Discussion:
ES, characterized by three or more ventricular arrhythmias (VA) or appropriate ICD shocks within 24 hours, represents a critical and life-threatening condition [1]. The transition from recurrent VT to electrical storm can be influenced by various factors such as the underlying cardiac pathology, comorbidities, and the efficacy of antiarrhythmic therapies. The exact rate of recurrent VT to ES is unclear. In addressing ES, the European Society of Cardiology recommends a multifaceted approach, involving antiarrhythmic medications, adrenergic blockades, sedation/anxiolysis, and hemodynamic support [12, 13]. Current therapeutic recommendations include the use of antiarrhythmic medications, such as amiodarone and lidocaine, to stabilize cardiac rhythm. Concurrently, adrenergic blockade is employed to modulate sympathetic activity, crucial in managing the heightened sympathetic tone often observed in ES. Sedation and anxiolysis play a pivotal role, ranging from benzodiazepine to general anesthesia with propofol and opioids. These measures collectively contribute to alleviating the electrical and hemodynamic disturbances [13]. Despite these interventions, cases of refractory ES pose a significant challenge. In such scenarios, percutaneous stellate ganglion block has been explored as an additional therapeutic option. While providing immediate relief in up to 92% of cases with a 50% reduction in VA burden, long-term follow-up data reveal a notable recurrence rate[14]. This prompts the consideration of more definitive interventions to address the underlying dysregulation of the sympathetic nervous system. Cardiac sympathetic denervation (CSD) through bilateral sympathetic ganglionectomy, has emerged as a promising strategy for managing persistent, refractory ES[15]. This surgical procedure involves the removal of terminal cervical and thoracic sympathetic ganglia, effectively reducing sympathetic discharge to the heart [16, 17]. Studies have demonstrated significant reductions in VT recurrence and ICD shocks, particularly in patients with ischemic and nonischemic cardiomyopathy [15, 18]. Notably, bilateral CSD has shown superiority over left-only procedures in terms of longer transplant-free survival and ICD-shock-free time[18]. Although the surgical approach commonly involves resecting one-third to one-half of the stellate ganglion with the sympathetic chain down to the fourth rib, the optimal extent of resection remains a subject of investigation [15]. The application of CSD in patients who have had a MI with structural heart abnormalities or ES due to other cardiomyopathies needs more investigation. Further research is required in order to assess the efficacy, safety, and long-term outcomes of CSD in these specific patient populations [19]. While concerns about perioperative risk and efficacy have limited the widespread adoption of CSD, most do not experience severe complications. One study showed a 7% perioperative death attributed to refractory arrythmia and decompensated heart failure, and 88% of patients were alive after 6 months of operation [15]. Potential complications include pneumothorax, Horner’s syndrome, and hemothorax[20]. Some patients have reported hypohidrosis in upper extremities, hyperhydrosis in lower extremities, neuropathic pain, and sensitivity in specific regions following CSD[16]. Our case study contributes to the growing body of evidence supporting the potential efficacy of CSD in managing refractory ES in post-MI patients with reduced LVEF. Our patient, unresponsive to multiple antiarrhythmic medications and left stellate ganglion block, exhibited successful resolution of VT storms following bilateral sympathetic ganglionectomy, with favorable tolerance and no complications. While promising, the broader application of CSD in treating refractory VA necessitates further study. Further study will be crucial for elucidating the specific role of CSD, especially in the context of post-MI patients with structural heart abnormalities or ES secondary to other cardiomyopathies. Long-term follow-ups are imperative for assessing potential complications and evaluating the sustained efficacy of CSD, shedding light on its impact on long-term mortalities in this complex patient population.