Cardiac Sympathetic Denervation for Refractory Ventricular Arrhythmias

BACKGROUND Cardiac sympathetic denervation (CSD) has been shown to reduce the burden of implantable cardioverter-defibrillator (ICD) shocks in a small series of patients with structural heart disease (SHD) and recurrent ventricular tachyarrhythmias (VT). OBJECTIVE We assessed the value of CSD and the characteristics associated with outcomes in this population. METHODS Patients with SHD who underwent CSD for refractory VT or VT storm in 5 international centers were analyzed by the International Cardiac Sympathetic Denervation Collaborative Group. Kaplan-Meier analysis was used to estimate freedom from ICD shock, transplantation, and death. Cox proportional hazards models were used to analyze variables associated with ICD shock recurrence and mortality after CSD. RESULTS Between 2009 and 2016, 121 patients (age 55 ± 13 years, 26% female, and an ejection fraction of 30 ± 13%) underwent left or bilateral CSD. One-year freedom from sustained VT/ICD shock and ICD shock-free survival were 58.2% and 50.4%, respectively. CSD reduced burden of ICD shocks from a mean of 18 ± 30 (median 10) in the year prior to study entry to 2.0 ± 4.3 (median 0) at a median follow-up of 1.1 years (p < 0.01). On multivariable analysis, pre-procedure New York Heart Association (NYHA) class III and IV heart failure and longer VT cycle lengths were associated with recurrent ICD shocks, while advanced NYHA class, longer VT cycle lengths, and a left-sided only procedure predicted the combined endpoint of sustained VT/ICD shock recurrence, death, and transplantation. Of the 120 patients on antiarrhythmic medication prior to CSD, 39 (32%) no longer required them at follow-up. CONCLUSIONS CSD decreased sustained VT and ICD shock recurrence in patients with refractory VT. Characteristics independently associated with recurrence and mortality were advanced heart failure, VT cycle length, and a left-sided only procedure.