Bilateral Vats Cervicothoracic Sympathectomy- A Novel Adjunct To Catheter Ablation For Treatment Of Refractory Ventricular Tacchyarrythmias
Hari Tandri, Todd Crawford, Hugh Calkins, Ronald Berger, KAUSHIK MANDAL.
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE, BALTIMORE, MD, USA.
OBJECTIVE: Ventricular Tachyarrythmias (VT) in end stage heart failure portends a dismal prognosis. Results of bilateral cervicothoracic sympathectomy in such patients with refractory VT despite optimal medical therapy, is reviewed.
METHODS: Consecutive patients, from July 2015, with recurrent VT despite optimal medical management, were considered for repeat catheter ablation and based on physician preference, adjunct bilateral video assisted thoracoscopic (VAT) cervicothoracic sympathectomy. Two port VATs approach was used and the sympathetic chain was divided from lower half of C8-T1 to T3. Post sympathectomy, a 8 week blanking period was observed.
RESULTS: Thirty subjects were considered for cervicothoracic sympathectomy. Fifteen had arrythmogenic cardiomyopathy, 6 cardiac sarcoidosis, 4 ischemic cardiomyopathy, 1 SLE myocarditis and remaining 4 had non-ischemic cardiomyopathy. Mean age was 49+/-16 years and 60% were men. Twenty-eight patients had monomorphic VT and 2 had polymorphic VT. All patients, except the 2 with polymorphic VT, underwent repeat catheter ablation prior to sympathectomy. Of the 30 patients, 11 could not have VAT sympathectomy due to dense adhesions (4), coagulopathy (1), refusal to consent (4) and inability to tolerate single lung ventilation (2). All 19 patients were extubated on table after sympathectomy, median hospital stay was 3 days. Complications included hemothorax (5%), prolonged air leak (15%), lower body hyperhidrosis (5%). None developed Horner's syndrome.In this non-randomised series, over a mean follow up of 7 months, only 2/19 in the sympathectomy+ablation group had recurrent VT compared to 10/11 in the ablation only group (p<0.001). Mortality was 36% in the ablation only group compared to 5% in those with adjunct sympathectomy. All (100%) patients in ablation only group remained on antiarrythmics while only 10% patients in the sympathectomy group required antiarrythmics. No deterioration in ventricular function was observed in the sympathectomy group.
CONCLUSIONS: Bilateral cervicothoracic sympathectomy has no detrimental effect on ventricular function and its antiarrythmic effect is independent of the myocardial substrate. Bilateral VATs cervicothoracic sympathectomy may be an useful adjunct to catheter ablation for management of refractory VT.
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