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Cardiac Sympathetic Denervation for the Management of Ventricular Arrhythmias

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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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Abbreviations

ANS:

Autonomic nervous system

CSD:

Cardiac sympathetic denervation

ICD:

Implantable cardioverter defibrillator

MI:

Myocardial ischemia

MIBG:

I-metaiodobenzylguanidine

VA:

Ventricular arrhythmia

VT:

Ventricular tachycardia

References

  1. Krul SPJ, Berger WR, Veldkamp MW, et al. Treatment of Atrial and Ventricular Arrhythmias Through Autonomic Modulation. JACC Clin Electrophysiol. 2015;1:496–508.

    Article  Google Scholar 

  2. Zipes DP, Barber MJ, Takahashi N, Gilmour RF Jr. Influence of the autonomic nervous system on the genesis of cardiac arrhythmias. Pacing Clin Electrophysiol. 1983;6:1210–20.

    Article  CAS  Google Scholar 

  3. Coumel P. Cardiac arrhythmias and the autonomic nervous system. J Cardiovasc Electrophysiol. 1993;4:338–55.

    Article  CAS  Google Scholar 

  4. Opthof T, Coronel R, Vermeulen JT, et al. Dispersion of refractoriness in normal and ischaemic canine ventricle: effects of sympathetic stimulation. Cardiovasc Res. 1993;27:1954–60.

    Article  CAS  Google Scholar 

  5. Priori SG, Mantica M, Schwartz PJ. Delayed afterdepolarizations elicited in vivo by left stellate ganglion stimulation. Circulation. 1988;78:178–85.

    Article  CAS  Google Scholar 

  6. Cao JM, Chen LS, KenKnight BH, et al. Nerve sprouting and sudden cardiac death. Circ Res. 2000;86:816–21.

    Article  CAS  Google Scholar 

  7. Cao JM, Fishbein MC, Han JB, et al. Relationship between regional cardiac hyperinnervation and ventricular arrhythmia. Circulation. 2000;101:1960–9.

    Article  CAS  Google Scholar 

  8. Yoshie K, Rajendran PS, Massoud L, et al. Cardiac TRPV1 afferent signaling promotes arrhythmogenic ventricular remodeling after myocardial infarction. JCI Insight. 2020;5(3).

  9. Wang HJ, Wang W, Cornish KG, Rozanski GJ, Zucker IH. Cardiac sympathetic afferent denervation attenuates cardiac remodeling and improves cardiovascular dysfunction in rats with heart failure. Hypertension. 2014;64:745–55.

    Article  CAS  Google Scholar 

  10. Han S, Kobayashi K, Joung B, et al. Electroanatomic remodeling of the left stellate ganglion after myocardial infarction. J Am Coll Cardiol. 2012;59:954–61.

    Article  Google Scholar 

  11. Ardell JL, Foreman RD, Armour JA, Shivkumar K. Cardiac sympathectomy and spinal cord stimulation attenuate reflex-mediated norepinephrine release during ischemia preventing ventricular fibrillation. JCI Insight. 2019;4(23).

  12. Ajijola OA, Wisco JJ, Lambert HW, et al. Extracardiac neural remodeling in humans with cardiomyopathy. Circ Arrhythm Electrophysiol. 2012;5:1010–116.

    Article  Google Scholar 

  13. Klein T, Abdulghani M, Smith M, et al. Three-dimensional 123I-meta-iodobenzylguanidine cardiac innervation maps to assess substrate and successful ablation sites for ventricular tachycardia: feasibility study for a novel paradigm of innervation imaging. Circ Arrhythm Electrophysiol. 2015;8:583–91.

    Article  Google Scholar 

  14. Ajijola OA, Hoover DB, Simerly TM, et al. Inflammation, oxidative stress, and glial cell activation characterize stellate ganglia from humans with electrical storm. JCI Insight. 2017;2(18).

  15. Ben-David J, Zipes DP. Differential response to right and left ansae subclaviae stimulation of early afterdepolarizations and ventricular tachycardia induced by cesium in dogs. Circulation. 1988;78:1241–50.

    Article  CAS  Google Scholar 

  16. Vaseghi M, Yamakawa K, Sinha A, et al. Modulation of regional dispersion of repolarization and T-peak to T-end interval by the right and left stellate ganglia. Am J Physiol Heart Circ Physiol. 2013;305:H1020-1030.

    Article  CAS  Google Scholar 

  17. Cai C, Dai MY, Tian Y, et al. Electrophysiologic effects and outcomes of sympatholysis in patients with recurrent ventricular arrhythmia and structural heart disease. J Cardiovasc Electrophysiol. 2019;30:1499–507.

    Article  Google Scholar 

  18. Wu G, DeSimone CV, Suddendorf SH, et al. Effects of stepwise denervation of the stellate ganglion: Novel insights from an acute canine study. Heart Rhythm. 2016;13:1395–401.

    Article  Google Scholar 

  19. Schwartz PJ, Snebold NG, Brown AM. Effects of unilateral cardiac sympathetic denervation on the ventricular fibrillation threshold. Am J Cardiol. 1976;37:1034–40.

    Article  CAS  Google Scholar 

  20. Dorian P. Antiarrhythmic action of beta-blockers: potential mechanisms. J Cardiovasc Pharmacol Ther. 2005;10(Suppl 1):S15-22.

    Article  CAS  Google Scholar 

  21. Meng L, Tseng CH, Shivkumar K, Ajijola O. Efficacy of Stellate Ganglion Blockade in Managing Electrical Storm: A Systematic Review. JACC Clin Electrophysiol. 2017;3:942–9.

    Article  Google Scholar 

  22. Bourke T, Vaseghi M, Michowitz Y, et al. Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121:2255–62.

    Article  Google Scholar 

  23. Assis FR, Yu DH, Zhou X, et al. Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation. Heart Rhythm. 2019;16:117–24.

    Article  Google Scholar 

  24. Yu DH, Assis FR, Lerner AD, Tandri H, Lee H. Endobronchial ultrasound-guided transtracheal cardiac plexus neuromodulation for refractory ventricular tachycardia. HeartRhythm Case Rep. 2020;6:370–4.

    Article  Google Scholar 

  25. Zhu C, Hanna P, Rajendran PS, Shivkumar K. Neuromodulation for Ventricular Tachycardia and Atrial Fibrillation: A Clinical Scenario-Based Review. JACC Clin Electrophysiol. 2019;5:881–96.

    Article  Google Scholar 

  26. Murphy DA, Johnstone DE, Armour JA. Preliminary observations on the effects of stimulation of cardiac nerves in man. Can J Physiol Pharmacol. 1985;63:649–55.

    Article  CAS  Google Scholar 

  27. Ajijola OA, Vaseghi M, Mahajan A, Shivkumar K. Bilateral cardiac sympathetic denervation: why, who and when? Expert Rev Cardiovasc Ther. 2012;10:947–9.

    Article  CAS  Google Scholar 

  28. Wilde AA, Bhuiyan ZA, Crotti L, et al. Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia. N Engl J Med. 2008;358:2024–9.

    Article  CAS  Google Scholar 

  29. Estes EH Jr, Izlar HL Jr. Recurrent ventricular tachycardia. A case successfully treated by bilateral cardiac sympathectomy. Am J Med. 1961;31:493–7.

    Google Scholar 

  30. Moss AJ, McDonald J. Unilateral cervicothoracic sympathetic ganglionectomy for the treatment of long QT interval syndrome. N Engl J Med. 1971;285:903–4.

    Article  CAS  Google Scholar 

  31. Reardon PR, Matthews BD, Scarborough TK, et al. Left thoracoscopic sympathectomy and stellate ganglionectomy for treatment of the long QT syndrome. Surg Endosc. 2000;14:86.

    CAS  Google Scholar 

  32. Tellez LJ, Garzon JC, Vinck EE, Castellanos JD. Video-assisted thoracoscopic cardiac denervation of refractory ventricular arrhythmias and electrical storms: a single-center series. J Cardiothorac Surg. 2019;14:17.

    Article  Google Scholar 

  33. Richardson T, Lugo R, Saavedra P, et al. Cardiac sympathectomy for the management of ventricular arrhythmias refractory to catheter ablation. Heart Rhythm. 2018;15:56–62.

    Article  Google Scholar 

  34. Nguyen NLT, Xue B, Bartness TJ. Sensory denervation of inguinal white fat modifies sympathetic outflow to white and brown fat in Siberian hamsters. Physiol Behav. 2018;190:28–33.

    Article  CAS  Google Scholar 

  35. Cauti FM, Rossi P, Bianchi S, et al. Outcome of a Modified Sympathicotomy for Cardiac Neuromodulation of Untreatable Ventricular Tachycardia. JACC Clin Electrophysiol. 2021;7:442–9.

    Article  Google Scholar 

  36. Wilkinson HA. Percutaneous radiofrequency upper thoracic sympathectomy. Neurosurgery. 1996;38:715–25.

    Article  CAS  Google Scholar 

  37. Bhandari AK, Scheinman MM, Morady F, et al. Efficacy of left cardiac sympathectomy in the treatment of patients with the long QT syndrome. Circulation. 1984;70:1018–23.

    Article  CAS  Google Scholar 

  38. Raskin JS, Liu JJ, Abrao A, et al. Minimally invasive posterior extrapleural thoracic sympathectomy in children with medically refractory arrhythmias. Heart Rhythm. 2016;13:1381–5.

    Article  Google Scholar 

  39. Coleman MA, Bos JM, Johnson JN, et al. Videoscopic left cardiac sympathetic denervation for patients with recurrent ventricular fibrillation/malignant ventricular arrhythmia syndromes besides congenital long-QT syndrome. Circ Arrhythm Electrophysiol. 2012;5:782–8.

    Article  Google Scholar 

  40. Schwartz PJ, Motolese M, Pollavini G, et al. Prevention of Sudden Cardiac Death After a First Myocardial Infarction by Pharmacologic or Surgical Antiadrenergic Interventions. J Cardiovasc Electrophysiol. 1992;3:2–16.

    Article  Google Scholar 

  41. Vaseghi M, Gima J, Kanaan C, et al. Cardiac sympathetic denervation in patients with refractory ventricular arrhythmias or electrical storm: intermediate and long-term follow-up. Heart Rhythm. 2014;11:360–6.

    Article  Google Scholar 

  42. Yalin K, Liosis S, Palade E, et al. Cardiac sympathetic denervation in patients with nonischemic cardiomyopathy and refractory ventricular arrhythmias: a single-center experience. Clin Res Cardiol. 2021;110:21–8.

    Article  CAS  Google Scholar 

  43. Vaseghi M, Barwad P, Malavassi Corrales FJ, et al. Cardiac Sympathetic Denervation for Refractory Ventricular Arrhythmias. J Am Coll Cardiol. 2017;69:3070–80.

    Article  Google Scholar 

  44. Romero J, Grushko M, Briceno DF, Natale A, Di Biase L. Radiofrequency Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). Curr Cardiol Rep. 2017;19:82.

    Article  Google Scholar 

  45. Te Riele AS, Ajijola OA, Shivkumar K, Tandri H. Role of Bilateral Sympathectomy in the Treatment of Refractory Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Circ Arrhythm Electrophysiol. 2016;9:e003713.

    Article  Google Scholar 

  46. Assis FR, Krishnan A, Zhou X, et al. Cardiac sympathectomy for refractory ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm. 2019;16:1003–10.

    Article  Google Scholar 

  47. Dusi V, De Ferrari GM. The sympathetic nervous system and arrhythmogenic right ventricular cardiomyopathy: Further evidence of a strong tie. Heart Rhythm. 2019;16:1011–2.

    Article  Google Scholar 

  48. Paul M, Wichter T, Kies P, et al. Cardiac sympathetic dysfunction in genotyped patients with arrhythmogenic right ventricular cardiomyopathy and risk of recurrent ventricular tachyarrhythmias. J Nucl Med. 2011;52:1559–65.

    Article  CAS  Google Scholar 

  49. Todica A, Siebermair J, Schiller J, et al. Assessment of right ventricular sympathetic dysfunction in patients with arrhythmogenic right ventricular cardiomyopathy: An (123)I-metaiodobenzylguanidine SPECT/CT study. J Nucl Cardiol. 2020;27:2402–9.

    Article  Google Scholar 

  50. Han J, Moon DH, Kim YH. Regional cardiac sympathetic denervation and systolic compression of a septal perforator branch in a sudden death survivor with hypertrophic cardiomyopathy. Clin Nucl Med. 2002;27:434–7.

    Article  Google Scholar 

  51. Johnson JN, Harris KM, Moir C, Lau YR, Ackerman MJ. Left cardiac sympathetic denervation in a pediatric patient with hypertrophic cardiomyopathy and recurrent ventricular fibrillation. Heart Rhythm. 2011;8:1591–4.

    Article  Google Scholar 

  52. Price J, Mah DY, Fynn-Thompson FL, Tsirka AE. Successful bilateral thoracoscopic sympathectomy for recurrent ventricular arrhythmia in a pediatric patient with hypertrophic cardiomyopathy. HeartRhythm Case Rep. 2020;6:23–6.

    Article  Google Scholar 

  53. Gutierrez O, Garita E, Salazar C. Autonomic nervous system and preventive treatment of ventricular arrhythmias in chagasic disease. Int J Cardiol. 2009;137:291–2.

    Article  Google Scholar 

  54. Simoes MV, Pintya AO, Bromberg-Marin G, et al. Relation of regional sympathetic denervation and myocardial perfusion disturbance to wall motion impairment in Chagas’ cardiomyopathy. Am J Cardiol. 2000;86:975–81.

    Article  CAS  Google Scholar 

  55. Miranda CH, Figueiredo AB, Maciel BC, Marin-Neto JA, Simoes MV. Sustained ventricular tachycardia is associated with regional myocardial sympathetic denervation assessed with 123I-metaiodobenzylguanidine in chronic Chagas cardiomyopathy. J Nucl Med. 2011;52:504–10.

    Article  CAS  Google Scholar 

  56. Saenz LC, Corrales FM, Bautista W, et al. Cardiac sympathetic denervation for intractable ventricular arrhythmias in Chagas disease. Heart Rhythm. 2016;13:1388–94.

    Article  Google Scholar 

  57. Matsuo S, Nakamura Y, Matsui T, Matsumoto T, Kinoshita M. Detection of denervated but viable myocardium in cardiac sarcoidosis with I-123 MIBG and Tl-201 SPECT imaging. Ann Nucl Med. 2001;15:373–5.

    Article  CAS  Google Scholar 

  58. Okada DR, Assis FR, Gilotra NA, et al. Cardiac sympathectomy for refractory ventricular arrhythmias in cardiac sarcoidosis. Heart Rhythm. 2019;16:1408–13.

    Article  Google Scholar 

  59. Goldenberg I, Zareba W, Moss AJ. Long QT Syndrome. Curr Probl Cardiol. 2008;33:629–94.

    Article  Google Scholar 

  60. Yanowitz F, Preston JB, Abildskov JA. Functional distribution of right and left stellate innervation to the ventricles. Production of neurogenic electrocardiographic changes by unilateral alteration of sympathetic tone. Circ Res. 1966;18:416–28.

    Article  CAS  Google Scholar 

  61. Schwartz PJ, Locati EH, Moss AJ, et al. Left cardiac sympathetic denervation in the therapy of congenital long QT syndrome. A worldwide report Circulation. 1991;84:503–11.

    CAS  Google Scholar 

  62. Schwartz PJ, Priori SG, Cerrone M, et al. Left cardiac sympathetic denervation in the management of high-risk patients affected by the long-QT syndrome. Circulation. 2004;109:1826–33.

    Article  Google Scholar 

  63. Li J, Liu Y, Yang F, et al. Video-assisted thoracoscopic left cardiac sympathetic denervation: a reliable minimally invasive approach for congenital long-QT syndrome. Ann Thorac Surg. 2008;86:1955–8.

    Article  Google Scholar 

  64. OldeNordkamp LR, Driessen AH, Odero A, et al. Left cardiac sympathetic denervation in the Netherlands for the treatment of inherited arrhythmia syndromes. Neth Heart J. 2014;22:160–6.

    Article  CAS  Google Scholar 

  65. Surman TL, Stuklis RG, Chan JC. Thoracoscopic Sympathectomy for Long QT Syndrome. Literature Review and Case Study. Heart Lung Circ. 2019;28:486–94.

    Article  Google Scholar 

  66. Turley AJ, Thambyrajah J, Harcombe AA. Bilateral thoracoscopic cervical sympathectomy for the treatment of recurrent polymorphic ventricular tachycardia. Heart. 2005;91:15–7.

    Article  CAS  Google Scholar 

  67. Bos JM, Bos KM, Johnson JN, Moir C, Ackerman MJ. Left cardiac sympathetic denervation in long QT syndrome: analysis of therapeutic nonresponders. Circ Arrhythm Electrophysiol. 2013;6:705–11.

    Article  Google Scholar 

  68. Reid DS, Tynan M, Braidwood L, Fitzgerald GR. Bidirectional tachycardia in a child. A study using His bundle electrography. Br Heart J. 1975;37:339–44.

    Article  CAS  Google Scholar 

  69. De Ferrari GM, Dusi V, Spazzolini C, et al. Clinical Management of Catecholaminergic Polymorphic Ventricular Tachycardia: The Role of Left Cardiac Sympathetic Denervation. Circulation. 2015;131:2185–93.

    Article  Google Scholar 

  70. Okajima K, Kiuchi K, Yokoi K, et al. Efficacy of bilateral thoracoscopic sympathectomy in a patient with catecholaminergic polymorphic ventricular tachycardia. J Arrhythm. 2016;32:62–6.

    Article  Google Scholar 

  71. Assis FR, Sharma A, Shah R, et al. Long-Term Outcomes of Bilateral Cardiac Sympathetic Denervation for Refractory Ventricular Tachycardia. JACC Clin Electrophysiol. 2021;7:463–70.

    Article  Google Scholar 

  72. Assis FR, Camm CF, Te Riele A, et al. Nocturnal Premature Ventricular Contraction Burden as a Marker of Disease Severity in Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol. 2017;3:1607–8.

    Article  Google Scholar 

  73. Chung IH, Oh CS, Koh KS, et al. Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy. J Thorac Cardiovasc Surg. 2002;123:498–501.

    Article  Google Scholar 

  74. Pardini BJ, Lund DD, Schmid PG. Organization of the sympathetic postganglionic innervation of the rat heart. J Auton Nerv Syst. 1989;28:193–201.

    Article  CAS  Google Scholar 

  75. Vaseghi M, Shivkumar K. The role of the autonomic nervous system in sudden cardiac death. Prog Cardiovasc Dis. 2008;50:404–19.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA

    Stephanie M. Kochav, Hasan Garan, Elaine Y. Wan & Hirad Yarmohammadi

  2. Department of Surgery, New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA

    Lyall A. Gorenstein

  3. Cardiology and Cardiac Electrophysiology, Columbia University, 177 Fort Washington Avenue New York, New York, NY, 10032, USA

    Hirad Yarmohammadi

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  1. Stephanie M. Kochav
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Correspondence to Hirad Yarmohammadi.

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Kochav, S.M., Garan, H., Gorenstein, L.A. et al. Cardiac Sympathetic Denervation for the Management of Ventricular Arrhythmias. J Interv Card Electrophysiol 65, 813–826 (2022). https://doi.org/10.1007/s10840-022-01211-2

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