Cardiac sympathetic denervation to prevent life-threatening arrhythmias

Journal name:
Nature Reviews Cardiology
Volume:
11,
Pages:
346–353
Year published:
DOI:
doi:10.1038/nrcardio.2014.19
Published online

Abstract

Experimental and clinical evidence indicating an antiarrhythmic effect of cardiac sympathetic denervation has been available for 100 years. Experimental data show that left cardiac sympathetic denervation (LCSD), in particular, is not only antiarrhythmic, but also antifibrillatory—an effect exquisitely important for any clinical condition associated with a high risk of ventricular fibrillation and sudden cardiac death. LCSD has additional effects on both the coronary circulation and the mechanical performance of the left ventricle, with important implications for patients with ischaemic cardiomyopathy. Evidence also shows that LCSD increases the vagal activity directed to the heart, which has potential implications for the management of heart failure. In this Review, the current and novel clinical indications for LCSD are discussed, particularly in the context of results obtained in patients with channelopathies, such as long QT syndrome and catecholaminergic polymorphic ventricular tachycardia.

At a glance

Figures

  1. Cardiac innervation and left sympathetic cardiac denervation.
    Figure 1: Cardiac innervation and left sympathetic cardiac denervation.

    Schematic showing the sympathetic and parasympathetic innervation of the heart, and the points at which the sympathetic chain is sectioned during left sympathetic cardiac denervation. Redrawn with permission of Elsevier. All rights reserved.

  2. Left stellate ganglion blockade is antiarrhythmic.
    Figure 2: Left stellate ganglion blockade is antiarrhythmic.

    Effect of a 90 s occlusion (arrows) of the circumflex coronary artery in a dog whose descending coronary artery was ligated at the beginning of the experiment. a | Under control conditions, episodes of ventricular tachycardia occur before and after release of the occlusion with several premature ventricular contractions. b | During left stellate ganglion blockade, no arrhythmias occur. c | After returning to control conditions, several premature ventricular contractions occur, which are followed by ventricular tachycardia and then ventricular fibrillation. The three traces are consecutive recordings. The asterisks indicate ectopic beats. Reprinted from Am. Heart J. 92 (5), Schwartz, P. J. et al. Effects of unilateral stellate ganglion blockade on the arrhythmias associated with coronary occlusion. 589599 © 1976, with permission from Elsevier.

  3. Effect of unilateral stellectomy and blockade on ventricular fibrillation threshold.
    Figure 3: Effect of unilateral stellectomy and blockade on ventricular fibrillation threshold.

    Right stellectomy and blockade (11 dogs) lowered the ventricular fibrillation threshold by 48 ± 14% compared with control values (P <0.001), whereas left stellectomy and blockade (nine dogs) raised the threshold by 72 ± 33% compared with control values (P <0.001). Reprinted from Am. J. Cardiol. 37 (7), Schwartz, P. J. et al. Effects of unilateral cardiac sympathetic denervation on the ventricular fibrillation threshold. 10341040 © 1976, with permission from Elsevier.

  4. Left stellectomy is accompanied by a reflex increase in cardiac vagal efferent nerve activity.
    Figure 4: Left stellectomy is accompanied by a reflex increase in cardiac vagal efferent nerve activity.

    Tracings showing activity of a single cardiac vagal efferent fibre at the same blood pressure levels induced by phenylephrine before (top panel) and after (bottom panel) left stellectomy. The fibre shows a pulse-synchronous activity. In each panel, the upper tracing shows blood pressure, and the lower tracing shows the electroneurogram. Reprinted from Cerati, D. & Schwartz, P. J. Single cardiac vagal fiber activity, acute myocardial ischemia, and risk for sudden death. Circ. Res. 69 (5), 13891401 (1991).

  5. LCSD reduces the incidence of sudden cardiac death after myocardial infarction.
    Figure 5: LCSD reduces the incidence of sudden cardiac death after myocardial infarction.

    In patients with an anterior myocardial infarction complicated by ventricular tachycardia or fibrillation, treatment with either β-blockers or LCSD significantly reduced mortality during the 20-month follow-up (P <0.05 for each group versus placebo). Abbreviation: LCSD, left cardiac sympathetic denervation. Reprinted from Schwartz, P. J. et al. Prevention of sudden cardiac death after a first myocardial infarction by pharmacologic or surgical antiadrenergic interventions.
    J. Cardiovasc. Electrophysiol. 3 (1), 216 (1992).

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  1. Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico Italiano, Casa di Cura San Carlo, Via Pier Lombardo 22, 20135 Milan, Italy.

    • Peter J. Schwartz

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  • Peter J. Schwartz

    Peter J. Schwartz is the head of the Center for Cardiac Arrhythmias of Genetic Origin, and director of the Cardiovascular Genetics Laboratory at the IRCCS Istituto Auxologico Italiano, and professor of cardiology at the Department of Molecular Medicine of the University of Pavia, Italy. His main area of research is sudden cardiac death, particularly the relationship between the autonomic nervous system and life-threatening arrhythmias, and the long QT syndrome. He is the author of almost 1,400 publications.

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