title: Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation.
abstract: BACKGROUND
  Reducing sympathetic output to the heart from the neuraxis can protect against ventricular arrhythmias. The purpose of this study was to assess the value of thoracic epidural anesthesia (TEA) and left cardiac sympathetic denervation (LCSD) in the management of ventricular arrhythmias in patients with structural heart disease.
  
  
  RESULTS
  Clinical data of 14 patients (25 to 75 years old, mean+/-SD of 54.2+/-16.6 years; 13 men) who underwent TEA, LCSD, or both to control ventricular tachycardia (VT) refractory to medical therapy and catheter ablation were reviewed. Twelve patients were in VT storm, and 2 experienced recurrent VT despite maximal medical therapy and catheter ablation procedures. The total number of therapies per patient before either procedure ranged from 5 to 202 (median of 24; 25th and 75th percentile, 5 and 56). Eight patients underwent TEA, and 9 underwent LCSD (3 patients had both procedures). No major procedural complications occurred. After initiation of TEA, 6 patients had a large (> or =80%) decrease in VT burden. After LCSD, 3 patients had no further VT, 2 had recurrent VT that either resolved within 24 hours or responded to catheter ablation, and 4 continued to have recurrent VT. Nine of 14 patients survived to hospital discharge (2 TEA alone, 3 TEA/LCSD combined, and 4 LCSD alone), 1 of the TEA alone patients underwent an urgent cardiac transplantation.
  
  
  CONCLUSIONS
  Initiation of TEA and LCSD in patients with refractory VT was associated with a subsequent decrease in arrhythmia burden in 6 (75%) of 8 patients (68% confidence interval 51% to 91%) and 5 (56%) of 9 patients (68% confidence interval 34% to 75%), respectively. These data suggest that TEA and LCSD may be effective additions to the management of refractory ventricular arrhythmias in structural heart disease when other treatment modalities have failed or may serve as a bridge to more definitive therapy.
authors.affiliation: UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
authors.forename: Tara
authors.initials: T
authors.lastname: Bourke
authors.forename: Marmar
authors.initials: M
authors.lastname: Vaseghi
authors.forename: Yoav
authors.initials: Y
authors.lastname: Michowitz
authors.forename: Vineet
authors.initials: V
authors.lastname: Sankhla
authors.forename: Mandar
authors.initials: M
authors.lastname: Shah
authors.forename: Nalla
authors.initials: N
authors.lastname: Swapna
authors.forename: Noel G
authors.initials: NG
authors.lastname: Boyle
authors.forename: Aman
authors.initials: A
authors.lastname: Mahajan
authors.forename: Calambur
authors.initials: C
authors.lastname: Narasimhan
authors.forename: Yash
authors.initials: Y
authors.lastname: Lokhandwala
authors.forename: Kalyanam
authors.initials: K
authors.lastname: Shivkumar
mesh_terms: D000328:Adult; D000368:Aged; D000767:Anesthesia, Epidural / Q000379:methods*; D017115:Catheter Ablation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013562:Sympathectomy / Q000379:methods*; D017180:Tachycardia, Ventricular / Q000503:physiopathology / Q000628:therapy*; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods; D016896:Treatment Outcome