Cardiac Sympathetic Denervation for the Management of Ventricular Arrhythmias

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.

Cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT), a rare inheritable fatal arrhythmogenic disorder, is difficult to diagnose and is a challenge to manage. A 21-years-old man presented with recurrent exertional syncope and complex multifocal ventricular ectopy. CPVT was diagnosed based on the clinical criteria, despite the absence of some classical findings. The patient underwent cardiac sympathetic denervation (CSD) after lifestyle modification and pharmacological management were ineffective. CSD proved to be effective. The patient did not have any exertional symptoms or recurrence of syncope at follow-up period of 1 year. The present case report adds to the growing evidence in favour of CSD for CPVT.

The sympathetic innervation of the heart: Important new insights

Autonomic control of the heart has a significant influence over development of life threatening arrhythmias that can lead to sudden cardiac death. Sympathetic activity is known to be upregulated during these conditions and hence the sympathetic nerves present a target for treatment. However, a better understanding of the anatomy and physiology of cardiac sympathetic nerves is required for the progression of clinical interventions. This review explores the organization of the cardiac sympathetic nerves, from the preganglionic origin to the postganglionic innervations, and provides an overview of literature surrounding anti-arrhythmic therapies including thoracic sympathectomy and dorsal spinal cord stimulation. Several features of the innervation are clear. The cardiac nerves differentially supply the nodal and myocardial tissue of the heart and are dependent on activity generated in spinal neurones in the upper thoracic cord which project to synapse with ganglion cells in the stellate complex on each side. Networks of spinal interneurones determine the pattern of activity. Groups of spinal neurones selectively target specific regions of the heart but whether they exhibit a functional selectivity has still to be elucidated. Electrical or ischemic signals can lead to remodeling of nerves in the heart or ganglia. Surgical and electrical methods are proving to be clinically beneficial in reducing atrial and ventricular arrhythmias, heart failure and severe cardiac pain. This is a rapidly developing area and we need more basic understanding of how these methods work to ensure safety and reduction of side effects.

Left cardiac sympathectomy prevents exercise-induced QTc prolongation in congenital long QT syndrome

Congenital long QT syndrome (LQTS) is a group of ion channel disorders of ventricular myocytes caused by mutations of genes that encode these ion channels. The main clinical features of LQTS are syncope, cardiac arrest and QT prolongation on body surface electrocardiogram. The present study reports on the case of a 42-year-old female patient with a 10-year history of LQTS and syncopal attacks resistant to beta-blocker therapy. Treadmill exercise testing in this patient increased the corrected QT interval (QTc) from 0.48 s to 0.54 s and reduced the amplitude of the T wave. Left cardiac sympathectomy did not affect the resting heart rate or QTc but it prevented exercise-induced T wave reduction and QTc prolongation. Therefore, sympathetic activation plays a key role in exerciseinduced QT prolongation and changes in T wave morphology in patients with congenital LQTS.