What Is the Role of Cardiac Sympathetic Denervation for Recurrent Ventricular Tachycardia?

OPINION STATEMENT: There is a subset of patients who have recurrent ventricular tachycardia despite optimal medical management with pharmacologic therapy and catheter ablation. The cardiac sympathetic nervous system is responsible for triggering and perpetuating ventricular arrhythmias, and surgery can reduce the sympathetic stimulation to the heart. Evidence supports the use of left cardiac sympathetic denervation in recurrent ventricular arrhythmias for long QT syndrome and catecholaminergic polymorphic ventricular tachycardia. There are emerging studies suggesting an improvement in symptoms and survival for cardiac sympathetic denervation in a diverse range of underlying cardiac pathology. Some evidence supports that bilateral cardiac sympathetic denervation may be more effective at preventing recurrent ventricular tachycardia compared to left sided alone. Despite recent studies demonstrating promising results, rigorous clinical trials demonstrating the effectiveness and safety of cardiac sympathetic denervation surgery are lacking. However, individuals with recurrent ventricular tachycardia have a poor prognosis and a low quality of life, and surgical treatment may be justified in some individuals. It is our opinion that for patients with recurrent ventricular tachycardia, a multimodal approach should be used, including treatment of the underlying condition, implantable cardioverter defibrillator, pharmacologic therapy, and catheter ablation. If ventricular tachycardia persists after exhausting medical management, then cardiac sympathetic denervation may be considered. Future studies should focus on determining the impact of laterality on effectiveness and using novel imaging modalities to select patients most likely to benefit.