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.