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Background: Cardiac sympathetic denervation (CSD) is an important adjunctive option for patients with refractory ventricular arrhythmias (VAs). Reports of efficacy of CSD in patients with structural heart disease (SHD) and refractory VA vary widely in literature., Objective: The purpose of this study was to conduct a systematic review of arrhythmic outcomes and complications in patients with SHD who underwent CSD due to recurrent VAs., Methods: Electronic databases (Google Scholar and PubMed) were searched to identify reports on CSD in SHD using appropriate medical subject terms. No sample size restriction was applied. All patients with known channelopathies were excluded. Baseline demographic and surgical data, arrhythmic outcomes, and procedural complications were evaluated., Results: A total of 13 studies and 173 patients were included. Of the 173 patients (121 [70%] male); pooled mean age 54.6 [95% confidence interval 52.6-56.7] years), 48 (28%) had ischemic cardiomyopathy, and 141 (82%) underwent bilateral CSD. Overall freedom from events ranged from 58% to 100%. Complications were reported in 49 patients(28%). Transient hypotension (9%), pneumothorax (5%), neuropathic pain (skin sensitivity) (4%), Horner syndrome (3%), sweating pattern changes (3%), and hemothorax (2%) were the most common complications. No procedure-related deaths were reported., Conclusion: CSD reduced the number of VA events in patients with SHD, and the benefit from the intervention seemed to be independent of the underlying SHD. Although overall rate of postprocedural complications was high, most of the complications were temporary. Major postprocedural complications after CSD were infrequent., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Ventricular arrhythmias (VAs) in cardiac sarcoidosis (CS) are frequently refractory to both antiarrhythmic drug (AAD) therapy and catheter ablation (CA). Cardiac sympathetic denervation (CSD) has been shown to reduce VA burden and implantable cardioverter-defibrillator (ICD) shocks in patients with nonischemic cardiomyopathy., Objective: We aimed to report our center's preliminary experience with CSD in patients with known or presumed CS and refractory VAs., Methods: Patients with CS and refractory VAs who underwent CSD at our institution were included. Patient characteristics, procedural outcomes, and number of arrhythmic events including ICD shocks pre- and post-CSD are reported., Results: Five patients with CS (mean age 53 ± 11 years; 2 men [40%]; mean left ventricular ejection fraction 38% ± 11%) underwent CSD for VA refractory to AAD therapy and CA. Four of 5 patients underwent bilateral CSD; 1 patient underwent right-sided sympathectomy only because of poor intraoperative visualization on the left. Procedural complications included hemothorax in 1 patient and azygous vein injury in 1 patient. The median number of ICD shocks in the 6 months pre-CSD was 5. During a median follow-up of 26 months (range 5-29 months), the median number of ICD shocks post-CSD was 0; 1 patient had sustained VA that was below the threshold for device therapy, and 1 patient had symptomatic premature ventricular contractions; both underwent repeat CA. In addition, 1 patient required cardiac transplantation for progressive heart failure., Conclusion: CSD may be a feasible therapeutic adjunct for patients with CS and VA refractory to AAD therapy and CA., (Copyright © 2019. Published by Elsevier Inc.)

Background: Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea., Objective: The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models., Methods: In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1% lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline., Results: Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes (%) in T-wave amplitude (282.8% ± 152.2% vs 20.1% ± 16.5%; P <.001 [LSG]; 338.9% ± 189.8% vs 28% ± 18.3%; P <.001 [RSG]), Tp-Te interval (87.9% ± 37.2% vs 6.9% ± 6.7%; P <.001 [LSG]; 32.6% ± 27.4% vs 6.9% ± 4.7%; P <.035 [RSG]), and left ventricular dP/dT max (148.3% ± 108.5% vs 16.5% ± 13.4%; P <.001 [LSG]; 243.1% ± 105.2% vs 19.0% ± 12.4%; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures., Conclusion: Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery., (Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)