Case Description
A 40-year-old male presented with a two-week duration of intermittent
retrosternal chest pain and was found to have a late presenting
anteroseptal ST-elevation myocardial infarction (STEMI). Coronary
angiography showed an occluded proximal left anterior descending (LAD)
artery, along with diffuse left main and LAD disease. After a heart team
discussion took place, the patient underwent coronary artery bypass
grafting (CABG), utilizing left mammary artery (LIMA) to LAD and
saphenous vein graft (SVG) to the diagonal branch. Pre-CABG
transthoracic echocardiogram (TTE) disclosed a 35% ejection fraction
with anterobasal, anterolateral and apical wall hypokinesis, and
post-CABG TTE noted a 27% ejection fraction with severe global
hypokinesis. Additionally, an EKG depicted Q wave anterior wall LV
infarction and a prolonged QTc interval of 573 ms. Despite successful
revascularization, the patient experienced a complex clinical course
marked by Torsade de pointes (TdP)/polymorphic VT (PMVT) progressing to
ventricular fibrillation (VFib) arrest. An urgent heart catheterization
showed patent bypass grafts and unchanged native CAD. Aggressive
measures were taken, including IV amiodarone and lidocaine, but the
patient experienced ongoing PMVT, leading to cardiogenic shock with
multiorgan failure, necessitating pressor support and intubation
followed by Impella 5.5. A dual chamber Medtronic ICD was inserted on
day 10 post-CABG, set to DDD mode with base rate originally set to 100
bmp, later decreased to 70 bmp. Although PMVT subsided for a brief
period, the patient developed monomorphic VT (MMVT), requiring more than
10 ICD shocks, resulting in reintubation and sedation with propofol.
Catheter ablation was contemplated, however, in the post-MI/cardiotomy
setting, along with a high PAINESD score12, it was
thought that the risk outweighed benefits and the patient underwent a
left stellate ganglion block with ropivacaine. Unfortunately, the
patient continued to experience refractory ES.
Ultimately, cardiothoracic surgery performed a video-assisted
thoracoscopic bilateral sympathectomy, resecting T2-T4 sympathetic
ganglia. This procedure led to substantial stabilization of the patient,
marked by the absence of further MMVT. The patient was discharged five
days post-surgery with optimized heart failure medications and oral
amiodarone. He had no recurrent VT since the procedure at 6 months
follow-up. This case highlights the critical role of bilateral
sympathetic ganglionectomy in managing refractory ventricular
arrhythmias in a challenging clinical scenario.