Controversies in Cardiac Sympathetic Denervation for Ventricular Arrhythmias

Cardiac sympathetic denervation (CSD) has been increasingly utilized for the management of patients with refractory ventricular tachycardia (VT). In addition, CSD has been employed for prevention of sudden death in those with hereditary ventricular arrhythmia disorders. Retrospective single-institution and registry studies suggest that CSD reduces VT episodes and ICD shocks, and improves freedom from heart transplantation or all-cause mortality in the setting of structural heart disease. In addition, left CSD has been associated with improved arrhythmia outcomes in those with hereditary disorders. For refractory arrhythmias in the setting of structural heart disease, low quality evidence suggests greater efficacy from bilateral CSD rather than solely left-sided. A high degree of heterogeneity exists in the extent of sympathetic denervation performed, though most contemporary studies utilize a partial (lower one-half to one-third) stellate ganglionectomy and sympathectomy through the fourth thoracic ganglia. Based on evidence available, we recommend consideration for bilateral stellate ganglionectomy and sympathectomy through T4 for refractory arrhythmias in those with structural heart disease, and left stellate ganglionectomy and sympathectomy for those with hereditary arrhythmia disorders.