Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation

Abstract

Background: Reducing sympathetic output to the heart from the neuraxis can protect against ventricular arrhythmias. The purpose of this study was to assess the value of thoracic epidural anesthesia (TEA) and left cardiac sympathetic denervation (LCSD) in the management of ventricular arrhythmias in patients with structural heart disease.

Methods and results: Clinical data of 14 patients (25 to 75 years old, mean+/-SD of 54.2+/-16.6 years; 13 men) who underwent TEA, LCSD, or both to control ventricular tachycardia (VT) refractory to medical therapy and catheter ablation were reviewed. Twelve patients were in VT storm, and 2 experienced recurrent VT despite maximal medical therapy and catheter ablation procedures. The total number of therapies per patient before either procedure ranged from 5 to 202 (median of 24; 25th and 75th percentile, 5 and 56). Eight patients underwent TEA, and 9 underwent LCSD (3 patients had both procedures). No major procedural complications occurred. After initiation of TEA, 6 patients had a large (> or =80%) decrease in VT burden. After LCSD, 3 patients had no further VT, 2 had recurrent VT that either resolved within 24 hours or responded to catheter ablation, and 4 continued to have recurrent VT. Nine of 14 patients survived to hospital discharge (2 TEA alone, 3 TEA/LCSD combined, and 4 LCSD alone), 1 of the TEA alone patients underwent an urgent cardiac transplantation.

Conclusions: Initiation of TEA and LCSD in patients with refractory VT was associated with a subsequent decrease in arrhythmia burden in 6 (75%) of 8 patients (68% confidence interval 51% to 91%) and 5 (56%) of 9 patients (68% confidence interval 34% to 75%), respectively. These data suggest that TEA and LCSD may be effective additions to the management of refractory ventricular arrhythmias in structural heart disease when other treatment modalities have failed or may serve as a bridge to more definitive therapy.

Figure 1. Anatomy and histology of left sympathetic chain

(A): Videoscopic still frame of LCSD demonstrating the sympathetic chain post dissection prior to resection. (B): Resected sympathetic chain from lower half of left stellate ganglion to fourth thoracic ganglion. (C): Hematoxylin-and-eosin (H&E) stained section of stellate ganglion (original magnification, 400×) exhibits a cluster of ganglion cells separated by bundles of myelinated nerve fibers and perineuronal satellite cells. The ganglion cells (arrows) demonstrate centrally placed nuclei with prominent nucleoli. Occasional ganglion cells can also be seen to contain fine, golden lipofuscin pigment. (LCSD= left cardiac sympathetic denervation, LSG=left stellate ganglion)

Figure 2. Effect of Thoracic Epidural Anesthesia (TEA)

Line graph demonstrating number of VT therapies both before and during TEA infusion. (TEA=Thoracic Epidural Anesthesia)