Background: Cardiac Sympathetic Denervation (CSD) has been recently proposed for the treatment of refractory ventricular arrhythmias (VAs) in patients with cardiomyopathy (CMP). Long-term outcome and predictors of recurrences after the procedure are still poorly defined.
Aim: To describe our multicenter Italian experience with CSD in CMP patients with refractory VAs.
Methods: 32 patients with CMP and refractory VAs underwent either left CSD (n=4) or BCSD (n=28). All patients had a Video Assisted Thoracoscopic Surgery, in 8 cases with the robotic technique. The main reason (3/4 cases, 75%) to perform LCSD instead of BCSD was sinus bradycardia in single ICD lead recipients.
Results: 84% of patients were male, mean age was 55 ± 16 yrs and mean LVEF was 32± 12%; most (n=26, 81%) had non-ischemic CMP (including 3 with hypertrophic CMP and 2 with cardiolaminopathy) and 34% were in NYHA class ≥3. Main indications for CSD were refractory polymorphic/fast VAs (>200 bpm) in 56% of pts and refractory monomorphic VAs in the rest. Except for 5 patients (15%) with previous thyrotoxicosis, the majority were either on amiodarone (n=20, 63%) or on sotalol (n=3, 9%) and 53% had previously undergone ≥1 catheter ablation for VAs. The median follow-up (FU) after CSD was 16 months (IQR 5-45 months). No major complications occurred. Eleven patients (34%) either died during FU (n=8, 25%), mostly due to end-stage heart failure, or underwent heart transplant (n=3, 9%). After CSD, the percentage of patients with ES decreased from 78% to 40% (p<0.01), while patients with appropriate ICD shocks decreased from 100% to 62%. The mean number of ICD shocks was reduced from 6 (IQR 3-16) in the 6 months before CSD to 0 (IQR 0-2) in the 6 months after (p=0.001). Overall, 69% of patients experienced a 6-months reduction in ICD shocks ≥ 75%, 81% a reduction ≥ 50%. At the univariate Kaplan Meier survival analysis, NYHA class ≥ 3 (p<0.001), VT heart rate < 180 bpm (p=0.02) and left ventricular ejection fraction (LVEF) ≤ 25% (p=0.02) were associated with ICD shock recurrences.
Conclusions: Our case series of CSD in CMP represents the largest reported in Europe and the one with the longest follow-up. The occurrence of electrical storms was almost halved by CSD, and most patients had a reduction in ICD shocks at 6 months larger than 75%. Patients with better functional class, better LVEF and faster VAs benefited more from CSD, suggesting the opportunity of an earlier referral of these patients.