Sympathectomy via a posterior approach after a failed trans-thoracic approach: a case of its use for arrhythmia

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OBJECTIVE

Congenital long QT syndrome (LQTS) provides an opportunity for neurosurgical intervention. Medication and implantable cardiac defibrillator (ICD)–refractory patients often require left cardiac sympathetic denervation (LCSD) via anterior video-assisted thoracoscopic surgery (VATS). However, this approach has major pulmonary contraindications and risks, with a common concern in children being their inability to tolerate single-lung ventilation. At Oregon Health & Science University, the authors have developed a posterior approach—extrapleural, minimally invasive, T1–5 LCSD—that minimizes this risk.

METHODS

A 9-year-old girl with LQTS type III presented to the emergency department while experiencing ventricular tachycardia (VT) and ventricular fibrillation (VF) with multiple ICD firings. Medical management failed to resolve the VF/VT. VATS was attempted but could not be safely performed due to respiratory insufficiency. The patient was reintubated for dual-lung ventilation and repositioned prone. Her respiratory insufficiency resolved. Using METRx serial dilating tubes under the microscope, the left T1–5 sympathetic ganglia were sectioned and removed.

RESULTS

Postoperatively, the patient had no episodes of VF/VT, pneumothorax, hemothorax, or Horner syndrome. With mexiletine and propranolol, she has remained largely VF/VT free, with only one VT episode during the 2-year follow-up period.

CONCLUSIONS

Minimally invasive, posterior, extrapleural, T1–5 LCSD is safe and effective for treating congenital LQTS in children, while minimizing the risks associated with VATS.

ABBREVIATIONS CSD = cardiac sympathetic denervation; ICD = implantable cardiac defibrillator; LCSD = left CSD; LQTS = long QT syndrome; VATS = video-assisted thoracoscopic surgery; VF = ventricular fibrillation; VT = ventricular tachycardia.
Article Information

Contributor Notes

Correspondence Ahmed M. Raslan: Oregon Health & Science University, Portland, OR. raslana@ohsu.edu.INCLUDE WHEN CITING Published online January 10, 2020; DOI: 10.3171/2019.11.PEDS19424.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Atallah JFynn-Thompson FCecchin FDiBardino DJWalsh EPBerul CI: Video-assisted thoracoscopic cardiac denervation: a potential novel therapeutic option for children with intractable ventricular arrhythmias. Ann Thorac Surg 86:162016252008

    • Search Google Scholar
    • Export Citation
  • 2

    Bhandari AKScheinman MMMorady FSvinarich JMason JWinkle R: Efficacy of left cardiac sympathectomy in the treatment of patients with the long QT syndrome. Circulation 70:101810231984

    • Search Google Scholar
    • Export Citation
  • 3

    Bos JMBos KMJohnson JNMoir CAckerman MJ: Left cardiac sympathetic denervation in long QT syndrome: analysis of therapeutic nonresponders. Circ Arrhythm Electrophysiol 6:7057112013

    • Search Google Scholar
    • Export Citation
  • 4

    Chen LQin YWZheng CZ: Left cervicothoracic sympathetic ganglionectomy with thoracoscope for the treatment of idiopathic long QT syndrome. Int J Cardiol 61:131997

    • Search Google Scholar
    • Export Citation
  • 5

    Chiou TSChen SC: Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis. Br J Surg 86:45471999

    • Search Google Scholar
    • Export Citation
  • 6

    Collura CAJohnson JNMoir CAckerman MJ: Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using video-assisted thoracic surgery. Heart Rhythm 6:7527592009

    • Search Google Scholar
    • Export Citation
  • 7

    Epstein AERosner MJHageman GRBaker JH IIPlumb VJKay GN: Posterior left thoracic cardiac sympathectomy by surgical division of the sympathetic chain: an alternative approach to treatment of the long QT syndrome. Pacing Clin Electrophysiol 19:109511041996

    • Search Google Scholar
    • Export Citation
  • 8

    Gardner PAOchalski PGMoossy JJ: Minimally invasive endoscopic-assisted posterior thoracic sympathectomy. Neurosurg Focus 25(2):E62008

    • Search Google Scholar
    • Export Citation
  • 9

    He DCostello JPNadler EPMoak JPJonas RANath DS: Left thoracoscopic sympathectomy used as primary therapy for a young child with intractable long QT syndrome. Pediatr Cardiol 34:196919712013

    • Search Google Scholar
    • Export Citation
  • 10

    Herbst FPlas EGFügger RFritsch A: Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations. Ann Surg 220:86901994

    • Search Google Scholar
    • Export Citation
  • 11

    Hofferberth SCCecchin FLoberman DFynn-Thompson F: Left thoracoscopic sympathectomy for cardiac denervation in patients with life-threatening ventricular arrhythmias. J Thorac Cardiovasc Surg 147:4044092014

    • Search Google Scholar
    • Export Citation
  • 12

    Hwang SWThomas JGWhitehead WECurry DJDauser RCKim ES: Left thorascopic sympathectomy for refractory long QT syndrome in children. J Neurosurg Pediatr 8:4554592011

    • Search Google Scholar
    • Export Citation
  • 13

    Li JLiu YYang FJiang GLi CHu D: Video-assisted thoracoscopic left cardiac sympathetic denervation: a reliable minimally invasive approach for congenital long-QT syndrome. Ann Thorac Surg 86:195519582008

    • Search Google Scholar
    • Export Citation
  • 14

    Raskin JSLiu JJAbrao AHolste KRaslan AMBalaji S: Minimally invasive posterior extrapleural thoracic sympathectomy in children with medically refractory arrhythmias. Heart Rhythm 13:138113852016

    • Search Google Scholar
    • Export Citation
  • 15

    Raskin JSLiu JJSun HNemecek ABalaji SRaslan AM: Minimal access posterior approach for extrapleural thoracic sympathectomy: a cadaveric study and cases. World Neurosurg 93:490.e1490.e62016

    • Search Google Scholar
    • Export Citation
  • 16

    Reardon PRMatthews BDScarborough TKPreciado AMarti JLConklin LD: Left thoracoscopic sympathectomy and stellate ganglionectomy for treatment of the long QT syndrome. Surg Endosc 14:862000

    • Search Google Scholar
    • Export Citation
  • 17

    Schwartz PJCrotti LInsolia R: Long-QT syndrome: from genetics to management. Circ Arrhythm Electrophysiol 5:8688772012

  • 18

    Schwartz PJPriori SGCerrone MSpazzolini COdero ANapolitano C: Left cardiac sympathetic denervation in the management of high-risk patients affected by the long-QT syndrome. Circulation 109:182618332004

    • Search Google Scholar
    • Export Citation
  • 19

    Silver ESLiberman LChung WKSpotnitz HMChen JMAckerman MJ: Long QT syndrome due to a novel mutation in SCN5A: treatment with ICD placement at 1 month and left cardiac sympathetic denervation at 3 months of age. J Interv Card Electrophysiol 26:41452009

    • Search Google Scholar
    • Export Citation
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