Background: Chronic intractable ventricular tachycardia can cause significant morbidity and mortality. In the setting of failed intracardiac ablation, interruption of the sympathetic nerve can provide relief. We present our series of thoracoscopic sympathectomy for chronic recurrent and intractable ventricular tachycardia. Methods: We retrospectively reviewed records of sympathectomies performed at a large academic medical center between January 2018 and February 2024. We collected information regarding patients’ procedures, cardiovascular history, hospital course, postoperative cardiovascular outcomes, and mortality. Results: A total of 20 patients underwent sympathectomy for refractory cardiac arrhythmias. Two patients died in the hospital for reasons unrelated to surgery. Three patients were lost to follow-up. Of the 15 remaining patients, 2 patients died after hospitalization due to recurrent arrythmias, 1 patient died due to unknown reasons, and 12 patients were living and had follow-up. Three of these patients were without further arrythmias. Four patients had notable reduction in their symptoms. Two patients had continued episodes of ventricular tachycardia, and 3 patients proceeded to listing for heart transplantation. After surgery, 7 patients were recorded as having further ablations, with a maximum of 2 postoperative ablations. The mean number of postoperative ablations was 0.4. Conclusions: In a cohort of critically ill patients with refractory cardiac arrhythmias, sympathectomy is well tolerated. In this case series, a large proportion of patients undergoing sympathectomy experienced significant symptom reduction or complete remission of their cardiac pathologies, indicating that this procedure should be considered in select patients with refractory arrhythmias.

Epicardial catheter ablation of ventricular tachycardia (VT) is a well-established ablation technique for a variety of myocardial substrates including ischemic cardiomyopathy. Epicardial VT ablation has several potential life-threatening complications including a 1.5% incidence of coronary artery (CA) injury. A 68-year-old woman with ischemic cardiomyopathy, coronary artery disease status post left circumflex PCI, and VT status post multiple endocardial ablations presented to our institution with persistent slow VT and hemodynamic compromise.

BackgroundElectrical storm (ES) patients who fail standard therapies have a high mortality rate. Previous studies report effective management of ES with bedside, ultrasound-guided percutaneous stellate ganglion block (SGB). We report our experience with sympathetic blockade administered via a novel alternative approach: proximal intercostal block (PICB). Compared with SGB, this technique targets an area typically free of other catheters and support devices, and may pose less strict requirements for anticoagulation interruption, along with lower risk of focal neurological side effects.ObjectivesThe authors sought to describe the safety and efficacy of PICB in patients with refractory ES.MethodsWe reviewed our institutional data on ES patients who underwent PICB between January 2018 and February 2023 to analyze procedural safety and short- and long-term outcomes.ResultsA total of 15 consecutive patients with ES underwent PICB during this period. Of those, 11 patients (73.3%) were maintained on PICB alone, and 4 patients (26.6%) were maintained on combined block with SGB and PICB. Overall, 72.7% patients who were maintained on PICB alone and 77.8% patients who were maintained on bilateral PICB had excellent arrhythmia suppression. After PICB, implantable cardioverter-defibrillator therapies were significantly reduced (P < 0.05), with 93.3% of patients receiving PICB having no implantable cardioverter-defibrillator shock until discharge or heart transplant. Anticoagulation was continued in all patients and there were no procedure-related complications. Apart from mild transient neurological symptoms seen in 3 patients, no significant neurological or hemodynamic sequelae were observed.ConclusionsIn patients with refractory ES, continuous PICB provided safe and effective sympathetic block (77.8% ventricular arrhythmia suppression), achievable without interruption of anticoagulation, and without significant side effects.

A 65-year-old gentleman with ischemic cardiomyopathy and left ventricular (LV) ejection fraction 25-30% status post primary prevention AICD, history of LV thrombus complicated by cardioembolic CVA, and ventricular tachycardia (VT) status post prior endocardial catheter ablation. The patient initially presented to an outside hospital with progressive dyspnea, palpitations, and hypotension following index VT ablation two months prior. He was transferred to our institution for acute on chronic decompensated heart failure in the setting of recurrent slow monomorphic VT despite oral and intravenous antiarrhythmic therapies.

Limited single-center studies suggest that a combined endocardial-epicardial (endo-epi) ablation strategy may be superior to endocardial ablation (endo) alone in patients with recurrent ventricular tachycardia (VT). However, small sample size impedes determining the precise impact, as well as the risks, associated with a combined strategy.