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.