Thoracoscopic Sympathectomy for Chronic Recurrent and Intractable Ventricular Tachycardia: A Case Series

Abstract

Background

Chronic intractable ventricular tachycardia can cause significant morbidity and mortality. In the setting of failed intracardiac ablation, interruption of the sympathetic nerve can provide relief. We present our series of thoracoscopic sympathectomy for chronic recurrent and intractable ventricular tachycardia.

Methods

We retrospectively reviewed records of sympathectomies performed at a large academic medical center between January 2018 and February 2024. We collected information regarding patients’ procedures, cardiovascular history, hospital course, postoperative cardiovascular outcomes, and mortality.

Results

A total of 20 patients underwent sympathectomy for refractory cardiac arrhythmias. Two patients died in the hospital for reasons unrelated to surgery. Three patients were lost to follow-up. Of the 15 remaining patients, 2 patients died after hospitalization due to recurrent arrythmias, 1 patient died due to unknown reasons, and 12 patients were living and had follow-up. Three of these patients were without further arrythmias. Four patients had notable reduction in their symptoms. Two patients had continued episodes of ventricular tachycardia, and 3 patients proceeded to listing for heart transplantation. After surgery, 7 patients were recorded as having further ablations, with a maximum of 2 postoperative ablations. The mean number of postoperative ablations was 0.4.

Conclusions

In a cohort of critically ill patients with refractory cardiac arrhythmias, sympathectomy is well tolerated. In this case series, a large proportion of patients undergoing sympathectomy experienced significant symptom reduction or complete remission of their cardiac pathologies, indicating that this procedure should be considered in select patients with refractory arrhythmias.

In Short.

• ▪Chronic intractable ventricular tachycardia is a cause of significant morbidity and mortality.
• ▪Minimally invasive thoracoscopic sympathectomy may provide relief in settings of failed intracardiac ablation.
• ▪In this case series, we demonstrate that in a cohort of critically ill patients with refractory cardiac arrhythmias, minimally invasive sympathectomy is well tolerated with significant reduction or remission of cardiac pathologies.

Refractory ventricular arrhythmias are a major cause of morbidity and mortality. Yearly, there are between 180,000 and 450,000 sudden cardiac deaths in the United States,¹ primarily due to ventricular arrythmias.² Standard treatment modalities for the management of chronic ventricular arrythmias are antiarrhythmic medications, catheter ablation, and treatment with an implantable cardioverter-defibrillator (ICD). However, ventricular arrythmias are often refractory to these treatments.³

Previous reports have described the efficacy of sympathetic denervation, which reduces the release of norepinephrine in the heart.^4,5 A few observational studies and 1 randomized controlled trial have examined cardiac sympathectomy in the treatment of refractory ventricular arrythmias.⁶ The 2017 guidelines from the American Heart Association and the American College of Cardiology state that cardiac sympathectomy is a class IIb recommendation for refractory ventricular tachycardia.⁶ The primary limitation to this recommendation is a lack of data.⁶ The only randomized trial of cardiac sympathetic denervation, published in 1992, included only patients with prior anterior myocardial infarctions. That study used either pharmacologic denervation or left cardiac sympathetic denervation, both of which led to significant reductions in sudden cardiac death among high-risk patients.⁷ More recently, a large retrospective study examining surgical thoracoscopic sympathetic denervation showed an 88% reduction in ICD shocks as compared with prior to study entry,⁸ and at 1 year 58% of patients were free from an endpoint of ICD shocks, ventricular tachycardia, death, and transplant.⁸

Despite a growing body of evidence, the surgical literature is lacking in comprehensive evaluations of this procedure, and prior studies have largely not included multiyear follow-up of patients undergoing sympathectomy. Additionally, these studies have largely not specified operative techniques. This study describes an institutional experience with sympathectomy for the treatment of refractory ventricular tachycardia.

Patients and Methods

We retrospectively reviewed records of sympathectomies performed at a single large academic medical center between January 2018 and February 2024. We collected information regarding patients’ demographics, procedure (unilateral vs bilateral sympathectomy) and information on cardiovascular outcomes and mortality. Data collection and analysis were performed using Microsoft Excel. This study was deemed exempt by the Brigham and Women’s Hospital institutional review board as a quality improvement study.

One surgeon (J.O.W.) performed the procedures. Most patients (n = 19, 95%) underwent bilateral cardiac sympathetic denervation via video-assisted thoracoscopic surgery approach. Patients were placed under general anesthesia, intubated with a double-lumen endotracheal tube, and positioned supine with arms extended and a roll under the spine. ICD pads were placed on the sternum and spine. With the patient slightly rotated, the left cardiac sympathetic denervation was addressed. The ipsilateral lung was deflated, three 5-mm incisions were made, and ports were placed near the axilla, laterally, and anteriorly. The sympathetic chain was identified and resected from the inferior aspect of the stellate ganglion to the fourth rib. The table was then rolled left, and the process was repeated on the right. After completion of the procedure, a chest tube was placed near the area of dissection.

Results

Participant Characteristics

A total of 20 patients underwent sympathectomy (Table 1). Prior to surgery, all patients were receiving antiarrhythmic medications. Nineteen patients had an ICD. Patients in the cohort were on a mean of 2.4 antiarrhythmic medications (SD, 0.8); 18 patients were receiving multiple antiarrhythmic medications. Patients had had a mean of 2.5 prior ablations (SD, 2.9). The median follow-up time was 361 days (maximum, 5.5 years). There were 16 male and 4 female patients, with a mean age of 56.3 years. Sixty percent (12 of 20) had a history of smoking or were current smokers at the time of surgery. Nineteen patients had cardiomyopathies (6 nonischemic, 6 ischemic, 2 familial, 3 idiopathic, 1 hypertrophic, 1 sarcoidosis) (Table 2).

Table 1.

Baseline Characteristics

Characteristic	Value (N = 20)
Sex, female	4 (20)
Age, y	56.27 (±14.89)
Current or past smoker	12 (60)
Implantable cardioverter-defibrillator at baseline	19 (95)
Procedure
Unilateral	1 (5)
Bilateral	19 (95)
Alive at most recent follow-up	12 (60)
Lost to follow-up	3 (15)
Deceased in hospital	2 (10)
Deceased after hospitalization	3 (15)
Number of antiarrhythmic meds	2.4 (±0.8)
Number of prior ablations	2.5 (±2.9)

Values are presented as n (%) or mean (±SD).

Table 2.

Patient Demographics, Cardiovascular History, and Post-sympathectomy Outcomes

Sex	Age, y	Race	Cardiomyopathy Etiology	Cardiac Diagnoses	Postoperative history	Postoperative Ablations
M	73	White	non-ischemic	non-ischemic cardiomyopathy, unknown etiology	recurrent VT and death	1
M	66	White	ischemic	ischemic cardiomyopathy and VT	None	1
M	60	White	ischemic	idiopathic VT	Intermittent hospitalization for arrhythmia	1
M	62	White	ischemic	HFrEF secondary to CAD	Died in hospital	0
M	71	White	ischemic	CAD complicated by recurrent VT	None	0
F	63	White	Ischemic	Severe coronary vasospasm, CAD	None	0
M	67	White	sarcoid	CAD, VT, cardiac sarcoidosis, HFrEF	intermittent chest pain, no further VT	0
M	64	White	non-ischemic	AF, VT/VF, Hypertension	Heart transplant 2023	2
M	73	White	ischemic	HFrEF (EF 15%), VT, VF, CAD, hypertension	Died due to VT storm	1
M	44	White	non-ischemic	HFrEF (EF 20-25%), VT	None	0
F	31	White	idiopathic	NSVT, VT/VF	PVCs, decreased relative to presurgery	0
M	38	White	idiopathic	Recurrent VT/VF	1 further episode of VF requiring hospitalization	0
F	46	White	familial arrhythmogenic	acute on chronic pericarditis, familial arrhythmogenic cardiomyopathy	improved NSVT	0
M	80	White	idiopathic	cardiac arrest, VT with complete heart block, AF, non-ischemic cardiomyopathy (EF 25%), mitral regurgitation, tricuspid regurgitation, bioprosthetic aortic valve replacement	died in hospital	0
M	33	White	familial idiopathic	familial idiopathic cardiomyopathy, VF, AF	intermittent VT/VF	1
F	65	Black	None	recurrent PVCs complicated by VF	Stable with intermittent palpitations	0
M	56	White	non-ischemic	nonobstructive CAD, bicuspid aortic valve s/p replacement	continued VT and PVCs, listed for transplant	0
M	59	White	hypertrophic	HCM, VT, paroxysmal AF, HFpEF (35%-40%)	multiple readmissions for VT, listed for transplant	0
M	55	White	non-ischemic	VT s/p cardiac arrest	asymptomatic	0
M	72	White	non-ischemic	coarctation of the aorta, recurrent VT	readmitted for orthostatic hypotension	1

AF, atrial fibrillation; CAD, coronary artery disease; EF, ejection fraction; HCM, hypertrophic cardiomyopathy; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; NSVT, non-sustained ventricular tachycardia; PVC, premature ventricular contraction; s/p, status post; VF, ventricular fibrillation; VT, ventricular tachycardia.

Postoperative Outcomes

One patient had a postoperative course complicated by a small pneumothorax requiring a chest tube for 1 day, which improved after chest tube removal. One patient had a postoperative hemothorax and a small pneumothorax. The mean hospital stay after surgery was 15.9 ± 12.5 days. Two patients died in hospital for reasons unrelated to surgery. One patient was found unresponsive without a clear etiology of death, and the second patient had a cerebral injury secondary to cardiac arrest in the setting of ventricular arrhythmias. After hospitalization, 3 patients were lost to follow-up (no information available in the last year). At the time of chart review, 2 patients died after hospitalization due to recurrent arrythmias, and 1 patient died for unknown reasons. Twelve patients were living with follow-up. Three of these patients were without further arrythmias. Four patients had significant reduction in their symptoms. One patient had intermittent hospitalizations for arrhythmias, but at last follow-up was greatly improved without recurrent events. One patient described continued chest pain without ventricular tachycardia and was found to only have premature ventricular contractions on device interrogation. The third was noted to have intermittent nonsustained ventricular tachycardia associated with pericarditis flares. Finally, 1 patient had intermittent ventricular events immediately postoperatively, but at most recent follow-up was noted to be well without concern. Two patients had continued episodes of ventricular tachycardia, and 3 patients proceeded to listing for heart transplantation. After surgery, 7 patients were recorded as having further ablations, with a maximum of 2 postoperative ablations. The mean number of postoperative ablations was 0.4. Four patients had postoperative compensatory hyperhidrosis.

Comment

In this study, we examined the efficacy of thoracoscopic sympathectomy in the treatment of patients with refractory ventricular tachycardia. We found that the procedure was well-tolerated, and that a high proportion of patients had significant reduction in their cardiac symptoms. The procedure was successful regardless of the underlying reason for ventricular tachycardia.

In the current study, we observed that 7 out of 15 patients who survived to discharge and had complete follow-up experienced significant symptom reduction, and 3 were completely without further symptoms. These findings generally align with those from prior studies. A case series from 2022 examined 13 patients in Chicago (10 of whom had undergone prior ablations) with refractory ventricular arrhythmias, all of whom underwent bilateral thoracoscopic sympathectomy.⁹ That study found that among those who survived to discharge, 6 out of 10 had complete cessation of their ICD discharges, while 2 out of 10 proceeded to requiring cardiac transplantation.⁹ Three patients in that series required postoperative cardiac ablations.⁹ All 10 patients were alive with a median follow-up time of 8.7 months.⁹ A 2014 study of 41 patients in the United States with refractory ventricular arrhythmias found that at 1 year of follow-up 90% of patients experienced significant symptom reduction while around 40% of patients remained ICD-shock free.⁸ A 2017 study examined 121 patients from 5 centers who underwent unilateral or bilateral sympathectomy for refractory ventricular arrhythmias: Among these patients at 1 year, one-third were free of antiarrhythmic medications at follow-up and 58% were alive without further ICD shocks; 26% of patients died, while 8% underwent heart transplant. In that study, no patients died during their index hospitalization.⁸

In this series we also found that cardiac sympathectomy was well tolerated, as no patients died for reasons directly related to surgery. Two patients in our series had notable postoperative complications (consisting of small pneumothoraxes and a small hemothorax). These findings are again similar to those reported in prior series. In the 2022 series from Chicago, 3 out of 13 patients died in hospital, all for reasons unrelated to surgery.⁹ Two surviving patients in that cohort were reported to have minor postoperative complications directly related to surgery.⁹ In the multicenter study, there were similarly no deaths directly due to the index operation.⁸

This study has several limitations. Most notably, due to the rarity of this procedure, even at highly specialized centers such as that included within the current study, we were limited to a sample of only 20 patients. Additionally, 3 patients were lost to follow-up after discharge. Finally, this study reports on procedures performed in highly selected patients at a tertiary academic center, and as such may not be generalizable to all care settings. Despite these limitations, this study adds to a growing body of literature showing that thoracoscopic sympathectomy is safe and effective in the setting of ventricular arrhythmias refractory to medical and catheter-based therapies. Providers should be aware of this treatment option, particularly given the low operative morbidity and lack of alternative treatment options in this patient population.