Percutaneous radiofrequency thoracic sympathectomy for refractory arrhythmogenic storms: first in man study of six cases

Abstract

Background: Catheter ablation has been shown to be effective in the treatment of scar-related ventricular tachycardia (VT). In limited number of patients ablation therapy failed to stop all incessant or unstable VTs. Several case reports and series have described the role of thoracic sympathectomy (VATS) in the treatment of refractory VTs. Method: We report three cases of patients with arrhythmic storm and nearly incessant refractory VTs who were treated with a percutaneous radiofrequency T2 and T3 sympathectomy on the left side. Results: 1) 42-y-old man with severe dilation CMP (LVEF 20%), after ICD storming. Both endocardial and epicardial radiofrequency and later alcohol ablations of the arrhythmogenic substrate were performed with insufficient effect. 2) 58-y-old man with ARVD was admit with arrhythmogenic storm. Both endocardial and epicardial RF ablations didn't stop recurrent VTs. 3) 62-y-old man post MI arrhythmic storm with several ICD shocks, complex catheter ablation failed to lessen the number of VT epizodes. 4) 40 y-old man post MI after CABG with ICD storming and unsuccessful catheter ablation 5) 51 y-old man postmyocarditis CMP with arrhythmic storm and repeated epicardial/endocardial ablation 6) 89 y-old man with ischemic CMP with severely depressed LV function (LV EF 15%), BiV ICD with storming and three catheter ablations failed to stabilised the rhythm The patients were indicated for a local anaesthetic block of the left stellate ganglion under real-time ultrasound guidance. Following the block both heart rate and blood pressure droped more than ten percent and patient did not experience any significant ventricular tachycardias for more than a week. He was then scheduled for the RF T2 and T3 left thoracic sympathectomy which was performed in supine position under local anaesthesia and mild sedation. A multi-planar fluoroscopy was used for a guidance. Six RF lesions (3 for each needle, medial, cranial and caudad rotation of the curved tip) were used, at the temperature of 70°C, 90 sec each. 0.5ml of 6% phenol was applied at the end of procedure into each needle to complete the sympathicolysis. Patients were not experienced with any ICD shocks since the sympathetic denervation., in two repeated ATPs terminated VTs. Conclusion: RF upper thoracic sympathectomy may become a considerable option for patients with refractory ventricular arrthythmias not responding on medical and electroinvasive treatment.