Left cardiac sympathetic denervation with VATS

Left cardiac sympathetic denervation with VATS

Video-assisted thoracic surgery (VATS) is being increasingly used for left cardiac sympathetic denervation. Left cardiac sympathetic denervation is useful as a secondary prevention modality to reduce life threatening arrhythmia for patients with long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). In a series of twenty patients presented by Christopher A Collura, Jonathan N Johnson, Christopher Moir and Michael J Ackerman [1], eighteen had undergone left cardiac sympathetic denervation by video-assisted thoracic surgery. The minimally invasive approach had only minimal perioperative complications and excellent immediate and short term outcomes. Average hospital stay for VATS was only 2.6 days (range: 1 day to 15 days), majority being discharged on the next day. This study was from the division of pediatric cardiology, Mayo Clinic, Rochester, Minnesota.

Joseph Atallah, Francis Fynn-Thompson, Frank Cecchin, Daniel J DiBardino, Edward P Walsh, Charles I Berul [2] from the Children’s Hospital Boston had also reported on 9 patients (four with long QT syndrome, four with catecholaminergic polymorphic ventricular tachycardia, and one idiopathic ventricular tachycardia) who had undergone left cardiac sympathetic denervation by video-assisted thoracic surgery. Their results were also similar. Left cardiac sympathetic denervation with video-assisted thoracic surgery is a minimally invasive and safe procedure for children with drug refractory sympathetically mediated life threatening ventricular arrhythmias.

In one study the left pleural cavity was entered through three 1.5 cm incisions in the left subaxillary area, under general anesthesia. The left thoracic sympathetic ganglia were identified and lower one third of left stellate ganglion along with T2 to T5 ganglia were resected [3].

Left stellectomy has been abandoned because it ablates only the left stellate ganglion providing partial cardiac denervation and produces Horner’s syndrome.

A meta-regression study evaluated 27 papers on LCSD in which VATS was used in 408 patients and open surgery in 239 [4]. 68% of the total patients were free of cardiac events. Mean decrease in QTc was from 522 ms to 494 ms. There was no difference between the two approaches in cardiac events and surgical complications. Open surgery was associated with a greater reduction in QTc in that study. Authors of the study suggested that a randomized trial is warranted.

References

1. Christopher A Collura, Jonathan N Johnson, Christopher Moir, Michael J Ackerman. Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using video-assisted thoracic surgery. Heart Rhythm. 2009 Jun;6(6):752-9.
2. Joseph Atallah, Francis Fynn-Thompson, Frank Cecchin, Daniel J DiBardino, Edward P Walsh, Charles I Berul. Video-assisted thoracoscopic cardiac denervation: a potential novel therapeutic option for children with intractable ventricular arrhythmias. Ann Thorac Surg. 2008 Nov;86(5):1620-5.
3. Jianfeng Li, Yanguo Liu, Fan Yang, Guanchao Jiang, Cuilan Li, Dayi Hu, Jun Wang. Video-assisted thoracoscopic left cardiac sympathetic denervation: a reliable minimally invasive approach for congenital long-QT syndrome. Ann Thorac Surg. 2008 Dec;86(6):1955-8.
4. Collura CA, Johnson JN, Moir C, Ackerman MJ. Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using video-assisted thoracic surgery. Heart Rhythm. 2009 Jun;6(6):752-9.