2023 FSA Podium and Poster Abstracts
P006: MANAGEMENT OF A PATIENT WITH REFRACTORY SYMPTOMATIC VENTRICULAR TACHYCARDIA FOR ELECTIVE VIDEO ASSISTED THORACOSCOPY FOR SYMPATHETIC CARDIAC DENERVATION
Karina Kohn Cordeiro, MD1; Alexander Harrington, MD, MBA1; Sina Ghafarripoor, MD2; 1Jackson Memorial Hospital/University of Miami; 2University of Miami
Introduction: Ventricular arrhythmias are a known cause of sudden cardiac death. Treatment options include medication, catheter ablation and ICDs (implantable cardioverter defibrillator devices). Thoracoscopic bilateral sympathectomy for cardiac denervation is a therapeutic option for patients with intractable life-threatening ventricular arrhythmias who are refractory to the treatment modalities mentioned above. Increased sympathetic stimulation results in increased chronotropy and inotropy. Modulation of the autonomic system is emerging as a therapeutic option for patients with refractory ventricular arrhythmias.
Method/Case presentation: A 48 year old male with a history CAD status post PCI to the left circumflex, heart failure with an EF of 25%, paroxysmal atrial fibrillation, hypertension, diabetes mellitus, chronic kidney disease stage 3, home oxygen use (2-3 L) and ventricular tachycardia (VT), status post attempted endocardial ablation, ICD placement which was upgraded to CRT-D (cardiac resynchronization therapy) presented to the ED with multiple episodes of syncope associated with chest pain and shortness of breath. ICD interrogation revealed 7 episodes of polymorphic VT/VF in 3 days terminated by anti-tachycardia pacing (ATP). Unable to perform cardiac MRI for cardiac scar evaluation as substrate for VT due to obesity. Trans-thoracic echocardiogram showed severally reduced EF (25%), reduced right ventricular function, severe pulmonary hypertension and severe elevation in right ventricular pressures. Cardiac catheterization demonstrated no evidence of obstructive coronary artery disease (CAD). The decision was made to perform a sympathetic cardiac denervation.
Results: Preoperatively, significant time was spent discussing the risks of surgery with the patient, up to and including extended intubation, ICU time, and death. In preoperative holding, the ICD was reprogrammed to deactivate the debilitation function and place it into asynchronous pacing, as the surgeons would be using electrocautery in close proximity to the device. An arterial line and defibrillator pads were placed prior induction in the OR. Patient was induced with Etomidate and Rocuronium and intubated with a left double lumen tube 39F using video laryngoscopy. Despite pacing, after intubation patient had an episode of VT, which was terminated with synchronized cardio-version. An amiodarone bolus and infusion was administered. No further episodes occurred intra-operatively. Upon successfully completion of surgery, patient was extubated and transported to the ICU. His device was reprogrammed back to preoperative settings post surgery. Four days later, patient was intubated following VT arrest with ROSC after AICD shock. The patient expired 14 days after surgery despite maximal vasopressor administration.
Discussion: According to the American heart association guidelines of 2017 autonomic nervous system modulation is emerging as a treatment option for prevention of ventricular arrhythmias. Modulation can be achieved either through interruption of sympathetic outflow to the heart or stimulation of the parasympathetic pathway (vagal nerve stimulator, spinal cord stimulator). Studies are ongoing on the applicability of sympathetic heart denervation to a broader group of ventricular arrhythmias, but this modality has proven efficacious for conditions like long QT syndrome and catecholaminergic polymorphic ventricular tachycardia. Although data is limited, due to the significant morbidity, cardiac denervation is a reasonable option in selected patients.