Sympathetic nerve pathways to the human heart, and their variations

Stimulated by the needs of surgery, common variations in the sympathetic pathways to the heart have acquired a practical significance. The cervical and upper thoracic sympathetic trunk was dissected on 24 sides in human fetuses at term, and the cardiac rami together with their communications studied and illustrated. To enable us to classify the cervical rami according to their sites of origin, the cervical sympathetic trunk was subdivided midway between ganglia into portions called ganglionic divisions; these divisions keeping the names applied to the ganglia in the Nomina Anatomica. Intermediate ganglia were found on the visceral outflow of the sympathetic trunk and are referred to as “ distal intermediate ganglia” to distinguish them from the intermediate ganglia that have been described proximal to the sympathetic trunk. Thoracic cardiac rami were almost invariably present, the third and fourth thoracic ganglia most frequently providing substantial contributions. Some thoracic cardiac rami were traced as far as the left anterior descending coronary plexus. The question of bilateral symmetry was also examined. Whilst a variety of features are commonly present on both sides, the first dissection in a cervicothoracic sympathectomy is no reliable guide to the detailed anatomy of the second side. The sympathetic pathways to the heart are extremely variable in their topography, and the diversity of arrangements encountered accounts for the morphological contradictions in the literature. So numerous are the possible variations that the outcome of a sympathectomy is unpredictable. Where denervation is incomplete, collateral sprouting and regeneration of nerves could even lead to hyperstimulation via the sympathetic pathways.