Cardiac Sympathetic Denervation for Recurrent VTs
What is the value of cardiac sympathetic denervation (CSD) in patients with structural heart disease and recurrent ventricular tachyarrhythmias (VTs)?
Data from five international centers participating in the International Cardiac Sympathetic Denervation Collaborative Group were analyzed. Kaplan-Meier analysis was used to estimate freedom from implantable cardioverter-defibrillator (ICD) shock, transplantation, and death. Cox proportional hazards models were used to analyze variables associated with ICD shock recurrence and mortality after CSD.
A total of 121 patients (age 55 ± 13 years, 26% female, and an ejection fraction of 30 ± 13%) underwent left or bilateral CSD. One-year freedom from sustained VT/ICD shock and ICD shock-free survival were 58% and 50%. CSD reduced burden of ICD shocks from a mean of 18 ± 30 (median 10) to 2.0 ± 4.3 (median 0) at a median follow-up of 1.1 years (p < 0.01). New York Heart Association (NYHA) class III and IV heart failure and longer VT cycle lengths were associated with recurrent ICD shocks. Advanced NYHA class, longer VT cycle lengths, and a left-sided only sympathetic denervation predicted the combined endpoint of sustained VT/ICD shock recurrence, death, and transplantation. Of the 120 patients on antiarrhythmic medication prior to CSD, 39 (32%) no longer required them at follow-up.
CSD decreased ICD shock recurrence in patients with refractory VT. Characteristics independently associated with recurrence and mortality were advanced heart failure, VT cycle length, and a left-sided only procedure.
CSD suppresses automaticity, lengthens repolarization, and reduces repolarization heterogeneity. It mediates its effects through the disruption of both the efferent and afferent nerves. Left-sided sympathetic denervation has been used successfully in refractory cases of long QT syndrome and catecholaminergic polymorphic VT, and an increasing number of single-center reports on patients with structural heart disease and frequent ventricular arrhythmia, especially ventricular tachycardia storm. The present study is remarkable for its size and multicenter character. In contrast to left-sided denervation, which is usually sufficient for long QT and catecholaminergic polymorphic VT, bilateral denervation appears necessary for patients with structural heart disease. This hypothesis should now be tested in prospective studies.
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