Dr. Ricardo Buitrago, Thoracic Surgeon
Dr. Andres Franco, Thoracic Surgeon
K. Eckland, Nurse Practitioner
Clinica Shaio
Bogota, Colombia
Left cardiac sympathetic denervation for uncontrolled ventricular arrhythmias in a young child
Case History: The patient, a 9-year-old Hispanic female child had a history of congenital long QT syndrome*, and had her first AICD (automated internal cardiac defibrillator) placed at two months of age, after receiving the initial diagnosis as a neonate.
After several years and multiple medical regimens were unsuccessful in controlling frequent episodes of ventricular tachycardia, the patient had undergone several additional procedures aimed at reducing the incidence of arrhythmia. The device had been checked thoroughly, evaluated and exchanged twice as part of on-going evaluation to ensure that the device was working properly, and was set at appropriate thresholds.
At the time of the initial referral to thoracic surgery, the child suffered from intense post-traumatic stress disorder symptoms and was being treated for psychiatric disturbances that were believed to be related to the extreme fear and stress related to frequent defibrillations delivered by her device. As a final resort, the department of electrophysiology requested evaluation for Video assisted thoracoscopic (VATS) sympathectomy for cardiac denervation.
Procedure: left cardiac sympathetic denervation by uniport VATS
After the patient is anesthetized and intubated with a double lumen endotracheal tube, a single anterior thoracic 10 mm port incision is made in the 5th intercostal space of the left chest without rib spreading. A 10mm port is inserted, for camera access to the interior of the chest. The left lung is deflated for easy identification and access to the sympathetic nerves at the T2 – T4 level on the chest wall. After successful identification, the nerves were cauterised. The lung was reinflated, and surgical instruments removed. Chest incision was closed with several layers of suture. The patient was awakened, extubated and transferred to the PACU.
In addition to the standard intra-operative hemodynamic and telemetry monitoring, an electrophysiology cardiologist was present during the case to monitor and treat the patient, if necessary.
Following surgery, the patient was transferred to the post-anesthesesia care unit (recovery room). Following an uneventful recovery, she was discharged home. At follow-up surgical visit, her incision was well-healed and family reported no further discharges from her AICD.
At six months, post surgery, the patient has had no further cardiac events or ventricular arrhythmias reported or recorded by her device.
Discussion
The cardiovascular effects of sympathectomy have been well-known and described in the medical literature since the early 20th century. However, limitations in surgical technique prior to the advent of thoracoscopic surgery as well as the potential side effects of sympathectomy procedures have limited the use and research into this technique for the treatment of cardiac conditions.
In recent years, researchers at the David Geffen School of Medicine at the UCLA Cardiac Arrhythmia Center (Ajijola et. al) have published several papers about their experiences treating patients with persistant ventricular arrhythmias. In their work, which is one of the largest studies to date, the authors report their experiences with both selective left-sided cardiac sympathetic denervation (LCSD) alone or bilateral cardiac sympathetic denervation (BCSD) as a last-ditch treatment for persistent ventricular arrhythmias. Many of their patients have previously undergone multiple ablation therapies and/or evaluation for cardiac transplantation.
On-going research and clinical trials
Their results have been so promising, in fact, that they have now made cardiac denervation a routine procedure at UCLA and have designed an international multi-center trial called PREVENT VT to study this procedure in a larger group of patients. Since the publication of their initial work, Aijiola et al. have continued their study, with over 40 cases under their belt. Dr. Kalyanam Shivkumar, MD, PhD, Director, UCLA Cardiac Arrhythmia Center & EP Programs reports that they will be presenting their surgical outcomes at an upcoming conference, the Heart Rhythm Meeting at Denver in May of 2013 (Vaseghi et al Cervicothoracic Sympathectomy In Patients With Refractory Vt: Intermediate And Long Term Follow Up).
Contact information for Dr. Kalyanam Shivkumar:
Kalyanam Shivkumar MD PhD
Professor of Medicine & Radiology
Director, UCLA Cardiac Arrhythmia Center & EP Programs
Co-director, Center for Neurobiology of Stress
UCLA Health System
100 UCLA Medical Plaza, Suite # 660
Los Angeles, CA 90095
Ph: 310 206 6433
Fax: 310 794 6492
Definition of persistent ventricular arrhythmias
For both their work, and the purposes of this post, persistent ventricular arrhythmias were defined as repeated episodes of ventricular tachycardia or ventricular fibrillation despite maximal medical therapy with a beta blocker and amiodarone**. (In a related article, Ajijola et al. further define which patients are the best candidates for successful outcomes with this procedure.) In their work, the researchers at UCLA were able to show increased effectiveness with the use of bilateral sympathetomy versus left-sided only.
However, the use of left-sided versus bilateral sympathectomy is also determined by the type of arrhythmia (monomorphic versus polymorphic) as well as previous patient history and medical treatments such as catheter based ablations or extensive scar tissue formation from previous cardiac injury.
Given the high morbidity, mortality and adverse effects on the quality of life for people with uncontrolled ventricular arrhythmias as well as the relative low risk, and ease of VATS procedures to treat this condition, cardiac sympathetic denervation should remain an important clinical tool in the treatment of this life-threatening condition, particularly when other treatments have failed.
*Patients with this condition are at very high risk of sudden cardiac risk.
**In the addition to implanted or external defibrillatory devices.
References and Resources
Ajijola OA, Lellouche N, Bourke T, Tung R, Ahn S, Mahajan A, Shivkumar K. (2012). Bilateral cardiac sympathetic denervation for the management of electrical storm. J Am Coll Cardiol. 2012 Jan 3;59(1):91-2. doi: 10.1016/j.jacc.2011.09.043
Ajijola OA, Vaseghi M, Mahajan A, Shivkumar K. (2012). Bilateral cardiac sympathetic denervation: why, who and when? Expert Rev Cardiovasc Ther. 2012 Aug;10(8):947-9. doi: 10.1586/erc.12.93
Bourke T, Vaseghi M, Michowitz Y, Sankhla V, Shah M, Swapna N, et al. (2010). Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation. Circulation. 2010;121:2255–2262.
Kenyon CA, Flick R, Moir C, Ackerman MJ, Pabelick CM. (2010). Anesthesia for videoscopic left cardiac sympathetic denervation in children with congenital long QT syndrome and catecholaminergic polymorphic ventricular tachycardia–a case series. Anaesth. 2010 May;20(5):465-70. doi: 10.1111/j.1460-9592.2010.03293.x. Epub 2010 Mar 22. The authors, a group of anesthesiologists at Mayo Clinic talk about their intra-operative experiences in cases similar to ours.
Schwartz PJ, Priori SG, Cerrone M, Spazzolini C, Odero A, Napolitano C, Bloise R, De Ferrari GM, Klersy C, Moss AJ, Zareba W, Robinson JL, Hall WJ, Brink PA, Toivonen L, Epstein AE, Li C, Hu D. (2004). Left cardiac sympathetic denervation in the management of high-risk patients affected by the long-QT syndrome. Circulation. 2004 Apr 20;109(15):1826-33. Epub 2004 Mar 29.
Wilde AA, Bhuiyan ZA, Crotti L, Facchini M, De Ferrari GM, Paul T, Ferrandi C, Koolbergen DR, Odero A, Schwartz PJ. (2008). Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia. N Engl J Med. 2008 May 8;358(19):2024-9. doi: 10.1056/NEJMoa0708006. Case report of a 17 year old boy. In this article, the authors also talk about the psychological trauma experienced by these patients due to frequent defibrillation from AICDs similar to the patient in Colombia.
Xie X, Visweswaran R, Guzman PA, Smith RM, Osborn JW, Tolkacheva EG (2011). The effect of cardiac sympathetic denervation through bilateral stellate ganglionectomy on electrical properties of the heart. Am J Physiol Heart Circ Physiol. 2011 Jul;301(1):H192-9. doi: 10.1152/ajpheart.01149.2010. Epub 2011 Apr 15. aka How bilateral sympathectomy works to prevent ventricular arrhythmias. Authors discuss their primary research using rats to explore the pathophysiology of cardiac denervation by sympathectomy.
Thoracic Surgery 