follow-up period, 88% of cases were considered successful. The results of this case study and literature review suggest that left thorascopic sympathectomy is a safe and effective approach for treating pediatric patients with LQTS.

Effects of bilateral stellate ganglion block on autonomic cardiovascular regulation

BACKGROUND

Stellate ganglion block (SGB) is performed for the diagnosis and treatment of sympathetic dependent pain in the head, neck and upper limbs. However, the effects of bilateral SGB on cardiovascular and autonomic regulation remain unknown. The aim of this study was to assess the effects of bilateral SGB on cardiovascular and autonomic function by measuring heart rate variability (HRV), systolic blood pressure variability (SBPV) and spontaneous baroreflex sensitivity (SBRS).

METHODS AND RESULTS

Twenty healthy volunteers were randomly allocated to receive right or left SGB with 8 ml 1% lidocaine solution; after 20 min, the contralateral side SGB was performed. Changes in the RR interval (RRI), systolic blood pressure (SBP), HRV, SBPV and SBRS were assessed before and after bilateral SGB. The low-frequency (LF, 0.04-0.15 Hz) and high-frequency (HF, 0.15-0.4 Hz) components of HRV and SBRS decreased significantly; however, no significant changes were found in RRI, SBP and the LF and HF components of SBPV after bilateral SGB. In subjects with symptoms of vagal blockade, HRV, SBP and SBRS were significantly affected by bilateral SGB.

CONCLUSIONS

Bilateral SGB should be performed cautiously because it can reduce cardiac vagal modulation and BRS, especially for those with symptoms of vagal blockade after bilateral SGB.

Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans

BACKGROUND

Upper thoracic sympathectomy is used to treat several disorders. Sympathetic nerve fibers emanating from thoracic ganglia innervate the heart. Whether unilateral or bilateral upper thoracic sympathectomy affects cardiac sympathetic innervation in humans in vivo has been unclear.

OBJECTIVES

The purpose of this study was to assess whether thoracic sympathectomy decreases cardiac sympathetic innervation, as indicated by positron emission tomographic scanning after intravenous injection of the sympathoneural imaging agent 6-[18F]fluorodopamine.

METHODS

Nine patients with previous upper thoracic sympathectomies (four right-sided, one left-sided, four bilateral) underwent thoracic 6-[18F]fluorodopamine scanning between 1 and 2 hours after injection of the imaging agent. In each case, a low rate of entry of norepinephrine into the arm venous drainage (norepinephrine spillover) verified upper limb sympathectomy. Data were compared with those from the interventricular septum of patients with cardiac sympathetic denervation associated with pure autonomic failure and from normal volunteers.

RESULTS

All four patients with bilateral sympathectomy had low septal myocardial 6-[18F]fluorodopamine-derived radioactivity (2,673 +/- 92 nCi-kg/cc-mCi at an average of 89 minutes after injection) compared with normal volunteers (3,634 +/- 311 nCi-kg/cc-mCi at 83 minutes, N = 22, P = .007) and higher radioactivity than in patients with pure autonomic failure (1,320 +/- 300 nCi-kg/cc-mCi at 83 minutes, N = 7, P = .003). Patients with unilateral sympathectomy had normal 6-[18F]fluorodopamine-derived radioactivity (3,971 +/- 337 nCi-kg/cc-mCi at 87 minutes).

CONCLUSIONS

Bilateral upper thoracic sympathectomy partly decreases cardiac sympathetic innervation density.

Bilateral thoracoscopic cervical sympathectomy for the treatment of recurrent polymorphic ventricular tachycardia

Congenital long QT syndrome (LQTS) is a disorder of prolonged cardiac repolarisation, manifest by a prolonged QT interval and characterised by recurrent presyncope/syncope, polymorphic ventricular tachycardia (PMVT), or sudden cardiac death. A 46 year old woman with no family history of sudden death or deafness presented with recurrent syncope. Physical examination and electrolytes were normal and a 12 lead ECG showed a corrected QT interval of 458 ms. A monitored syncopal episode documented PMVT. Despite potassium and magnesium supplements, beta blockade, implantation of a single then dual chamber implantable cardioverter defibrillator (ICD), amiodarone, nicorandil, and mexiletine, the patient continued to experience arrhythmia storms, receiving more than 700 ICD discharges over seven months. She was ultimately treated successfully with bilateral thoracoscopic cervicothoracic sympathectomies. This is the first reported bilateral thoracoscopic treatment of a patient with LQTS and symptomatic life threatening ventricular tachyarrhythmias refractory to current pharmacological and pacing techniques.

Long reflections on the QT interval: the sixth annual Gordon K. Moe Lecture

This review of accumulated knowledge about the long QT syndromes begins with an iteration of the original papers and then proceeds to a broader historic reflection that includes my personal work as well as many studies by others. Next come reflections upon the current status of knowledge on the subject, combined with comments about remaining challenges and questions grouped as follows: (1) morphologic abnormalities of the cardiac conduction system and their pathophysiologic significance in the long QT syndromes; (2) cardioneuropathy in the pathogenesis of long QT syndromes; (3) variability of QT prolongation, including consideration of peripheral and central dysautonomic conditions with certain diagnostic and therapeutic implications; (4) some caveats about the popular use of left cervical sympathectomy to treat symptomatic individuals with long QT syndrome, emphasizing hazards for future electrical instability of the heart; (5) consideration of genetic influences in the long QT syndromes, a field holding great promise as well as fraught with many puzzling dilemmas; and (6) apoptosis and the pathogenesis of the long QT syndromes, based upon personal observations previously made with electron microscopic studies of the sinus node and now including new immunohistochemical evidence expanding the relevance of this novel view-point. These intentionally provocative presentations are made to stimulate physicians and other scientists to consider these several different perspectives in planning future studies aimed at better understanding of one of the most challenging medical entities facing cardiology today.

Clinical assessment of adrenergic tone and responsiveness to beta-blocker therapy in patients with symptomatic ventricular tachycardia and no apparent structural heart disease

To further define the relation between changing adrenergic tone, beta-blocker therapy, and clinical ventricular tachycardia (VT), we evaluated these factors in 35 patients with VT unrelated to coronary artery disease or ventricular dysfunction. Testing included Holter monitoring (91% had VT), exercise test (69% had VT), Adrenergic responsiveness of VT was graded according to diurnal variation, response to exercise, isoproterenol infusion, and response to beta-blockers. beta-Blockers were effective and well tolerated in this population. There was also a predictable relation between changing adrenergic tone and the arrhythmia response to beta-blocker therapy.

Sympathectomy in the treatment of angina and arrhythmias

Sympathectomy has been used as treatment for several different cardiac conditions. These include classic angina pectoris, Prinzmetal's angina, paroxysmal atrial tachycardia, ventricular tachycardia, and long QT syndrome. To understand the rationale of such treatment, the innervation of the human heart is reviewed with discussion of the cardiac plexus and coronary innervation. Results in published studies are summarized and discussed.

When is myocardial mapping clinically valuable?

All cardiac arrhythmias are either automatic or reentrant. Automatic arrhythmias occur in the periinfarction or perioperative period. Chronic, recurrent arrhythmias are typically reentrant. By definition, reentrant arrhythmias are inducible with programmed electrical stimulation. When a malignant cardiac arrhythmia is identified, the patient is taken to the electrophysiologic laboratory for study. Reentrant ventricular tachyarrhythmias are induced with programmed electrical stimulation. Pharmacologic suppression is guided by electrophysiologic testing. When antiarrhythmic suppression fails, surgical intervention may be an effective alternative. Endocardial catheter mapping before surgery may serve as an important guide to the surgeon. Myocardial mapping is clinically valuable only when all antiarrhythmic therapy has failed, and the patient is considered to be a candidate for surgical intervention. When surgical intervention is planned, we consider preoperative catheter mapping desirable and intraoperative electrophysiologic localization mandatory.

The long QT syndrome; effects of drugs and left stellate ganglion block

Four patients, two with congenital QT prolongation (Romano-Ward syndrome) and two with acquired idiopathic QT prolongation not related to bradycardia, drug toxicity, electrolyte imbalance, or neurological disorder were investigated for the onset of recurrent palpitations and/or syncope. The effects on the measured QT interval of intravenously administered propranolol (QTp), an infusion of isoproterenol (QTi) and left stellate ganglion block (QTs) were assessed at identical atrial paced rates and during sinus rhythm, corrected for rate change (QTc). Propranolol shortened the QTc in all patients. The QTp shortened only in those with congenital QT prolongation. Isoproterenol lengthened the QTc in the three patients studied. However, the QTi lengthened in the congenital syndrome whereas it shortened in the acquired syndrome. The QTs was uninfluenced by left stellate ganglion block in all patients. It is suggested that the congenital and acquired forms can be differentiated by pharmacological interventions and that the efficacy of propranolol in the former may result from its ability not only to increase the threshold for ventricular fibrillation, but also its ability to shorten the QT interval.

Electrocardiographic changes induced by the stellate ganglion block in normal subjects

In order to examine the laterality of the sympathetic control of the human heart, electrocardiographic changes induced by a unilateral stellate ganglion block (SGB) were observed. 10ml of 1% lidocaine was used for the block and post-block ECG was recorded just after the appearance of Horner's sign. Patients who developed vocal hoarseness were excluded. 15 recordings of 14 subjects with right SGB and 16 recordings of 12 subjects with left SGB were used for analysis. A significant increase in the P-P interval from 0.90 +/- 0.17 sec to 0.96 +/- 0.16 sec. was observed only with right SGB and the predominance of the right side in the sympathetic nervous control of the human heart was thus demonstrated. The atrioventricular conduction time was not affected by either the right or left SGB. The QTc was slightly but significantly prolonged only by the right SGB, from 0.40 +/- 0.04 sec. to 0.43 +/- 0.04 sec. This prolongation was not large enough to support a definite conclusion and further investigations should be made.

The surgical treatment of ventricular tachycardia

Recurrent ventricular tachycardia is a well-recognized complication of ischemic heart disease. Coronary bypass operation with or without aneurysmectomy has been disappointing as therapy for these arrhythmias. With the advent of programmed electrical stimulation, it has become possible to distinguish automatic and reentrant ventricular tachyarrhythmias. The latter have recently proved amenable to operative intervention. This review examines the pathophysiology and diagnosis of ventricular tachycardia using programmed electrical stimulation. Surgical therapy with resection, revascularization, autonomic modulation, thermal ablation, cardiac pacing, reentrant circuit interruption, and endocardial excision is explored. Operation for cardiac arrhythmias is on a firm electrophysiological foundation. Surgical treatment of refractory ventricular tachyarrhythmias is now rational, recommended, and rewarding.

Catecholamine induced double tachycardia: case report in a child

A six-year-old girl with syncope in association with atrial flutter-fibrillation and ventricular tachycardia produced by exercise or emotion is presented. The tachycardias could be reproduced by low-dose isoproterenol infusion and were blocked by high dose propranolol therapy. Catecholamine-induced tachyarrhythmias should be suspected in children with unexplained syncope in association with exercise or emotion.

Surgical treatment of arrhythmias: current status and future directions

A variety of surgical interventions have evolved for the treatment of intractable or life-threatening arrhythmias unresponsive to conventional pharmacologic or pacemaker therapy. Supraventricular arrhythmias associated with rapid ventricular responses can be indirectly treated with ablation of the atrioventricular conduction system and insertion of a pacemaker. Ventricular tachyarrhythmias have previously been treated with sympathectomy, resection of tissue or revascularization. More recent approaches include the simple ventriculotomy, encircling endocardial ventriculotomy, cryosurgical ablation and insertion of the automatic implantable defibrillator. Refinement of methods to localize more precisely the origin of ventricular arrhythmias may allow design of more direct surgical procedures. The surgical treatment of arrhythmias related to the preexcitation syndromes remains the model of electrophysiologic surgery. It is now feasible to divide accessory pathways with a high degree of success and at low risk in selected patients.

Effect of electroconvulsive therapy on cardiac rhythm, conduction and repolarization

Because sympathetic stimulation has been implicated in the genesis of arrhythmias, we studied the effects on arrhythmias of electroconvulsive therapy (ECT). Fifteen psychiatric patients (male: 8, female: 7, age: 19-51, mean: 29.8) without known heart disease underwent 24-hout Holter recordings before, during, and after ECT (25 episodes). All patients were taking psychotropic drugs and received atropine (0.4-1.2 mg, mean: 1.1 mg IV), methohexital, and succinylcholine prior to ECT. Following ECT, mean maximum heart rate increased (106 +/- 3.2 to 142 +/- 6.0 beats/min, p less than .001), PR interval decreased (149 +/- 3.3 to 131 +/- 3.7 msec, p less than .001) and QTc interval increased (132 +/- 6.5 to 454 +/- 9.7 msec, p less than .001) compared to values obtained after atropine administration. Mean PVC or PAC frequently immediately after ECT or per 24 hours did not change significantly (PVC per 24 hours 6.8 +/- 3.2 to 10.4 +/- 6.4, NS; PAC per 24 hours 0.4 +/- 0.3 to 0.3 +/- 0.2, NS) and no complex arrhythmias were noted. Rate and PR changes suggest adrenergic effects of ECT and QTc increase may be due to imbalanced sympathetic discharge. Autonomic stimulation produced by ECT did not induce arrhythmias in these patients without heart disease. The possible antiarrhythmic role of psychotropic agents or premedication is unknown.

Cardiac pacing and pacemakers II. Serial electrophysiologic-pharmacologic testing for control of recurrent tachyarrhythmias

The place of pacemakers in the treatment of tachyarrhythmias has expanded far beyond the initial role in the brady-tachy syndrome, of providing a "minimum guaranteed rate" while medications suppress the tachycardia. Techniques have been developed for prevention, termination, and duplication of a patient's spontaneous tachycardia under safe catheterization laboratory conditions. Combined with accumulating information about the normal responses to electrophysiologic stresses, these techniques have led to a new dimension in arrhythmia control. Most tachycardias previously felt to be refractory can be controlled after serial electrophysiologic-pharmacologic testing, during which sequential pharmacologic and pacer regimens are tested until a combination is found which prevents induction of tachycardias, and/or a pace mode is found which reliably terminates the tachycardia. Use of such an approach reduces hospital admissions and referral for surgery, and eliminates prolonged hospitalization for assessment of therapy in patients with infrequent but potentially lethal spontaneous tachycardias.

Sympathetic denervation in association with coronary artery grafting in patients with Prinzmetals' angina

Myocardial revascularization in patients with Prinzmetal's angina has yielded variable results. Two patients are presented who underwent partial cardiac sympathectomy in combination with coronary artery grafting for typical variant angina associated with severe organic obstructive coronary artery disease. Late results 12 and 18 months postoperatively have been excellent in both instances as shown by clinical and angiographic evaluation. Although the exact mechanism responsible for Prinzmetal's angina is not known, it is believed that spasm through increased activity of vasomotor tone or of the autonomic nervous system plays a major role. Since this variant form of angina encompasses a whole spectrum at angiography, ranging from normal arteries to severely narrowed ones, including those with spasm, it is suggested that surgical treatment be planned accordingly. Thus, in patients who have organic stenoses with and without spasm, operative treatment may consist of removal of the preaortic or pretracheal plexus in association with conventional coronary artery grafting. In patients who have intractable episodes of ventricular arrhythmia or angina and who angiogram is normal or shows isolated spasm, coronary artery grafting should be abandoned, in view of the poor results reported in the literature in these circumstances, and cervicothoracic sympathectomy should be considered.